Telemedicine is associated with rapid transfer and fewer involuntary holds among patients presenting with suicidal ideation in rural hospitals: a propensity matched cohort study.

OBJECTIVE: The purpose of this study was to evaluate the impact of telemedicine in clinical management and patient outcomes of patients presenting to rural critical access hospital emergency departments (EDs) with suicidal ideation or attempt. METHODS: Retrospective propensity-matched cohort study of patients treated for suicidal attempt and ideation in 13 rural critical access hospital EDs participating in a telemedicine network. Patients for whom telemedicine was used were matched 1:1 to those who did not have telemedicine as an exposure (n=139 TM+, n=139 TM-) using optimal matching of propensity scores based on administrative data. Our primary outcome was ED length-of-stay (LOS), and secondary outcomes included admission proportion, use of chemical or physical restraint, 30 day ED return, involuntary detention orders, treatment/follow-up plan and 6-month mortality. Analyses for multivariable models were conducted using conditional linear and logistic regression clustered on matched pairs with purposeful selection of covariates. RESULTS: Mean ED LOS was not associated with telemedicine consultation among all patients, but was associated with a 29.3% decrease in transferred patients (95% CI 11.1 to 47.5). The adjusted odds of hospital admission (either local or through transfer) was 2.35 (95% CI 1.10 to 5.00) times greater among TM+ patients compared with TM- patients. Involuntary hold placement was lower in those exposed to telemedicine (adjusted odds ratio (aOR): 0.48; 95% CI 0.23 to 0.97). We did not observe significant differences in other outcomes. CONCLUSION: The role of telemedicine in influencing access, quality and efficiency of care in underserved rural hospitals is critically important as these networks become more prevalent in rural healthcare environments.

The anesthetic management of children with neonatal-onset multi-system inflammatory disease.

BACKGROUND: Neonatal-onset multi-system inflammatory disease (NOMID), a rare autosomal dominantly inherited disease, belongs to a growing spectrum of autoinflammatory diseases, is characterized by urticarial rash, arthropathy, and chronic aseptic meningitis, and is associated with mutations in the cold-induced autoinflammatory gene, CIAS1, the gene that encodes the protein, cryopyrin. As little is known about the anesthetic considerations of the disease, we sought to identify the main features and respective anesthetic and perioperative implications of NOMID. METHODS: We examined perianesthetic records of children with NOMID who were anesthetized for invasive diagnostic and therapeutic interventions between 2003 and 2006. In addition, we conducted an extensive literature review of the genetic, clinical, and biochemical abnormalities of the disease. RESULTS: Seventeen children with NOMID (median age 8 yr, range 9 mo to 11 yr) were anesthetized for diagnostic and therapeutic procedures. All patients had neurological involvement, including increased intracranial pressure, chronic aseptic meningitis, and developmental delay; 7 had bony overgrowth, 15 ocular, and 14 otological manifestations of NOMID. Despite the complexity of the disease, the perioperative course was uncomplicated, and no serious adverse events were observed. CONCLUSIONS: This study is the first to investigate the anesthetic implications of NOMID, an autoinflammatory disease associated with arthropathy, recurrent fevers, urticarial rash, and chronic aseptic meningitis. While for the pediatric anesthesiologist, the presence of fever and aseptic meningitis might make the conduct of anesthetics for elective procedures less desirable, our findings suggest that without evidence of active infection, even in the presence of fever and chronic aseptic meningitis, general and regional anesthesia may be conducted in patients with NOMID without untoward complications.

Spatial and visual discrimination reversals in adult and geriatric rats exposed during gestation to methylmercury and n-3 polyunsaturated fatty acids.

Fish contain essential long chain polyunsaturated fatty acids (PUFAs), particularly docosahexaenoic acid (DHA), an omega-3 (or n-3) PUFA, but are also the main source of exposure to methylmercury (MeHg), a potent developmental neurotoxicant. Since n-3 PUFAs support neural development and function, benefits deriving from a diet rich in n-3s have been hypothesized to protect against deleterious effects of gestational MeHg exposure. To determine whether protection occurs at the behavioral level, female Long-Evans rats were exposed, in utero, to 0, 0.5, or 5ppm of Hg as MeHg via drinking water, approximating exposures of 0, 40, and 400 microgHg/kg/day and producing 0, 0.29, and 5.50ppm of total Hg in the brains of siblings at birth. They also received pre- and postnatal exposure to one of two diets, both based on the AIN-93 semipurified formulation. A "fish-oil" diet was high in, and a "coconut-oil" diet was devoid of, DHA. Diets were approximately equal in alpha-linolenic acid and n-6 PUFAs. As adults, the rats were first assessed with a spatial discrimination reversal (SDR) procedure and later with a visual (nonspatial) discrimination reversal (VDR) procedure. MeHg increased the number of errors to criterion for both SDR and VDR during the first reversal, but effects were smaller or non-existent on the original discrimination and on later reversals. No such MeHg-related deficits were seen when the rats were retested on SDR after 2 years of age. These results are consistent with previous reports and hypotheses that gestational MeHg exposure produces perseverative responding. No interactions between diet and MeHg were found, suggesting that n-3 PUFAs do not guard against these behavioral effects. Brain Hg concentrations did not differ between the diets, either. In geriatric rats, failures to respond were less common and response latencies were shorter for rats fed the fish-oil diet, suggesting that exposure to a diet rich in n-3s may lessen the impact of age-related declines in response initiation.

World-wide consumption of trans fatty acids.

Dietary trans fatty acids (TFA) originate from commercially hydrogenated oils and from dairy and meat fats. Estimates of dietary TFA consumption vary with dietary habits and food supply as well as methods used to estimate consumption. Methods include: (1) market share data, (2) laboratory analysis of duplicate portions or composite diets, (3) analysis of consumption data of a representative population, and (4) biomarkers, such as human milk. In North America, daily intakes have been estimated by food frequency questionnaire to be 3-4 g/person and by extrapolation of human milk data to be greater than 10 g/person. Diets in northern Europe traditionally have contained more TFA than in Mediterranean countries where olive oil is used. Intakes in Europe range from minimal values in Italy, Portugal, Greece and Spain (1.4-2.1 g/day) to greater values for Germany, Finland, Denmark, Sweden, France, United Kingdom, Belgium, Norway, The Netherlands, and Iceland (2.1-5.4 g/day) Recent decreases in dietary TFA have been observed due to modifications of commercial fats and changes in consumer choices. The impact of legislation restricting use of hydrogenated fats and requiring TFA content on food labels awaits future studies.

Gestational exposure to methylmercury and n-3 fatty acids: effects on high- and low-rate operant behavior in adulthood.

Fish in the diet is the major source of methylmercury (MeHg) exposure, but eating fish also provides important nutrients. Many fish species contain essential long chain polyunsaturated fatty acids, especially docosahexaenoic acid (DHA), an omega-3 (or n-3) fatty acid, that is important for neural development and function. To examine interactions between MeHg and n-3 fatty acids, female Long-Evans rats were exposed, in utero, to 0, 0.5, or 5 ppm MeHg via drinking water, approximating exposures of 0, 40, and 400 mug/kg/day. They also received pre- and postnatal exposure to a diet containing either fish oil or coconut oil, creating a 2 (Diet)x3 (MeHg) full factorial design, with 6-8 rats per cell. The diets were high or marginal, respectively, in n-3 fatty acids but approximately equal in n-6 fatty acids. No exposure-related effects on developmental milestones or growth were noted. Behavior was evaluated using a series of rapidly increasing fixed ratio (FR) schedules of sucrose reinforcement; 1, 5, 25 and 75 lever presses were required for sucrose delivery, with three sessions provided at each requirement. This phase was followed by four sessions of a differential-reinforcement-of-low-rate-behavior (DRL) schedule, in which presses preceded by 10 s (or more) without a press were reinforced. Subsequently, several progressive ratio (PR) schedules that increased response requirements throughout a single session by a rate of 5%, 10%, or 20% were imposed. Rats exposed during gestation to MeHg had significantly higher response rates than controls under the large FR schedules, during the first session of DRL, and the PR 5% schedule, but neither fish oil nor coconut oil modified MeHg's effects. This finding is consistent with hypotheses that developmental MeHg exposure produced perseverative responding or altered the sensitivity of behavior to its reinforcing consequences and that certain reinforcement contingencies can unmask MeHg's effects.

Urolithiasis in rats consuming a dl bitartrate form of choline in a purified diet.

Urolithiasis appeared in rats maintained to study the effects of nutrients and methylmercury on development and aging. After a year, the mortality rate was approximately 10%, and by 2 years, it had increased to nearly 30%. Clinical signs and urinary tract pathology were examined as a function of diet, duration on diet, gender, methylmercury exposure, genetics, and other potential risk factors by using survival analyses and qualitative comparisons. Urolithiasis in female rats appeared 15 weeks after beginning a purified diet and after 5 weeks for male rats. After 97 weeks, the mortality rate of female rats was 22% and for male rats was 64%. Lifetime urolithiasis-associated mortality was about 2% in a group of rats that consumed the contaminated diet for < 30 weeks. No urolithiasis occurred in siblings or cohorts of the rats described here that were maintained on a standard rodent chow containing choline chloride. Urolithiasis was traced to racemic, rather than levo-, bitartaric acid in some purified diets shipped in 2001 and 2002. It is unknown when the impurity first appeared in the diet, so estimates of exposure duration are upper limits. Chronic methylmercury exposure increased vulnerability. Some families (dam + offspring) had multiple cases of urolithiasis, but probability models constructed to evaluate familial clustering revealed no evidence for a genetic predisposition to urolithiasis apart from gender. Removing racemic tartaric acid did not decrease mortality once rats had been on the diet for 20 to 30 weeks, but it helped when exposure duration was shorter.

Polycystic ovary (Stein-Leventhal) syndrome: etiology, complications, and treatment.

Polycystic ovary syndrome (PCOS) occurs in approximately 3% to 5% of the female population and may be the leading cause of infertility in those of reproductive age. PCOS presents clinically with a variety of signs and symptoms; the most common being menstrual irregularities, hyperandrogenism, infertility, and obesity. The true pathophysiology has not been clearly elucidated; however, there is growing agreement that gonadotropin dynamic dysfunction, hyperandrogenism, and insulin resistance are key features. The diagnosing of PCOS involves radiologic and laboratory studies. Radiologic studies typically include pelvic ultrasound; laboratory data should be obtained regarding pertinent gonadotropins and other hormone levels. PCOS is not a benign condition. It may lead to complications involving glucose metabolism, dyslipidemias, cardiovascular disease, and cancer. The goals of treatment should focus on restoring menstrual regularity, decreasing androgen excesses, and decreasing insulin resistance.