BACKGROUND There is no prior study that has documented emergency department (ED) outcomes or stra... more BACKGROUND There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). OBJECTIVE To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. METHODS A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. RESULTS Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. CONCLUSION Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.
The COVID-19 pandemic has dramatically affected medical education. Emergency medicine (EM) requir... more The COVID-19 pandemic has dramatically affected medical education. Emergency medicine (EM) requires excellence in multiple core competencies, including leadership, teamwork, and communication skills as well as procedural experience. To meet these How to cite this article: Austin A, Rudolf F, Fernandez J, et al. COVID-19 educational innovation: Hybrid in-person and virtual simulation for emergency medicine trainees. AEM
Background Prescription opioid related deaths have increased dramatically over the past 17 years.... more Background Prescription opioid related deaths have increased dramatically over the past 17 years. Although emergency physicians (EPs) have not been the primary force behind this rise, previous literature has suggested that EPs could improve their opioid prescribing practices. We designed this study to evaluate the trend in emergency department (ED) opioid prescriptions over time during the US opioid epidemic. Methods We conducted a retrospective cohort study from July 1, 2012 to June 30, 2018, evaluating all adult patients who presented to two study EDs for a pain-related complaint and received an analgesic prescription upon ED discharge. We compared these data to trends in lay media and medical literature regarding the opioid epidemic. We also evaluated the incidence of repeat ED visits based on the type of analgesic prescriptions provided. Results Opioid prescriptions decreased from 37.76% to 13.29% over the six year study period. This coupled with an increase in non-opioid medications from 6.12% to 11.33% and an increase in "no prescription" from 56.12% to 75.37%. This corresponded with an increase in the number of publications on the opioid epidemic within the lay-public and medical literature. Additionally, those patients that received no opiates were less likely to require a repeat ED visit. Conclusions ED physicians are prescribing less opiates, while increasing the amount of non-narcotic analgesic prescriptions. This may be in response to the literature suggesting that prescription opioids play a large role in the opioids crisis. This decrease in opioid prescriptions did not increase the need for repeat ED visits.
Ear, nose, and throat foreign bodies may be encountered in outpatient clinics and emergency depar... more Ear, nose, and throat foreign bodies may be encountered in outpatient clinics and emergency department (ED) visits. Both adult and pediatric patients may present with this chief complaint. The etiology of these foreign bodies may or may not be known. Particularly in those cases when the etiology is unknown, the presenting complaint may be pain or discomfort, and without a history that points to the diagnosis of foreign body, the diagnosis may be missed. Avoiding premature closure and performing a thorough physical examination will aid in the process of discovering a foreign body as the etiology of a patient's complaint. Foreign bodies of the ear and nose often can be managed in the outpatient setting without significant risk. Foreign bodies in the throat are often medical emergencies that could potentially progress to surgical emergencies. Care must be maintained while examining for a potential foreign body in the throat so as not to cause an acute airway complication. Imaging may or may not aid in diagnosis of a foreign body to the ear, nose, or throat. Both an understanding of the anatomy involved as well as an understanding of the most appropriate setting for removal are important to the successful and safe removal of
Rosen's Emergency Medicine – Concepts and Clinical Practice, 2010
The liver is one of the largest organs in the body, serving a multitude of critical functions. Th... more The liver is one of the largest organs in the body, serving a multitude of critical functions. The average weight of the normal adult liver is 1500 g. It receives approximately 30% of the resting cardiac output by way of the portal vein and the hepatic artery. The liver can be affected by a variety of disorders, and because of its varied synthetic and metabolic functions, liver disease may manifest with a broad range of clinical signs and symptoms. Acute and chronic diseases of the liver are common in the general population and represent a common cause for presentation to the emergency department (ED).
Emergency Medicine (EM) residency program directors and faculty spend significant time and effort... more Emergency Medicine (EM) residency program directors and faculty spend significant time and effort creating a residency rank list. To date, however, there have been few studies to assist program directors in determining which pre-residency variables best predict performance during EM residency. To evaluate which pre-residency variables best correlated with an applicant's performance during residency. This was a retrospective multicenter sample of all residents in the three most recent graduating classes from nine participating EM residency programs. The outcome measure of top residency performance was defined as placement in the top third of a resident's graduating class based on performance on the final semi-annual evaluation. A total of 277 residents from nine institutions were evaluated. Eight of the predictors analyzed had a significant correlation with the outcome of resident performance. Applicants' grade during home and away EM rotations, designation as Alpha Omega Alpha (AOA), U.S. Medical Licensing Examination (USMLE) Step 1 score, interview scores, "global rating" and "competitiveness" on nonprogram leadership standardized letter of recommendation (SLOR), and having five or more publications or presentations showed a significant association with residency performance. We identified several predictors of top performers in EM residency: an honors grade for an EM rotation, USMLE Step 1 score, AOA designation, interview score, high SLOR rankings from nonprogram leadership, and completion of five or more presentations and publications. EM program directors may consider utilizing these variables during the match process to choose applicants who have the highest chance of top performance during residency.
As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of th... more As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of the past year. Without their generous contributions of time and expertise to the peer-review process, the Journal would not be able to advance its mission of emphasizing practical, efficient, and world-class emergency care. The top section editors and reviewers are chosen based on their quality of work, number of assignments, and timeliness of reviews.
Although an elevated white blood cell count is a widely utilized measure for evidence of infectio... more Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections. Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections. This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia and were subsequently discharged from the ED. These patients were screened for repeat ED visits within 7 days and death within 30 days. In patients with severe bandemia who were discharged from the ED, there was a 20.9% revisit rate at 7 days and a 4.9% mortality rate at 30 days, placing severely bandemic patients at 5 times significantly greater mortality compared to nonbandemic patients (P = .032). Our review of patient outcomes suggests that the degree of bandemia, especially in the setting of concurrent tachycardia or fever, is associated with greater likelihood of negative clinical outcomes.
Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a ... more Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year ro...
The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool ... more The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction. We aimed to document medical student perceptions and expectations of the instruction of the EM OCP. We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions. One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship eva...
The aim of this study was to develop a mobile software solution that will merge patient data with... more The aim of this study was to develop a mobile software solution that will merge patient data with a centralized patient database, aid surgical decision making, and document clinical services. iIncise is a computerized, menu-driven database that was developed for real-time entry of historical, clinical, and laboratory data. Within the process, examination data, testing rationale, and test results are captured. AAST staging criteria are presented during data entry to describe and classify organ injuries accurately. A legible, time-stamped, conclusive report can be generated for printed or electronic entry into the medical record. The handheld version of the database runs on a Compaq iPAQ Pocket PC in either stand-alone mode or via LAN or WAN through the Internet. Microsoft Information Internet Server 5.0 provides data transaction services to Microsoft SQL Server 2000 to merge multiuser replicate data between the back ends stored on the desktop and handheld devices. The printed report provides superior documentation for comprehensive evaluation and management services, including history and physical examination, documentation of medical decision making, appropriateness of diagnostic/or therapeutic services, and coordination of care in accordance with Health Care Financing Administration (HCFA) regulations. Rapid data entry, ease of use, and appropriate documentation of detailed and legible patient visits and procedural notes are early benefits. Wireless data transmission between handheld devices and the desktop database provides the required speed, flexibility, and multitasking environment necessary for the mobile surgeon.
To examine influenza vaccination status and predictors for vaccine receipt among healthcare worke... more To examine influenza vaccination status and predictors for vaccine receipt among healthcare workers (HCWs) caring for patients with spinal cord injuries and disorders. Cross-sectional, nationwide anonymous survey. Twenty-three Veterans Affairs spinal cord injury centers. One thousand five hundred fifty-six HCWs. The primary outcome was staff vaccination status. Independent variables included staff demographic and employment characteristics, health status, attitudes and beliefs about the vaccine, and implications for its use. The staff vaccination rate was 51%. Leading motivators of vaccine receipt were self-protection (77%) and patient protection (49%). The most common reasons for nonreceipt were concerns about side effects (49%), preventive quality (20%), and inconvenience (14%). Logistic regression results suggested that age of 50 years or older (OR, 1.47; P = .021), male gender (OR, 2.50; P < .001), strong belief in vaccine effectiveness (OR, 19.03; P = .008), and importance of HCW vaccination (OR, 20.50; P = .005) significantly increased the probability of vaccination. Recommending the vaccine to coworkers, patients, or patients' families was also associated with HCW vaccination (OR, 3.20; P < .001). Providers who did not believe the vaccine was protective (P < .001) or effective (P < .001) were less likely to recommend it to patients. Strategies to increase vaccination rates among HCWs should address concerns about side effects, effectiveness, and protective value of the vaccine and access to it. The impact of provider recommendations should be stressed. Vaccination and subsequent prevention of illness may limit morbidity and mortality, thus benefiting HCWs, healthcare facilities, and patients.
Although adrenal glucocorticoids were known to be important for adequate milk production, little ... more Although adrenal glucocorticoids were known to be important for adequate milk production, little is known about their effects on the metabolism of mammary glands during lactation. In this study, lactating Wistar rats on the 12th day of lactation were divided in the following groups: sham-operated (SO) and adrenalectomized (ADX) receiving no treatment; SO and ADX starved for 24 h and refed intragastrically with 2.5 ml of 50% glucose solution, 2 h before the experiment (SOR and ADXR) and ADX receiving substitute therapy with dexamethasone (ADX + DEX). Sacrifices were performed 2 days after surgery. Weight, lipid content and in vivo lipogenesis rate were evaluated in mammary gland (M.GLAND), liver, parametrial white adipose tissue (PARA) and interescapular brown adipose tissue (BAT). ATP citrate lyase activity was measured in M.GLAND, liver and PARA of SO, ADX and ADX + DEX. The rate of lipogenesis and 14CO2 production from 14C-glucose by isolated acini from M.GLAND and plasma glucose were also determined. In ADX rats, food intake, lipid content, in vivo lipogenesis rate and ATP citrate lyase activity in M.GLAND were significantly lower than those in SO rats. The M.GLAND lipogenesis rate of SOR group was similar to the value found in SO rats. In ADXR rats, the M.GLAND lipogenesis rate was not normalized. However, the therapy with DEX elevated lipid content, in vivo lipogenesis rate and ATP citrate lyase activity to levels similar to those in SO. These results suggest that the glucocorticoids are essential for the occurrence of normal lipid synthesis in M.GLAND during lactation.
BACKGROUND There is no prior study that has documented emergency department (ED) outcomes or stra... more BACKGROUND There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). OBJECTIVE To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. METHODS A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. RESULTS Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. CONCLUSION Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.
The COVID-19 pandemic has dramatically affected medical education. Emergency medicine (EM) requir... more The COVID-19 pandemic has dramatically affected medical education. Emergency medicine (EM) requires excellence in multiple core competencies, including leadership, teamwork, and communication skills as well as procedural experience. To meet these How to cite this article: Austin A, Rudolf F, Fernandez J, et al. COVID-19 educational innovation: Hybrid in-person and virtual simulation for emergency medicine trainees. AEM
Background Prescription opioid related deaths have increased dramatically over the past 17 years.... more Background Prescription opioid related deaths have increased dramatically over the past 17 years. Although emergency physicians (EPs) have not been the primary force behind this rise, previous literature has suggested that EPs could improve their opioid prescribing practices. We designed this study to evaluate the trend in emergency department (ED) opioid prescriptions over time during the US opioid epidemic. Methods We conducted a retrospective cohort study from July 1, 2012 to June 30, 2018, evaluating all adult patients who presented to two study EDs for a pain-related complaint and received an analgesic prescription upon ED discharge. We compared these data to trends in lay media and medical literature regarding the opioid epidemic. We also evaluated the incidence of repeat ED visits based on the type of analgesic prescriptions provided. Results Opioid prescriptions decreased from 37.76% to 13.29% over the six year study period. This coupled with an increase in non-opioid medications from 6.12% to 11.33% and an increase in "no prescription" from 56.12% to 75.37%. This corresponded with an increase in the number of publications on the opioid epidemic within the lay-public and medical literature. Additionally, those patients that received no opiates were less likely to require a repeat ED visit. Conclusions ED physicians are prescribing less opiates, while increasing the amount of non-narcotic analgesic prescriptions. This may be in response to the literature suggesting that prescription opioids play a large role in the opioids crisis. This decrease in opioid prescriptions did not increase the need for repeat ED visits.
Ear, nose, and throat foreign bodies may be encountered in outpatient clinics and emergency depar... more Ear, nose, and throat foreign bodies may be encountered in outpatient clinics and emergency department (ED) visits. Both adult and pediatric patients may present with this chief complaint. The etiology of these foreign bodies may or may not be known. Particularly in those cases when the etiology is unknown, the presenting complaint may be pain or discomfort, and without a history that points to the diagnosis of foreign body, the diagnosis may be missed. Avoiding premature closure and performing a thorough physical examination will aid in the process of discovering a foreign body as the etiology of a patient's complaint. Foreign bodies of the ear and nose often can be managed in the outpatient setting without significant risk. Foreign bodies in the throat are often medical emergencies that could potentially progress to surgical emergencies. Care must be maintained while examining for a potential foreign body in the throat so as not to cause an acute airway complication. Imaging may or may not aid in diagnosis of a foreign body to the ear, nose, or throat. Both an understanding of the anatomy involved as well as an understanding of the most appropriate setting for removal are important to the successful and safe removal of
Rosen's Emergency Medicine – Concepts and Clinical Practice, 2010
The liver is one of the largest organs in the body, serving a multitude of critical functions. Th... more The liver is one of the largest organs in the body, serving a multitude of critical functions. The average weight of the normal adult liver is 1500 g. It receives approximately 30% of the resting cardiac output by way of the portal vein and the hepatic artery. The liver can be affected by a variety of disorders, and because of its varied synthetic and metabolic functions, liver disease may manifest with a broad range of clinical signs and symptoms. Acute and chronic diseases of the liver are common in the general population and represent a common cause for presentation to the emergency department (ED).
Emergency Medicine (EM) residency program directors and faculty spend significant time and effort... more Emergency Medicine (EM) residency program directors and faculty spend significant time and effort creating a residency rank list. To date, however, there have been few studies to assist program directors in determining which pre-residency variables best predict performance during EM residency. To evaluate which pre-residency variables best correlated with an applicant's performance during residency. This was a retrospective multicenter sample of all residents in the three most recent graduating classes from nine participating EM residency programs. The outcome measure of top residency performance was defined as placement in the top third of a resident's graduating class based on performance on the final semi-annual evaluation. A total of 277 residents from nine institutions were evaluated. Eight of the predictors analyzed had a significant correlation with the outcome of resident performance. Applicants' grade during home and away EM rotations, designation as Alpha Omega Alpha (AOA), U.S. Medical Licensing Examination (USMLE) Step 1 score, interview scores, "global rating" and "competitiveness" on nonprogram leadership standardized letter of recommendation (SLOR), and having five or more publications or presentations showed a significant association with residency performance. We identified several predictors of top performers in EM residency: an honors grade for an EM rotation, USMLE Step 1 score, AOA designation, interview score, high SLOR rankings from nonprogram leadership, and completion of five or more presentations and publications. EM program directors may consider utilizing these variables during the match process to choose applicants who have the highest chance of top performance during residency.
As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of th... more As 2011 draws to a close, WestJEM would like to honor the top reviewers and section editors of the past year. Without their generous contributions of time and expertise to the peer-review process, the Journal would not be able to advance its mission of emphasizing practical, efficient, and world-class emergency care. The top section editors and reviewers are chosen based on their quality of work, number of assignments, and timeliness of reviews.
Although an elevated white blood cell count is a widely utilized measure for evidence of infectio... more Although an elevated white blood cell count is a widely utilized measure for evidence of infection and an important criterion for evaluation of systemic inflammatory response syndrome, its component band count occupies a more contested position within clinical emergency medicine. Recent studies indicate that bandemia is highly predictive of a serious infection, suggesting that clinicians who do not appreciate the value of band counts may delay diagnosis or overlook severe infections. Whereas previous studies focused on determining the quantitative value of the band count (ie, determining sensitivity, threshold for bandemia, etc.), this study directs attention to patient-centered outcomes, hypothesizing that the degree of bandemia predisposes patients to subsequent negative clinical outcomes associated with underappreciated severe infections. This retrospective study of electronic medical records includes patients who initially presented to the emergency department (ED) with bandemia and were subsequently discharged from the ED. These patients were screened for repeat ED visits within 7 days and death within 30 days. In patients with severe bandemia who were discharged from the ED, there was a 20.9% revisit rate at 7 days and a 4.9% mortality rate at 30 days, placing severely bandemic patients at 5 times significantly greater mortality compared to nonbandemic patients (P = .032). Our review of patient outcomes suggests that the degree of bandemia, especially in the setting of concurrent tachycardia or fever, is associated with greater likelihood of negative clinical outcomes.
Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a ... more Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year ro...
The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool ... more The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction. We aimed to document medical student perceptions and expectations of the instruction of the EM OCP. We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions. One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship eva...
The aim of this study was to develop a mobile software solution that will merge patient data with... more The aim of this study was to develop a mobile software solution that will merge patient data with a centralized patient database, aid surgical decision making, and document clinical services. iIncise is a computerized, menu-driven database that was developed for real-time entry of historical, clinical, and laboratory data. Within the process, examination data, testing rationale, and test results are captured. AAST staging criteria are presented during data entry to describe and classify organ injuries accurately. A legible, time-stamped, conclusive report can be generated for printed or electronic entry into the medical record. The handheld version of the database runs on a Compaq iPAQ Pocket PC in either stand-alone mode or via LAN or WAN through the Internet. Microsoft Information Internet Server 5.0 provides data transaction services to Microsoft SQL Server 2000 to merge multiuser replicate data between the back ends stored on the desktop and handheld devices. The printed report provides superior documentation for comprehensive evaluation and management services, including history and physical examination, documentation of medical decision making, appropriateness of diagnostic/or therapeutic services, and coordination of care in accordance with Health Care Financing Administration (HCFA) regulations. Rapid data entry, ease of use, and appropriate documentation of detailed and legible patient visits and procedural notes are early benefits. Wireless data transmission between handheld devices and the desktop database provides the required speed, flexibility, and multitasking environment necessary for the mobile surgeon.
To examine influenza vaccination status and predictors for vaccine receipt among healthcare worke... more To examine influenza vaccination status and predictors for vaccine receipt among healthcare workers (HCWs) caring for patients with spinal cord injuries and disorders. Cross-sectional, nationwide anonymous survey. Twenty-three Veterans Affairs spinal cord injury centers. One thousand five hundred fifty-six HCWs. The primary outcome was staff vaccination status. Independent variables included staff demographic and employment characteristics, health status, attitudes and beliefs about the vaccine, and implications for its use. The staff vaccination rate was 51%. Leading motivators of vaccine receipt were self-protection (77%) and patient protection (49%). The most common reasons for nonreceipt were concerns about side effects (49%), preventive quality (20%), and inconvenience (14%). Logistic regression results suggested that age of 50 years or older (OR, 1.47; P = .021), male gender (OR, 2.50; P < .001), strong belief in vaccine effectiveness (OR, 19.03; P = .008), and importance of HCW vaccination (OR, 20.50; P = .005) significantly increased the probability of vaccination. Recommending the vaccine to coworkers, patients, or patients' families was also associated with HCW vaccination (OR, 3.20; P < .001). Providers who did not believe the vaccine was protective (P < .001) or effective (P < .001) were less likely to recommend it to patients. Strategies to increase vaccination rates among HCWs should address concerns about side effects, effectiveness, and protective value of the vaccine and access to it. The impact of provider recommendations should be stressed. Vaccination and subsequent prevention of illness may limit morbidity and mortality, thus benefiting HCWs, healthcare facilities, and patients.
Although adrenal glucocorticoids were known to be important for adequate milk production, little ... more Although adrenal glucocorticoids were known to be important for adequate milk production, little is known about their effects on the metabolism of mammary glands during lactation. In this study, lactating Wistar rats on the 12th day of lactation were divided in the following groups: sham-operated (SO) and adrenalectomized (ADX) receiving no treatment; SO and ADX starved for 24 h and refed intragastrically with 2.5 ml of 50% glucose solution, 2 h before the experiment (SOR and ADXR) and ADX receiving substitute therapy with dexamethasone (ADX + DEX). Sacrifices were performed 2 days after surgery. Weight, lipid content and in vivo lipogenesis rate were evaluated in mammary gland (M.GLAND), liver, parametrial white adipose tissue (PARA) and interescapular brown adipose tissue (BAT). ATP citrate lyase activity was measured in M.GLAND, liver and PARA of SO, ADX and ADX + DEX. The rate of lipogenesis and 14CO2 production from 14C-glucose by isolated acini from M.GLAND and plasma glucose were also determined. In ADX rats, food intake, lipid content, in vivo lipogenesis rate and ATP citrate lyase activity in M.GLAND were significantly lower than those in SO rats. The M.GLAND lipogenesis rate of SOR group was similar to the value found in SO rats. In ADXR rats, the M.GLAND lipogenesis rate was not normalized. However, the therapy with DEX elevated lipid content, in vivo lipogenesis rate and ATP citrate lyase activity to levels similar to those in SO. These results suggest that the glucocorticoids are essential for the occurrence of normal lipid synthesis in M.GLAND during lactation.
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