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Poisoning, drug overdose, and adverse drug effects continue to be a common encounter, especially in the intensive care unit (ICU). Patients are often critically ill or have a potential to rapidly deteriorate and warrant ICU admission. Adults suffering from overdoses rarely give a complete and accurate description of the quantity or type of medications ingested. In most adult cases, multiple substances are involved. A tentative diagnosis in most overdose and poisoning cases can be made by physical examination and simple laboratory tests (electrolyte panel, creatinine, serum osmolarity, urinalysis, etc). Supportive care, with particular attention to airway management, oxygenation, and circulation, is the mainstay of treatment. Basic treatment principles include limiting the amount of toxin absorbed, enhancing the elimination of ingested toxin, and preventing the conversion of non-toxic compounds to toxic metabolites. Drugs or poisons, where specific antidotes or effective therapies exist (especially acetaminophen, salicylates, methanol, ethylene glycol, and digitalis), should be aggressively sought and treated after initial stabilization has been accomplished. For those drugs or poisons where specific quantitative tests are available, levels should be obtained before treatment and may be repeated as clinically indicated.

To evaluate acceptability, efficiency, and quality of a new digital care management system in a residential aged care home (RACH).Improving care quality and efficiency in RACH, while simultaneously upgrading data management, is a priority for communities and governments.Participatory action research with mixed methods data collection was employed to evaluate a digital care management system implemented at a 169-bed RACH. This paper reports qualitative findings of the 2-year evaluation.Qualitative data were collected using focus groups with residents, visitors, nurses, managers, care workers, and consultants; resident/visitor and staff hallway interviews and responses to open-ended questions in online staff surveys. Data were analysed thematically under the four predetermined study objectives. Reporting adhered to COREQ guidelines.325 data captures from 88 participants, over seven data sources were coded. Findings indicate that the system was acceptable to both residents and staff due to perceptions of time-saving and improved quality of care. Increased efficiency was perceived through timeliness as well as reduced time spent retrieving and documenting information. Quality of care was improved through care scheduling individualised to resident needs, with reminders to avoid missed care. Relatives were reassured and activities were scheduled to loved one's preferences. The co-design implementation process was successful through commitment to quality from leadership teams and prioritising the focus on the holistic needs of the residents.A strong emphasis on co-design with care staff in developing and implementing the digital care system contributed to a system that supported nursing and care work, facilitated reporting and documentation, and improved resident care and well-being including identification of missed care.Nurses, carers, administrators, and advocates can support the co-design creation of information systems that suit the workflow of an organisation and keep the focus on individualised models of care provision.

Background Motivational messaging is a frequently used digital intervention to promote positive health behavior changes, including smoking cessation. Typically, motivational messaging systems have not actively sought feedback on each message, preventing a closer examination of the user-system engagement. This study assessed the granular user-system engagement around a recommender system (a new system that actively sought user feedback on each message to improve message selection) for promoting smoking cessation and the impact of engagement on cessation outcome. Methods We prospectively followed a cohort of current smokers enrolled to use the recommender system for 6 months. The system sent participants motivational messages to support smoking cessation every 3 days and used machine learning to incorporate user feedback (i.e., user’s rating on the perceived influence of each message, collected on a 5-point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement on perceiving the influence on quitting smoking) to improve the selection of the following message. We assessed user-system engagement by various metrics, including user response rate (i.e., the percent of times a user rated the messages) and the perceived influence of messages. We compared retention rates across different levels of user-system engagement and assessed the association between engagement and the 7-day point prevalence abstinence (missing outcome = smoking) by using multiple logistic regression. Results We analyzed data from 731 participants (13% Black; 73% women). The user response rate was 0.24 (SD = 0.34) and user-perceived influence was 3.76 (SD = 0.84). The retention rate positively increased with the user response rate (trend test P Conclusions High user-system engagement was positively associated with both high retention rate and smoking cessation, suggesting that investigation of methods to increase engagement may be crucial to increase the impact of the recommender system for smoking cessation. Trial registration Registration Identifier: NCT03224520. Registration date: July 21, 2017.

Voyager and Galileo observations of Jupiter's largest moon Ganymede revealed numerous fractures and evidence of strike-slip faulting. The formation of these features has been studied by considering gravitational tidal forces and extensional tectonism, but remains enigmatic. In this study, we continue to advance the assessment of Ganymede’s geologic history by examining the high-resolution Galileo Solid State Imaging (SSI) camera images (∼100m/pixel) available for the area of Nippur/Philus Sulci (Figure 1). Here, various geologic units align on a single line of longitude, providing an excellent sampling region of Ganymede’s deformed surface and eliminating the need to correct for possible leading/trailing hemisphere disparities in the cratering record (Figure 2). First, we produced new crater counts and size frequency distributions to define the relative ages of terrains and their individual geologic units. The chronology of tectonic activity implied by mapped crosscutting relationships is consistent with our findings from analyses of crater densities for each unit, revealing three eras of distinct geologic activity: ancient, intermediate and youngest. Moreover, crosscutting bands of light terrain throughout the surface of Ganymede (and at the Nippur/Philus Sulci site) show varying degrees of tectonic distortion related to these eras of activity, ranging from smooth and less distorted bands to highly grooved and deformed terrain with indicators of shear deformation and strike-slip offsets. To further constrain the timing of geologic activity, we conducted a tidal stress analysis to better understand the formation of shear deformation inferred within the region. Previous studies suggest that tidal stresses resulting from a high eccentricity can generate stress fields capable of driving shear failure and promoting tectonism. At present, Ganymede’s diurnal tidal stresses are not large enough to initiate shear failure. However, the Galilean satellites could have been captured for a period of 10 Ma to 1 Ga years in two Laplace-like resonances previous to the current state and eccentricity. In this past phase, the eccentricity could have been as high as e = ∼0.07, driving internal activity as well as subsequent resurfacing. Using examples of shear deformation indicators found in the Nippur/Philus Sulci area, we examined higher values of past eccentricity to evaluate the promotion of shear failure using the SatStress tidal stress model and Coulomb failure theory, where tractions are resolved onto shallow fault planes (100 m depth) with azimuthal orientations consistent with mapped observations (Figure 3). We find that candidate past eccentricities > 0.02 provide optimal conditions for shear failure throughout the Nippur/Philus Sulci region in its intermediate phase of geologic activity, implied by the positioning of shear indicators within intermediate units as identified by the cratering analysis. Moreover, a past higher eccentricity could have produced a stress field conducive to shear failure of the icy upper crust and possibly promoted the formation of the inferred shear features of Nippur/Philus Sulci and beyond. Future high-resolution images, provided by NASA’s Juno mission, as well as future observations by ESA’s Jupiter Icy Moons Explorer (JUICE) mission and NASA’s Europa Clipper mission, may further aid in our understanding of synergies within Ganymede’s cratering record and tectonic history, especially in the far-field regions surrounding this study, for which only lower resolution Voyager data is currently available.

Background Infectious diseases (ID) consultation improves health outcomes for certain infections but has not been well described for Pseudomonas aeruginosa (PA) bloodstream infection (BSI). Therefore, the goal of this study was to examine ID consultation of inpatients with PA BSI and factors impacting outcomes. Methods This was a retrospective cohort study from January 1, 2012, to December 31, 2018, of adult hospitalized veterans with PA BSI and antibiotic treatment 2 days before through 5 days after the culture date. Multidrug-resistant (MDR) cultures were defined as cultures with resistance to at least 1 agent in ≥3 antimicrobial categories tested. Multivariable logistic regression models were fit to assess the impact of ID consults and adequate treatment on mortality. Results A total of 3256 patients had PA BSI, of whom 367 (11.3%) were multidrug resistant (MDR). Most were male (97.5%), over 65 years old (71.2%), and White (70.9%). Nearly one-fourth (n = 784, 23.3%) died during hospitalization, and 870 (25.8%) died within 30 days of their culture. Adjusted models showed that ID consultation was associated with decreased in-hospital (odds ratio [OR], 0.47; 95% CI, 0.39–0.56) and 30-day mortality (OR, 0.51; 95% CI, 0.42–0.62). Conclusions Consultation with ID physicians improves clinical outcomes such as in-hospital and 30-day mortality for patients with PA BSI. ID consultation provides value and should be considered for patients with PA BSI.

Online patient portals like the Veteran Health Administration's (VA) My HealthRetrospective database analysis.VA SCI/D System of Care.Veterans with SCI/D who utilize VA care.N/A.MHV registration and use of key portal features among Veterans who newly registered for MHV. Veteran characteristics associated with registration and use of portal features using multiple logistic regression.14.6% of Veterans with SCI/D in our sample registered to use MHV. 48.7% used the medication refill feature, 28.7% used the appointment view feature, 25.0% sent or read at least one secure message and 10.8% used the Blue Button feature. Adjusted analyses indicate that having a C5-8 (OR: 1.36, CI95%: 1.06-1.76, P 0.05) or T1-S5 (OR: 1.41, CI95%: 1.13-1.78, P 0.01) (vs. C1-C4), having (vs. not having) neurogenic bladder (OR: 1.45, CI95%: 1.18-1.77, P 0.01), being married (vs. not married) (OR: 2.00, CI95%: 1.67-2.39, P 0.01), and increased healthcare utilization in the third (OR: 1.71, CI95%: 1.31-2.24, P 0.01) and fourth (OR: 1.73, CI95%: 1.27-2.34, P 0.01) quartiles (vs. first quartile) were associated with increased odds of MHV registration. We also identified factors associated with use of key MHV features.Our results suggest that MHV registration and use of key portal features was limited among Veterans with SCI/D. Effort to increase portal use in this population are warranted.

To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex.Retrospective cross-sectional design.National VA Polytrauma System of Care outpatient settings.Veterans with a confirmed TBI event (N=6065).Not applicable.Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis.The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item.There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.

Context/Objective: Provisions of the Affordable Care Act (ACA) potentially increase insurance options for Veterans with disabilities. We examined Veterans with spinal cord injuries and disorders (SCI/D) to assess whether the ACA was associated with changes in healthcare utilization from Department of Veterans Affairs (VA) healthcare facilities. Design: Using national VA data, we investigated impacts on VA healthcare utilization pre- (2012/13) and post-ACA (2014/15) implementation with negative binomial regression models. Setting: VA healthcare facilities. Participants: 8,591 VA users with SCI/D. Veterans with acute myelitis, Guillain-Barré syndrome, multiple sclerosis, or amyotrophic lateral sclerosis were excluded as were patients who died during the study period. Interventions: We assessed VA healthcare utilization before and after ACA implementation. Outcome Measures: Total numbers of VA visits for SCI/D care, diagnostic care, primary care, specialty care, and mental health care, and VA admissions. Results: The number of VA admissions was 7% higher in the post than pre-ACA implementation period (P

Objective Anaphylaxis is a potentially life-threatening reaction requiring prompt treatment with intramuscular epinephrine (EPI). We sought to describe presenting features of pediatric anaphylaxis and compare patient characteristics and outcomes of children treated with prehospital EPI with those untreated. Methods We abstracted data from emergency department (ED) records for children meeting the National Institute of Allergy & Infectious Disease criteria for anaphylaxis (2015-2017) in one tertiary care children's hospital. We analyzed associations between patient characteristics and outcomes and receipt of prehospital EPI using descriptive statistics and multivariate logistic regression. Results Of 414 children presenting with anaphylaxis, 39.4% received IM EPI and 62.1% received antihistamines before hospital arrival. Children with Medicaid received pre-emergency department EPI less frequently than did children with private insurance (24.5% vs 43.8%, P = 0.001). Factors positively associated with prehospital EPI administration were history of food allergy (odds ratio [OR], 4.4 [95% confidence interval {CI}, 2.4-8.2]) or arrival by emergency medical services (OR, 8.0 [95% CI, 4.2-15.0]). Medicaid insurance was associated with decreased odds of prehospital EPI (OR, 0.33 [95% CI, 0.16-0.66]) and prehospital H1-antihistamine use (OR, 0.30 [95% CI, 0.17-0.56]). Prehospital EPI treatment was also associated with decreased rates of observation (37% vs 63%), inpatient admission (38% vs 62%), and intensive care unit admission (20% vs 80%) compared with no pretreatment (P = 0.03). Conclusions Prehospital treatment with EPI remains low, and barriers to optimal treatment are more pronounced in children with public insurance. Prehospital treatment with EPI was associated with decreased morbidity including hospitalization and intensive care unit admission.