Antonios Likourezos

Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit.

Objective:Numerous factors can cause delays in transfer to an intensive care unit for critically ill emergency department patients. The impact of delays is unknown. We aimed to determine the association between emergency department “boarding” (holding admitted patients in the emergency department pending intensive care unit transfer) and outcomes for critically ill patients. Design:This was a cross-sectional analytical study using the Project IMPACT database (a multicenter U.S. database of intensive care unit patients). Patients admitted from the emergency department to the intensive care unit (2000–2003) were included and divided into two groups: emergency department boarding ≥6 hrs (delayed) vs. emergency department boarding <6 hrs (nondelayed). Demographics, intensive care unit procedures, length of stay, and mortality were analyzed. Groups were compared using chi-square, Mann-Whitney, and unpaired Student’s t-tests. Setting:Emergency department and intensive care unit. Patients:Patients admitted from the emergency department to the intensive care unit (2000–2003). Interventions:None. Measurements and Main Results:Main outcomes were intensive care unit and hospital survival and intensive care unit and hospital length of stay. During the study period, 50,322 patients were admitted. Both groups (delayed, n = 1,036; nondelayed, n = 49,286) were similar in age, gender, and do-not-resuscitate status, along with Acute Physiology and Chronic Health Evaluation II score in the subgroup for which it was recorded. Among hospital survivors, the median hospital length of stay was 7.0 (delayed) vs. 6.0 days (nondelayed) (p < .001). Intensive care unit mortality was 10.7% (delayed) vs. 8.4% (nondelayed) (p < .01). In-hospital mortality was 17.4% (delayed) vs. 12.9% (nondelayed) (p < .001). In the stepwise logistic model, delayed admission, advancing age, higher Acute Physiology and Chronic Health Evaluation II score, male gender, and diagnostic categories of trauma, intracerebral hemorrhage, and neurologic disease were associated with lower hospital survival (odds ratio for delayed admission, 0.709; 95% confidence interval, 0.561–0.895). Conclusions:Critically ill emergency department patients with a ≥6-hr delay in intensive care unit transfer had increased hospital length of stay and higher intensive care unit and hospital mortality. This suggests the need to identify factors associated with delayed transfer as well as specific determinants of adverse outcomes.

Elevated Serum Total and LDL Cholesterol in Very Old Patients with Alzheimer’s Disease

The relationships of serum lipids with Alzheimer’s disease (AD) and other dementias in very old patients are not clear. All residents of an academic nursing home were studied clinically for dementia and for serum lipids. All those autopsied over a 7.7-year period had apolipoprotein E (apoE) genotyping and detailed neuropathological examination. Those with pathologically defined criteria for AD (n = 84) were compared to all others who also had clinical dementia but did not show AD changes (n = 22). In contrast to most other reports of serum lipids in very old patients with AD, total cholesterol (TC) and low density lipoprotein cholesterol levels were each significantly higher for those with AD. The lipid-AD associations were progressively stronger with increasing pathological certainty of AD diagnosis. These relationships remained significant after adjustment for apoE genotype and for other known risk factors. The lipid-AD associations in a very old cohort, and prior evidence that elevated TC in middle life is a risk factor for later dementia, prompt consideration of factors associated with lipid metabolism in the development of Alzheimer’s dementia.

Relationships of sex hormone levels to dependence in activities of daily living in the frail elderly

OBJECTIVES We undertook this nursing home study in order to determine the relationships between dependency in activities of daily living (ADL) and blood levels of estrone, testosterone, androstenedione, and dehydroepiandrosterone (DHEA). Little is known about this issue. METHODS cross-sectional study of 370 nursing home residents. Hormone levels in blood specimens drawn in 1997 and 1998 were correlated with degree of ADL dependency recorded in medical charts. RESULTS Because of multiple comparisons associations were deemed significant for P-values < or =0.017 for males and < or =0.0125 for females. In males, the following were inversely related: testosterone levels with dependency in transferring and eating; estrone with eating and a summary ADL index; and androstenedione with toileting and a summary ADL index (in all cases, r=-0.4; P=0.007-0.015). Inverse trends existed between testosterone levels and dependency in mobility and a summary ADL index; and androstenedione and eating (in all cases r=-0.3; P=0.030-0.055). Among females the following were directly related: estrone levels with dependence in mobility, toileting, transferring, and a summary ADL index; and DHEA with transferring and a summary ADL index (r=0.2-0.3, P=0.0001-0.01). Trends existed between estrone and eating, and DHEA and toileting (r=0.1-0.2, P=0.04). CONCLUSION In male residents, higher sex hormone levels are associated with better ADL performance. Among females the opposite is true. While further studies are needed to elucidate these relationships, our results and recent findings of others suggest sex hormone actions in older women differ from those in younger populations. A possible stress-related mechanism is also presented.

Factors used by pharmacy residency programs to select residents.

Obtaining a pharmacy residency training position is becoming competitive as the number of applicants participating in the ASHP Resident Matching Program (RMP) exceeds the number of positions.[1][1]–[3][2] The competitive nature of the RMP impresses on applicants the need to thoroughly prepare for

Screening for Depression in Nursing Home Palliative Care Patients

The purpose of the this study was to evaluate the existing tools for assessing depression in nursing home patients referred to palliative care services. The patients referred to palliative care were assessed for depression by a geriatric fellow and a psychiatrist (gold standard). The questions asked by the fellow were derived from the existing validated screening scales and diagnostic tools. The psychiatrist’s assessment had a strong agreement with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV;. = 0.400) and Geriatric Depression Scale (GDS;. = 0.462) and least agreement with the Cornell Scale for Depression in Dementia (CDS). However, depression in the most severe dementia patients (Mini-Mental State Examination = 0) was able to be assessed only by the CDS. Thus, although items from the DSM-IV and GDS may be used to ascertain depression in geriatric patients, to date there is no scale valid and reliable enough to effectively ascertain depression in the most severely demented patients.

Sociodemographic and Health Characteristics of Older Chinese on Admission to a Nursing Home: A Cross-Racial/Ethnic Study

OBJECTIVES:  To investigate sociodemographic characteristics (SDCs) and health status of older Chinese newly admitted to a nursing home (NH) and to compare them with the characteristics of residents from other racial/ethnic groups.

Health status and functional status in relationship to nursing home subacute rehabilitation program outcomes.

Likourezos A, Si M, Kim WO, Simmons S, Frank J, Neufeld R: Health status and functional status in relationship to nursing home subacute rehabilitation program outcomes. Am J Phys Med Rehabil 2002;81:373–379. Objective To assess the relationship of health status and functional status to key nursing home subacute rehabilitation program outcomes: motor function at discharge, discharge destination, and length of stay in the program. Design Using a prospective cohort study design, 164 patients were assessed on entering the rehabilitation program for the first time after discharge from an acute hospital. Their median length of stay was 40 days. Results The patients’ motor function improved over time (P < 0.0001), and a large majority were discharged to the community. At admission, health status was positively associated with motor function (P < 0.05) and cognitive function (P < 0.01). Higher cognitive function and higher motor function at admission were correlated with higher motor function at discharge (rs = 0.386, P < 0.0001; rs = 0.563, P < 0.0001 respectively). Better health status was independently associated with discharge to the community (P < 0.01). Only motor function at admission was independently associated with length of stay (P < 0.01). Conclusion Health status and functional status are related, and both are independently associated with nursing home subacute rehabilitation program outcomes. Therefore, an improvement in one may result in an improvement in the other, and both aid in the attainment of positive subacute rehabilitation outcomes.

The association of fecal impaction and urinary retention in elderly nursing home patients

The objective of this study was to examine the association of fecal impaction and urinary retention in an elderly nursing home population. Two-hundred and three nursing home patients with urinary dysfunction (77% female, median age: 85 years (range: 61-104)) underwent an evaluation which included rectal examination, measurement of residual urine, and cystometric studies. Bivariate analyses indicated that fecal impaction was not associated with urinary retention. However, dependency in transfer was directly associated with fecal impaction (OR=2.91; P=0.004), and with urinary retention (OR=3.13; P=0.017). There was no association between detrusor underactivity and fecal impaction. When urinary retention and fecal impaction occurred in the same patient, detrusor overactivity was the most common cystometric finding. Rather than implicating an anatomic or neurologic link between poor bladder emptying and poor bowel emptying, a third factor (e.g. immobility) causing both urinary retention and fecal impaction should be sought.

Continuous Intravenous Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the Emergency Department

Introduction Our objective was to describe dosing, duration, and pre- and post-infusion analgesic administration of continuous intravenous sub-dissociative dose ketamine (SDK) infusion for managing a variety of painful conditions in the emergency department (ED). Methods We conducted a retrospective chart review of patients aged 18 and older presenting to the ED with acute and chronic painful conditions who received continuous SDK infusion in the ED for a period over six years (2010–2016). Primary data analyses included dosing and duration of infusion, rates of pre- and post-infusion analgesic administration, and final diagnoses. Secondary data included pre- and post-infusion pain scores and rates of side effects. Results A total of 104 patients were enrolled in the study. Average dosing of SDK infusion was 11.26 mg/hr, and the mean duration of infusion was 135.87 minutes. There was a 38% increase in patients not requiring post-infusion analgesia. The average decrease in pain score was 5.04. There were 12 reported adverse effects, with nausea being the most prevalent. Conclusion Continuous intravenous SDK infusion has a role in controlling pain of various etiologies in the ED with a potential to reduce the need for co-analgesics or rescue analgesic administration. There is a need for more robust, prospective, randomized trials that will further evaluate the analgesic efficacy and safety of this modality across a wide range of pain syndromes and different age groups in the ED.

A Targeted Mindfulness Curriculum for Medical Students During Their Emergency Medicine Clerkship Experience

Introduction Despite high rates of burnout in senior medical students, many schools provide the majority of their wellness training during the first and second preclinical years. Students planning a career in emergency medicine (EM) may be at particularly high risk of burnout, given that EM has one of the highest burnout rates of all the specialties in the United States We developed an innovative, mindfulness-based curriculum designed to be integrated into a standard EM clerkship for senior medical students to help students manage stress and reduce their risk of burnout. Methods The curriculum included these components: (1) four, once-weekly, 60-minute classroom sessions; (2) prerequisite reading assignments; (3) individual daily meditation practice and journaling; and (4) the development of a personalized wellness plan with the help of a mentor. The design was based on self-directed learning theory and focused on building relatedness, competence, and autonomy to help cultivate mindfulness. Results Thirty students participated in the curriculum; 20 were included in the final analysis. Each student completed surveys prior to, immediately after, and six months after participation in the curriculum. We found significant changes in the self-reported behaviors and attitudes of the students immediately following participation in the curriculum, which were sustained up to six months later. Conclusion Although this was a pilot study, our pilot curriculum had a significantly sustained self-reported behavioral impact on our students. In the future, this intervention could easily be adapted for any four-week rotation during medical school to reduce burnout and increase physician wellness.