Calvary Hospital

The recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted for the period beginning March 2008 through April 2010. Searches were limited to studies, reviews, and other evidence conducted in human subjects and published in English. Key search words included, but were not limited to, African Americans, Asian Americans, albuminuria, asymptomatic, asymptomatic screening and brachial artery reactivity, atherosclerosis imaging, atrial fibrillation, brachial artery testing for atherosclerosis, calibration, cardiac tomography, compliance, carotid intima-media thickness (IMT), coronary calcium, coronary computed tomography angiography (CCTA), C-reactive protein (CRP), detection of subclinical atherosclerosis, discrimination, endothelial function, family history, flow-mediated dilation, genetics, genetic screening, guidelines, Hispanic Americans, hemoglobin A, glycosylated, meta-analysis, Mexican Americans, myocardial perfusion imaging (MPI), noninvasive testing, noninvasive testing and type 2 diabetes, outcomes, patient compliance, peripheral arterial tonometry (PAT), peripheral tonometry and atherosclerosis, lipoprotein-associated phospholipase A2, primary prevention of coronary artery disease (CAD), proteinuria, cardiovascular risk, risk scoring, receiver operating characteristics (ROC) curve, screening for brachial artery reactivity, stress echocardiography, subclinical atherosclerosis, subclinical and Framingham, subclinical and Multi-Ethnic Study of Atherosclerosis (MESA), and type 2 diabetes. Additionally, the writing committee reviewed documents related to the subject matter previously published by the ACCF and AHA, American Diabetes Association (ADA), European Society of Cardiology, and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 7. References selected and published in this document are representative and not all-inclusive.

This article surveys worldwide medical, ethical, and legal trends and initiatives related to the concept of pain management as a human right. This concept recently gained momentum with the 2004 European Federation of International Association for the Study of Pain (IASP) Chapters-, International Association for the Study of Pain- and World Health Organization-sponsored "Global Day Against Pain," where it was adopted as a central theme. We survey the scope of the problem of unrelieved pain in three areas, acute pain, chronic noncancer pain, and cancer pain, and outline the adverse physical and psychological effects and social and economic costs of untreated pain. Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. The biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Strategies currently applied for improvement include framing pain management as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies. The role of the World Health Organization is discussed, particularly with respect to opioid availability for pain management. We conclude that, because pain management is the subject of many initiatives within the disciplines of medicine, ethics and law, we are at an "inflection point" in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.

The IDEA (International Deep Endometriosis Analysis group) statement is a consensus opinion on terms, definitions and measurements that may be used to describe the sonographic features of the different phenotypes of endometriosis. Currently, it is difficult to compare results between published studies because authors use different terms when describing the same structures and anatomical locations. We hope that the terms and definitions suggested herein will be adopted in centers around the world. This would result in consistent use of nomenclature when describing the ultrasound location and extent of endometriosis. We believe that the standardization of terminology will allow meaningful comparisons between future studies in women with an ultrasound diagnosis of endometriosis and should facilitate multicenter research. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

A systematic review of the literature on predictors of complicated grief (CG) was undertaken with the aim of clarifying the current knowledge and to inform future planning and work in CG following bereavement. Predictors of CG prior to the death include previous loss, exposure to trauma, a previous psychiatric history, attachment style, and the relationship to the deceased. Factors associated with the death include violent death, the quality of the caregiving or dying experience, close kinship relationship to the deceased, marital closeness and dependency, and lack of preparation for the death. Perceived social support played a key role after death, along with cognitive appraisals and high distress at the time of the death. Inconsistent definitions of CG and measurement tools were noted in the earlier studies reviewed. Limitations identified in the studies included use of cross-sectional designs, heterogeneous samples, high attrition, demographic differences between cases and controls, differences in length of time since death, and differences in types of death experienced. Notwithstanding these limitations, some consistent findings have emerged. Further research into conceptualizations of CG in terms of attachment theory and constructivist and cognitive-behavioral concepts of finding purpose and meaning after bereavement is warranted.

OBJECTIVE: To characterize the neuropsychological profile of vascular cognitive impairment (VCI) and vascular dementia (VaD). METHODS: The authors examined 170 patients with stroke or TIA at 3 to 6 months after the vascular event, and 96 age-matched healthy controls, with detailed neuropsychological and medical-psychiatric assessments, with a majority (66.7%) undergoing MRI brain scans. The subjects were diagnosed as having VaD, VCI, or no cognitive impairment by consensus. The neuropsychological tests were classified into cognitive domains, and composite z-scores adjusted for age and education. RESULTS: VaD subjects had disturbance in all cognitive domains, with verbal memory, especially retention, being less affected. VCI subjects had similar but less severe disturbance. The domains that best discriminated cognitively impaired from unimpaired patients were abstraction, mental flexibility, information processing speed, and working memory. Cognitive impairment had a significant correlation with deep white matter hyperintensities, but not with volume and number of infarctions, even though the VaD subjects had larger infarct volumes than VCI subjects. The MRI variables did not provide additional discrimination between subgroups. CONCLUSIONS: The cognitive deficits in VaD and VCI are characterized by disturbance of frontal functions, with less verbal memory impairment. VaD and VCI differ in severity but not pattern of disturbance. The brain lesions that best account for these deficits are noninfarct subcortical white matter and gray matter changes due to ischemia. The picture of VaD/VCI presented shows subcortical deficits embellished by cognitive deficits from cortical infarctions.

Abstract Rationale Initial reports of case fatality rates (CFRs) among adults with coronavirus disease (COVID-19) receiving invasive mechanical ventilation (IMV) are highly variable. Objectives To examine the CFR of patients with COVID-19 receiving IMV. Methods Two authors independently searched PubMed, Embase, medRxiv, bioRxiv, the COVID-19 living systematic review, and national registry databases. The primary outcome was the “reported CFR” for patients with confirmed COVID-19 requiring IMV. “Definitive hospital CFR” for patients with outcomes at hospital discharge was also investigated. Finally, CFR was analyzed by patient age, geographic region, and study quality on the basis of the Newcastle-Ottawa Scale. Measurements and Results: Sixty-nine studies were included, describing 57,420 adult patients with COVID-19 who received IMV. Overall reported CFR was estimated as 45% (95% confidence interval [CI], 39–52%). Fifty-four of 69 studies stated whether hospital outcomes were available but provided a definitive hospital outcome on only 13,120 (22.8%) of the total IMV patient population. Among studies in which age-stratified CFR was available, pooled CFR estimates ranged from 47.9% (95% CI, 46.4–49.4%) in younger patients (age ≤40 yr) to 84.4% (95% CI, 83.3–85.4%) in older patients (age >80 yr). CFR was also higher in early COVID-19 epicenters. Overall heterogeneity is high (I2 >90%), with nonsignificant Egger’s regression test suggesting no publication bias. Conclusions Almost half of patients with COVID-19 receiving IMV died based on the reported CFR, but variable CFR reporting methods resulted in a wide range of CFRs between studies. The reported CFR was higher in older patients and in early pandemic epicenters, which may be influenced by limited ICU resources. Reporting of definitive outcomes on all patients would facilitate comparisons between studies. Systematic review registered with PROSPERO (CRD42020186997).

CONTEXT: Synthetic cannabinoids (SCs) such as "Spice", "K2", etc. are widely available via the internet despite increasing legal restrictions. Currently, the prevalence of use is typically low in the general community (<1%) although it is higher among students and some niche groups subject to drug testing. Early evidence suggests that adverse outcomes associated with the use of SCs may be more prevalent and severe than those arising from cannabis consumption. OBJECTIVES: To identify systematically the scientific reports of adverse events associated with the consumption of SCs in the medical literature and poison centre data. METHOD: We searched online databases (Medline, PsycInfo, Embase, Google Scholar and Pubmed) and manually searched reference lists up to December 2014. To be eligible for inclusion, data had to be from hospital, emergency department, drug rehabilitation services or poison centre records of adverse events involving SCs and included both self-reported and/or analytically confirmed consumption. RESULTS: From 256 reports, we identified 106 eligible studies including 37 conference abstracts on about 4000 cases involving at least 26 deaths. Major complications include cardiovascular events (myocardial infarction, ischemic stroke and emboli), acute kidney injury (AKI), generalized tonic-clonic seizures, psychiatric presentations (including first episode psychosis, paranoia, self-harm/suicide ideation) and hyperemesis. However, most presentations were not serious, typically involved young males with tachycardia (≈ 37-77%), agitation (≈ 16-41%) and nausea (≈ 13-94%) requiring only symptomatic care with a length of stay of less than 8 hours. CONCLUSIONS: SCs most frequently result in tachycardia, agitation and nausea. These symptoms typically resolve with symptomatic care, including intravenous fluids, benzodiazepines and anti-emetics, and may not require inpatient care. Severe adverse events (stroke, seizure, myocardial infarction, rhabdomyolysis, AKI, psychosis and hyperemesis) and associated deaths manifest less commonly. Precise estimates of their incidence are difficult to calculate due to the lack of widely available, rapid laboratory confirmation, the variety of SC compounds and the unknown number of exposed individuals. Long-term consequences of SCs use are currently unknown.

BACKGROUND: Delirium is a serious neuropsychiatric syndrome frequently experienced by palliative care inpatients. This syndrome is under-recognized by clinicians. While screening increases recognition, it is not a routine practice. AIM AND DESIGN: This systematic review aims to examine methods, quality, and results of delirium prevalence and incidence studies in palliative care inpatient populations and discuss implications for delirium screening. DATA SOURCES: A systematic search of the literature identified prospective studies reporting on delirium prevalence and/or incidence in inpatient palliative care adult populations from 1980 to 2012. Papers not in English or those reporting the occurrence of symptoms not specifically identified as delirium were excluded. RESULTS: Of the eight included studies, the majority (98.9%) involved participants (1079) with advanced cancer. Eight different screening and assessment tools were used. Delirium incidence ranged from 3% to 45%, while delirium prevalence varied, with a range of: 13.3%-42.3% at admission, 26%-62% during admission, and increasing to 58.8%-88% in the weeks or hours preceding death. Studies that used the Diagnostic and Statistical Manual-Fourth Edition reported higher prevalence (42%-88%) and incidence (40.2%-45%), while incidence rates were higher in studies that screened participants at least daily (32.8%-45%). Hypoactive delirium was the most prevalent delirium subtype (68%-86% of cases). CONCLUSION: The prevalence and incidence of delirium in palliative care inpatient settings supports the need for screening. However, there is limited consensus on assessment measures or knowledge of implications of delirium screening for inpatients and families. Further research is required to develop standardized methods of delirium screening, assessment, and management that are acceptable to inpatients and families.

BACKGROUND AND PURPOSE: Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains. A randomized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait speed), step length, and single support time. SUBJECTS: Forty-one subjects with acute ankle inversion sprains (<72 hours) and no other injury to the lower limb entered the trial. METHODS: Subjects were randomly assigned to 1 of 2 treatment groups. The control group received a protocol of rest, ice, compression, and elevation (RICE). The experimental group received the anteroposterior mobilization, using a force that avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met, and all subjects were given a home program of continued RICE application. Outcomes were measured before and after each treatment. RESULTS: The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion. The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions. The experimental group also had greater increases in stride speed during the first and third treatment sessions. DISCUSSION AND CONCLUSION Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone. Improvement in step length symmetry and single support time was similar in both groups.

1 Introduction Humanitarian aspects of pain relief have been the subject of editorials in this journal (Janeti and Liebeskind, 1994; Liebeskind and Melzack, 1987) and the writings of one of the present authors (Cousins, 1999, 2000; Cousins and Bridenbaugh, 1980; Cousins and Phillips, 1986) and others (James, 1993; Somerville, 1994). Yet the gap between deepening knowledge about pain and clinically inadequate treatment is widening—in aggregate, fewer than 50% of patients with acute, chronic or cancer pain receive adequate relief. Nonetheless, a consensus is now emerging that failure to treat pain appropriately is substandard medicine with adverse outcomes, is unethical, and is susceptible to both legal and professional action. This consensus has culminated in the concept of ‘Pain Relief: a Universal Human Right’, which is the theme of a joint International Association for the Study of Pain (IASP) European Federation of IASP Chapters (EFIC) ‘Global Day Against Pain’ to be launched for the first time with the World Health Organisation (WHO) in Geneva, October 11th, 2004. 2 Disease burden of severe pain Acute pain is a major challenge worldwide. Chronic pain poses a massive disease burden affecting an estimated 20% of adults rising to 50% of the older age population (Blyth et al., 2001; Crombie et al., 1999; Harstall and Ospina, 2003; Verhaak et al., 1998). Cancer pain affects 70% of the 10 million cancer patients diagnosed annually—doubling by 2020 (Goudas et al., 2001). In hundreds of millions of patients suffering HIV/AIDS, 60–100% will experience pain during their illness (Breitbart et al., 1996). 3 Adverse outcomes of unrelieved pain Severe unrelieved pain increases morbidity and even mortality in the settings of acute, chronic and cancer pain (Cleeland et al., 1996; Cousins, 1999; Siddall and Cousins, 2004). Chronic pain must be regarded as a diseaseentity because of the constellation of physical, psychological and environmental changes produced by pain per se (Cousins, 1999; EFIC, 2001; Siddall and Cousins, 2004). Social and economic costs fall on individuals, families and communities: absenteeism and reduced effectiveness (‘presenteeism’); costs of health care; loss of income; nonproductivity at home; workers compensation and welfare payments. In the USA total annual costs of chronic pain are estimated at US$100 billion, not to speak of tremendous human suffering there and globally. 4 Reasons for inadequate pain relief 4.1 Attitudes of health care professionals Misconceptions or ignorance among health care professionals regarding pain and its treatment include: concern about opioid tolerance, dependence and addiction; inappropriate anxieties about opioid use and related side effects (Bennett and Carr, 2002); a belief that analgesia makes diagnosis difficult; and a belief that opioid dose should relate to disease severity rather than pain intensity. 4.2 Cultural and societal attitudes Mirroring, if not determining the attitudes of clinicians, are often the erroneous attitudes of society at large (Morris, 1991, 1998; Papper, 1995). These include: the inevitability of pain; under reporting of pain due to stoicism; waiting until pain is severe before using opioids; the wish to be a ‘good’ patient. Such beliefs are cross-cultural. Societal attitudes to pain relief are influenced by prevailing concepts of pain and its significance to the individual and to society (Procacci and Maresca, 1984). In early societies pain was linked to evil spirits or demons in the body. Later, and still today in some cultures, pain was punishment (poena=punishment in Latin). Some societies, or their members belittle or mock patients—for example, with headache or back pain. Powerful myths (and their proponents) persist and spread with the ease of an epidemic—without the need for logic or evidence (Carr, 1996). Such myths include the often dysfunctional attitudes of healthcare workers noted above, and also that: pain is necessary and beneficial; undertreated pain has negligible adverse effects on treatment outcomes or costs. Combating such myths is difficult. Government-endorsed clinical practice guidelines do not necessarily change attitudes and practices—and do not spread with the ease of myths! The efforts of thought leaders have had more impact. These pain champions include: John Bonica, founder of IASP and promoter of many clinical, research and educational initiatives; one US congressman (Senator Orrin Hatch) and a small group of US clinicians and scientists who spearheaded the pain assessment and treatment initiative of the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), and the Decade of Pain Research and Treatment, proclaimed by US Congress. 4.3 Religious attitudes Religion, philosophy and folklore have ‘saturated pain with meaning’ (Morris, 1998). In many faiths the presence of pain has been incorporated into the very spiritual dimension of the human condition striving to achieve transcendence. The large majority of modern religions, however, place no real impediment to patients’ pain control. 4.4 Political attitudes If all other issues were addressed, formidable political and legal barriers to effective pain control would remain. Complex political and legal issues vary among countries but include: low political priorities for support of palliative care and pain clinics; problems in opioid availability and access; limits on types of pain and/or prescription duration for opioid use—e.g. some countries permit opioid use only for postoperative pain, others forbid their use in children. Another often-ignored issue is pain associated with torture (Williams et al., 2003). In addition to acute pain, torture victims have a high risk of experiencing chronic pain. 5 Strategies for improvement Improvements in pain management require simultaneous initiatives in medicine, law and ethics. All the factors discussed above have significantly impeded an ethical and legal focus on pain and its management. Extraordinary examples include: withholding anesthesia for surgery for 19th century combat soldiers as part of a ‘masculine cult of toughness and callousness’ (Pernick, 1983), and as official military policy of some countries in that era; and withholding of anesthesia for neonatal surgery until the late 1980s (Anand and McGrath, 1993). 6 Pain relief as an ethical issue The responsibility of doctors to provide pain control is articulated in the Hippocratic oath (”I will keep them from harm”) and the Declaration of Geneva. Increasingly, professional bodies craft ethical statements about pain relief, e.g. the American Medical Association “physicians have an obligation to relieve pain and suffering”. The relief of pain is a classic example of the bioethical principle of beneficence (Post et al., 1996). Failing to relieve severe pain may cause harm (see above); the principle of nonmalificence prohibits the infliction of harm. Failure to provide relief when this is available is a form of abandonment. In extreme cases it could be regarded as ‘torture by omission’ (Cousins, 1999). As Somerville (1994) states “many persons would rather be dead, than unloved, abandoned and, too often, left in pain”. Unrelieved pain undermines patients’ ability to think or interact socially. Unrelieved pain contravenes the right of the patient to self-determine his or her healthcare and if severe can destroy autonomy. The bioethical principle of justice can be used to assess the massive humanitarian and financial costs of severe pain and to argue for pain relief as a high social priority. A virtue ethics approach also places pain as a high priority. The current lack of a strong application of these principles to pain relief raises questions about the ethical foundations of current healthcare. 7 Pain relief as a legal right Is the statement that patients have a right to pain relief a hypothetical exercise in moral persuasion or can it become law? 7.1 Negligence law An unreasonable failure to provide adequate pain relief may constitute negligence (Somerville, 1994). Breaches in reasonable pain care may be: an unreasonable failure to take an adequate pain history (Giurelli v Girgis, 1980); an unreasonable failure to adequately treat the pain (Estate of Henry James, 1991) or in the context of uncontrolled pain, an unreasonable failure to secure expert consultation (a general principle of referral is stated in Dillon v LeRoux (1994)). Negligence cases against health professionals and hospitals, based on these principles, have resulted in multimillion dollar (USD) judgements. 7.2 Constitutional guarantees Many of the world's nations have written constitutions that entitle their citizens to adequate healthcare. None expressly articulate a right to pain relief. In the US Supreme Court, in the case of Vacco v Quill (1997) and Washington v Glucksburg (1997) the court expressed sympathy for a constitutional right to adequate palliative care, including pain management (Burt, 1997). In Europe, EFIC has made a proposal to the European Parliament for pain relief to be included in the constitution (EFIC, 2001). 7.3 Statutory regimes Several statutory models exist. There is a statutory right to pain relief in the Australian Capital Territory (‘Medical Treatment Act of 1994’). Doctors who provide pain relief in the terminally ill are immune from prosecution through the ‘Consent to Medical Treatment and Palliative Care Act 1995’ in South Australia. The Medical Boards of several US states also offer protection from disciplinary action when controlled substances are used for treatment of ‘intractable pain’ (Hyman, 1996). Detailed clarification, in the format of frequently asked questions, has recently addressed ‘the unwarranted fear that doctors who treat pain aggressively are singled out for enforcement actions’ (Drug Enforcement Administration, 2004). A wider array of statutory requirements for undergraduate and continuing medical education about pain control appears in a recently enacted California statute (Charatan, 2001) and in a statute introduced to the New York State legislature in 2004. 8 Pain relief and the UN International human rights are articulated in the foundation covenants of the UN. The International Covenant on Economic, Social and Cultural Rights (ICESCR) describes the right of “everyone to the enjoyment of the highest attainable standard of physical and mental health”. Although no explicit right to pain relief is expressed, this does fall comfortably within that definition. Arguably therefore, pain relief is an implied universal human right. The Universal Declaration of Human Rights in Article 5 states in part …“no one shall be subject…to inhuman or degrading treatment”. Although originally aimed at treatment of prisoners, this declaration underscores patients’ right to pain relief and reinforces judicial condemnation of the worst cases of negligent pain treatment. Options for further action include: amendment to the UN Covenants to expressly state a universal right to pain relief (a difficult option, since the foundation documents that make up the International Bill of Rights have never been amended); submissions from IASP and related bodies to the committee overseeing the ICESCR highlighting the central role of pain relief in the attainment of universal health, and by ICESCR exerting pressure on countries to provide basic pain control for their populations. 9 Professional misconduct Patients have a right to complain to a professional or governmental disciplinary body. The definitions of professional misconduct (‘shameful’ or ‘infamous’, etc.) vary among jurisdictions; there may be the lesser finding of ‘unprofessional conduct’. The latter is a more likely finding in cases of poor pain management unless the situation fits the statutory definition of professional misconduct for the jurisdiction. 10 Statements by professional bodies Major national and international bodies have issued guidelines, statements or recommendations on pain management, e.g. in the US, Europe and Australia (Carr, 2001).1 Many express pain relief as a patient right. Although guidelines have no force in law, they are not uncommonly quoted in legal proceedings. At the very least healthcare professionals can no longer claim a lack of credible guidance to achieve pain control. 11 Role of the WHO The WHO, a uniquely influential and effective global public health body, placed cancer pain control on its official agenda in the 1980s. Today, the WHO plays a critical role for worldwide recognition of pain control as a universal right (Breivik, 2002). Its agenda now includes: deregulation of opioid availability (WHO, 2000); assuring access to affordable opioids worldwide; fostering national pain and palliative care programs (e.g. the JCAHO); promoting campaigns such as EFIC's ‘European Week Against Pain’ and in 2004 IASP-EFIC-WHO's joint ‘Global Day Against Pain’; and assisting IASP-EFIC and other bodies to lobby the UN to declare an ‘International Year of Pain Relief’. The last initiative would highlight the importance of pain relief before the international community. 12 Conclusion Despite many hurdles surveyed in this editorial there is clear evidence that humanitarian aspects of pain relief are being addressed in a wide range of approaches across medicine, ethics and law whose rationale is consolidated under the call for ‘Pain Relief: a Universal Human Right.’ Acknowledgements Prof. Margaret Somerville for helpful criticism.

RATIONALE: The role of procalcitonin (PCT), a widely used sepsis biomarker, in critically ill patients with sepsis is undetermined. OBJECTIVES: To investigate the effect of a low PCT cut-off on antibiotic prescription and to describe the relationships between PCT plasma concentration and sepsis severity and mortality. METHODS: This was a multicenter (11 Australian intensive care units [ICUs]), prospective, single-blind, randomized controlled trial involving 400 patients with suspected bacterial infection/sepsis and expected to receive antibiotics and stay in ICU longer than 24 hours. The primary outcome was the cumulative number of antibiotics treatment days at Day 28. MEASUREMENTS AND MAIN RESULTS: PCT was measured daily while in the ICU. A PCT algorithm, including 0.1 ng/ml cut-off, determined antibiotic cessation. Published guidelines and antimicrobial stewardship were used in all patients. Primary analysis included 196 (PCT) versus 198 standard care patients. Ninety-three patients in each group had septic shock. The overall median (interquartile range) number of antibiotic treatment days were 9 (6-21) versus 11 (6-22), P = 0.58; in patients with positive pulmonary culture, 11 (7-27) versus 15 (8-27), P = 0.33; and in patients with septic shock, 9 (6-22) versus 11 (6-24), P = 0.64; with an overall 90-day all-cause mortality of 35 (18%) versus 31 (16%), P = 0.54 in the PCT versus standard care, respectively. Using logistic regression, adjusted for age, ventilation status, and positive culture, the decline rate in log(PCT) over the first 72 hours independently predicted hospital and 90-day mortality (odds ratio [95% confidence interval], 2.76 [1.10-6.96], P = 0.03; 3.20 [1.30-7.89], P = 0.01, respectively). CONCLUSIONS: In critically ill adults with undifferentiated infections, a PCT algorithm including 0.1 ng/ml cut-off did not achieve 25% reduction in duration of antibiotic treatment. Clinical trial registered with http://www.anzctr.org.au (ACTRN12610000809033).

BACKGROUND: Dementia following stroke is common but its determinants are still incompletely understood. METHODS: In the Sydney Stroke Study, we performed detailed neuropsychological and medical-psychiatric assessments on 169 patients aged 50-85 years, 3-6 months after a stroke, and 103 controls with a majority of both groups undergoing MRI brain scans. Stroke subjects were diagnosed as having vascular mild cognitive impairment (VaMCI) or vascular dementia (VaD) or no cognitive impairment by consensus. Demographic, functional, cerebrovascular risk factors and neuroimaging parameters were examined as determinants of dementia using planned logistic regression. RESULTS: 21.3% of subjects were diagnosed with VaD, with one case in those aged 50-59 years, 24% in those aged 60-69 years and 23% in those 70-79 years. There was no difference by sex. The prevalence of VaMCI was 36.7%. VaD subjects had lower premorbid intellectual functioning and had 0.9 years less education than controls. The VaD and VaMCI groups did not differ from the no cognitive impairment group on any specific cerebrovascular risk factor, however overall those with impairment had a greater number of risk factors. They did not differ consistently on depression severity, homocysteine levels and neuroimaging parameters (atrophy, infarct volume and number of infarcts) except for an excess of white matter lesions on MRI and greater number of infarcts in the VaD and VaMCI groups. On a series of logistic regression analyses, stroke volume and premorbid function were significant determinants of cognitive impairment in stroke patients. CONCLUSION: Post-stroke dementia and MCI are common, especially in older individuals. Cerebrovascular risk factors are not independent risk factors for VaD, but stroke volume is a significant determinant of dementia. Premorbid functioning is a determinant of post- stroke impairment.

Importance: There remains a lack of randomized trials investigating aspirin monotherapy for symptomatic venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA) or total knee arthroplasty (TKA). Objective: To determine whether aspirin was noninferior to enoxaparin in preventing symptomatic VTE after THA or TKA. Design, Setting, and Participants: Cluster-randomized, crossover, registry-nested trial across 31 hospitals in Australia. Clusters were hospitals performing greater than 250 THA or TKA procedures annually. Patients (aged ≥18 years) undergoing hip or knee arthroplasty procedures were enrolled at each hospital. Patients receiving preoperative anticoagulation or who had a medical contraindication to either study drug were excluded. A total of 9711 eligible patients were enrolled (5675 in the aspirin group and 4036 in the enoxaparin group) between April 20, 2019, and December 18, 2020. Final follow-up occurred on August 14, 2021. Interventions: Hospitals were randomized to administer aspirin (100 mg/d) or enoxaparin (40 mg/d) for 35 days after THA and for 14 days after TKA. Crossover occurred after the patient enrollment target had been met for the first group. All 31 hospitals were initially randomized and 16 crossed over prior to trial cessation. Main Outcomes and Measures: The primary outcome was symptomatic VTE within 90 days, including pulmonary embolism and deep venous thrombosis (DVT) (above or below the knee). The noninferiority margin was 1%. Six secondary outcomes are reported, including death and major bleeding within 90 days. Analyses were performed by randomization group. Results: Enrollment was stopped after an interim analysis determined the stopping rule was met, with 9711 patients (median age, 68 years; 56.8% female) of the prespecified 15 562 enrolled (62%). Of these, 9203 (95%) completed the trial. Within 90 days of surgery, symptomatic VTE occurred in 256 patients, including pulmonary embolism (79 cases), above-knee DVT (18 cases), and below-knee DVT (174 cases). The symptomatic VTE rate in the aspirin group was 3.45% and in the enoxaparin group was 1.82% (estimated difference, 1.97%; 95% CI, 0.54%-3.41%). This failed to meet the criterion for noninferiority for aspirin and was significantly superior for enoxaparin (P = .007). Of 6 secondary outcomes, none were significantly better in the enoxaparin group compared with the aspirin group. Conclusions and Relevance: Among patients undergoing hip or knee arthroplasty for osteoarthritis, aspirin compared with enoxaparin resulted in a significantly higher rate of symptomatic VTE within 90 days, defined as below- or above-knee DVT or pulmonary embolism. These findings may be informed by a cost-effectiveness analysis. Trial Registration: ANZCTR Identifier: ACTRN12618001879257.

National health expenditures are projected to grow at an average annual rate of 5.5 percent for 2018-27 and represent 19.4 percent of gross domestic product in 2027. Following a ten-year period largely influenced by the Great Recession and major health reform, national health spending growth during 2018-27 is expected to be driven primarily by long-observed demographic and economic factors fundamental to the health sector. Prices for health care goods and services are projected to grow 2.5 percent per year, on average, for 2018-27-faster than the average price growth experienced over the last decade-and to account for nearly half of projected personal health care spending growth. Among the major payers, average annual spending growth in Medicare (7.4 percent) is expected to exceed that in Medicaid (5.5 percent) and private health insurance (4.8 percent) over the projection period, mostly as a result of comparatively higher projected enrollment growth. The insured share of the population is expected to remain stable at around 90 percent throughout the period, as net gains in health coverage from all sources are projected to keep pace with population growth.

Employees in EDs report increasing role overload because of critical staff shortages, budgetary cuts and increased patient numbers and acuity. Such overload could compromise staff satisfaction with their working environment. This integrative review identifies, synthesises and evaluates current research around staff perceptions of the working conditions in EDs. A systematic search of relevant databases, using MeSH descriptors ED/EDs, Emergency room/s, ER/s, or A&E coupled with (and) working environment, working condition/s, staff perception/s, as well as reference chaining was conducted. We identified 31 key studies that were evaluated using the mixed methods assessment tool (MMAT). These comprised 24 quantitative-descriptive studies, four mixed descriptive/comparative (non-randomised controlled trial) studies and three qualitative studies. Studies included varied widely in quality with MMAT scores ranging from 0% to 100%. A key finding was that perceptions of working environment varied across clinical staff and study location, but that high levels of autonomy and teamwork offset stress around high pressure and high volume workloads. The large range of tools used to assess staff perception of working environment limits the comparability of the studies. A dearth of intervention studies around enhancing working environments in EDs limits the capacity to recommend evidence-based interventions to improve staff morale.

National health expenditures are projected to grow at an average annual rate of 5.4 percent for 2019-28 and to represent 19.7 percent of gross domestic product by the end of the period. Price growth for medical goods and services is projected to accelerate, averaging 2.4 percent per year for 2019-28, which partly reflects faster expected growth in health-sector wages. Among all major payers, Medicare is expected to experience the fastest spending growth (7.6 percent per year), largely as a result of having the highest projected enrollment growth. The insured share of the population is expected to fall from 90.6 percent in 2018 to 89.4 percent by 2028.

The concept of access to pain management as a human right has gained increasing currency in recent years. Commencing as individual advocacy, it was later embraced by the disciplines of pain medicine and palliative care and by mainstream human rights organizations.Today, United Nations and regional human rights bodies have accepted the concept and incorporated it into key human rights reports, reviews, and standards. We review the foundations in law of this right and the obligations that flow from it to governments. We analyze the nature and content of the obligation in the context of acute, chronic nonmalignant and cancer pain.Finally, we examine this right in light of the twin crises of inadequate access to pain management and the opioid crisis in the United States and other nations.

Specialist palliative care, within hospices in particular, has historically led and set the standard for caring for patients at end of life. The focus of this care has been mostly for patients with cancer. More recently, health and social care services have been developing equality of care for all patients approaching end of life. This has mostly been done in the context of a service delivery approach to care whereby services have become increasingly expert in identifying health and social care need and meeting this need with professional services. This model of patient centred care, with the impeccable assessment and treatment of physical, social, psychological and spiritual need, predominantly worked very well for the latter part of the 20th century. Over the last 13 years, however, there have been several international examples of community development approaches to end of life care. The patient centred model of care has limitations when there is a fundamental lack of integrated community policy, development and resourcing. Within this article, we propose a model of care which identifies a person with an illness at the centre of a network which includes inner and outer networks, communities and service delivery organisations. All of these are underpinned by policy development, supporting the overall structure. Adoption of this model would allow individuals, communities, service delivery organisations and policy makers to work together to provide end of life care that enhances value and meaning for people at end of life, both patients and communities alike.

Postsurgical spine syndrome is becoming an increasingly common challenge for clinicians who deal with spinal disorders owing to the expanding indications for spinal surgery and the aging world population. A multidisciplinary approach is most appropriate for patients who are unlikely to benefit from further formal surgical intervention. Anticonvulsant medications are effective in managing neuropathic pain after surgery, whereas opioids are rarely beneficial. Neuromodulation via a surgically implanted dorsal column neurostimulator is gaining popularity owing to its substantial superiority over conventional medical management and/or further surgical intervention. However, considering that prevention is always better than cure, spinal surgeons need to be well aware of the many poor prognostic indicators for spinal surgery, particularly psychosocial overlay.

OBJECTIVE: Despite Level 1b evidence and international consensus that exercise is beneficial in ankylosing spondylitis (AS), there is a paucity of detailed information to guide exercise prescription, including the type and dosage of exercise required for the most benefit. This collaborative project, combining evidence with clinical expertise, was established to develop practical recommendations to guide sustainable exercise prescription for individuals with AS. METHODS: Using a modified Delphi technique, 10 clinical questions were generated and a systematic literature review was conducted for each. Draft recommendations were developed at a 2-day meeting, based on the integration of evidence summaries and expert opinion. Feedback was obtained from patient and health professional groups prior to finalisation. RESULTS: Recommendations and practice points were developed for the following areas: assessment; monitoring; safety; disease management; AS-specific exercise; physical activity; dosage, adherence and setting. A framework was developed that could also be adapted for exercise in other chronic musculoskeletal conditions. Feedback suggests that the final consensus statement provides useful information for those seeking to provide best practice exercise prescription for people with AS. CONCLUSION: The recommendations provide an up-to-date, evidence-based approach to the full range of issues related to the use of exercise in AS, as well as identifying evidence gaps for further research. Most importantly, this includes investigation of aspects of exercise programme design required to produce the largest effect, long-term adherence with exercise programs and the specific exercise requirements of sub-groups of people with AS. Widespread dissemination and implementation of the guidelines will be required to optimise exercise outcomes.