Household food insecurity during the COVID-19 pandemic and associated socioeconomic demographic factors in Papua New Guinea: evidence from the Comprehensive Health and Epidemiological Surveillance System.

INTRODUCTION: The COVID-19 pandemic had an unprecedented impact on global food security, but little is known about the impact on food security at the household level. We examined the prevalence and socioeconomic demographic factors for household food insecurity during the COVID-19 pandemic in Papua New Guinea. METHODS: Household socioeconomic demographic data from the Comprehensive Health and Epidemiological Surveillance System were collected from six main provinces in 2020 (37880 participants) and compared with the 2018 data (5749 participants). The prevalence of household food insecurity was estimated and stratified by household socioeconomic demographic characteristics. Multinomial logistic regression was conducted to estimate adjusted OR (aOR) and 95% CI of risk factors. RESULTS: The overall prevalence of household food insecurity increased from 11% in 2018 to 20% in 2020, but varied across provinces, with the highest level reported in Central Province (35%) and the lowest level in East New Britain Province (5%).Food shortages were 72% less likely among urban residents than those living in rural areas (aOR 0.28 (95% CI 0.21 to 0.36)). The risk of food insecurity was 53% higher among adults aged 25+ years with primary education (grades 3-8) than those with university education (aOR 1.53 (95% CI 1.09 to 2.13)). People from households in the poorest wealth quintiles were 80% more likely to report food shortage than those from the richest wealth quintile (aOR 1.78 (95% CI 1.29 to 2.45). CONCLUSION: The study provides evidence to develop policy and intervention to deal with food insecurity in emergency situations in the future.

Validating the InterVA-5 cause of death analytical tool: using mortality data from the Comprehensive Health and Epidemiological Surveillance System in Papua New Guinea.

OBJECTIVE: InterVA-5 is a new version of an analytical tool for cause of death (COD) analysis at the population level. This study validates the InterVA-5 against the medical review method, using mortality data in Papua New Guinea (PNG). DESIGN AND SETTING: This study used mortality data collected from January 2018 to December 2020 in eight surveillance sites of the Comprehensive Health and Epidemiological Surveillance System (CHESS), established by the PNG Institute of Medical Research in six major provinces. METHODS: The CHESS demographic team conducted verbal autopsy (VA) interviews with close relatives of the deceased, who died in communities within the catchment areas of CHESS, using the WHO 2016 VA instrument. COD of the deceased was assigned by InterVA-5 tool, and independently certified by the medical team. Consistency, difference and agreement between the InterVA-5 model and medical review were assessed. Sensitivity and positive predictive value (PPV) of the InterVA-5 tool were calculated with reference to the medical review method. RESULTS: Specific COD of 926 deceased people was included in the validation. Agreement between the InterVA-5 tool and medical review was high (kappa test: 0.72; p<0.01). Sensitivity and PPV of the InterVA-5 were 93% and 72% for cardiovascular diseases, 84% and 86% for neoplasms, 65% and 100% for other chronic non-communicable diseases (NCDs), and 78% and 64% for maternal deaths, respectively. For infectious diseases and external CODs, sensitivity and PPV of the InterVA-5 were 94% and 90%, respectively, while the sensitivity and PPV of the medical review method were both 54% for classifying neonatal CODs. CONCLUSION: The InterVA-5 tool works well in the PNG context to assign specific CODs of infectious diseases, cardiovascular diseases, neoplasms and injuries. Further improvements with respect to chronic NCDs, maternal deaths and neonatal deaths are needed.

Leading causes of deaths in the mortality transition in Papua New Guinea: evidence from the Comprehensive Health and Epidemiological Surveillance System.

BACKGROUND: Changing causes of deaths in the mortality transition in Papua New Guinea (PNG) are poorly understood. This study analysed community-level data to identify leading causes of death in the population and variations across age groups and sexes, urban-rural sectors and provinces. METHOD: Mortality surveillance data were collected from 2018-20 as part of the Comprehensive Health and Epidemiological Surveillance System (CHESS), using the World Health Organization 2016 verbal autopsy (VA) instrument. Data from 926 VA interviews were analysed, using the InterVA-5 cause of death analytical tool to assign specific causes of death among children (0-14 years), those of working age (15-64 years) and the elderly (65+ years). RESULT: Nearly 50% of the total deaths were attributed to non-communicable diseases (NCDs), followed by infectious and parasitic diseases (35%), injuries and external causes (11%) and maternal and neonatal deaths (4%). Leading causes of death among children were acute respiratory tract infections (ARTIs) and diarrhoeal diseases, each contributing to 13% of total deaths. Among the working population, tuberculosis (TB) contributed to 12% of total deaths, followed by HIV/AIDS (11%). TB- and HIV/AIDS-attributed deaths were highest in the age group 25-34 years, at 20% and 18%, respectively. These diseases killed more females of working age (n = 79, 15%) than males (n = 52, 8%). Among the elderly, the leading causes of death were ARTIs (13%) followed by digestive neoplasms (10%) and acute cardiac diseases (9%). CONCLUSION: The variations in leading causes of death across the populations in PNG suggest diversity in mortality transition. This requires different strategies to address specific causes of death in particular populations.

Social determinants of injury-attributed mortality in Papua New Guinea: new data from the Comprehensive Health and Epidemiological Surveillance System.

OBJECTIVE: This study reported the prevalence and sociodemographic distribution of mortalities attributed to injuries in Papua New Guinea (PNG). SETTING: As part of a longitudinal study, mortality data were collected from the population who live in eight surveillance sites of the Comprehensive Health and Epidemiological Surveillance System, established in six major provinces in PNG. Verbal autopsy (VA) interviews were conducted by the surveillance team with close relatives of the deceased, using the WHO 2016 VA instrument from January 2018 to December 2020. PARTICIPANT AND INTERVENTION: Mortality data from 926 VA interviews were analysed, using the InterVA-5 diagnostic tool to assign specific cause of death (COD). Distributions of injury-attributed mortality were calculated and multinomial logistic regression analyses were conducted to identify sociodemographic factors and provide ORs, 95% CIs of estimates and p values. RESULT: Injury-attributed deaths accounted for 13% of the total deaths recorded in the surveillance population, with the highest proportion in Madang (22%), followed by Port Moresby and Central Province (13%). Road traffic accidents were the leading COD, accounting for 43% of the total injury-attributed deaths, followed by assaults (25%) and accidental falls (10%). Young adults (aged 15-24 years) accounted the largest proportion of injury-attributed deaths (34%) and were nearly six times more likely to die from injuries than those aged 75+ years (OR: 5.89 (95% CI: 2.18 to 15.9); p<0.001). Males were twice more likely to die from injuries than females (OR: 2.0 (95% CI: 1.19 to 3.36); p=0.009). Another significant sociodemographic factor associated with the increased injury-attributed mortalities included urban versus rural residence (OR: 2.0 (95% CI: 1.01 to 3.99); p=0.048). CONCLUSION: Young adults, particularly those who live in urban areas, were at the highest risk of dying from injuries. Public health policies and interventions are needed to reduce premature mortality from injuries in PNG.

Tuberculosis and HIV/AIDS-attributed mortalities and associated sociodemographic factors in Papua New Guinea: evidence from the comprehensive health and epidemiological surveillance system.

OBJECTIVE: Tuberculosis (TB) and HIV/AIDS are public health concerns in Papua New Guinea (PNG). This study examines TB and HIV/AIDS mortalities and associated sociodemographic factors in PNG. METHOD: As part of a longitudinal study, verbal autopsy (VA) interviews were conducted using the WHO 2016 VA Instrument to collect data of 926 deaths occurred in the communities within the catchment areas of the Comprehensive Health and Epidemiological Surveillance System from 2018 to 2020.InterVA-5 cause of deaths analytical tool was used to assign specific causes of death (COD). Multinomial logistic regression analyses were conducted to identify associated sociodemographic factors, estimate adjusted ORs (AOR), 95% CIs and p values. RESULT: TB and HIV/AIDS were the leading CODs from infectious diseases, attributed to 9% and 8% of the total deaths, respectively.Young adults (25-34 years) had the highest proportion of deaths from TB (20%) and the risk of dying from TB among this age group was five times more likely than those aged 75+ years (AOR: 5.5 (95% CI 1.4 to 21.7)). Urban populations were 46% less likely to die from this disease compared rural ones although the difference was not significant (AOR: 0.54 (95% CI 0.3 to 1.0)). People from middle household wealth quintile were three times more likely to die from TB than those in the richest quintile (AOR: 3.0 (95% CI 1.3 to 7.4)).Young adults also had the highest proportion of deaths to HIV/AIDS (18%) and were nearly seven times more likely to die from this disease compared with those aged 75+years (AOR: 6.7 (95% CI 1.7 to 25.4)). Males were 48% less likely to die from HIV/AIDS than females (AOR: 0.52 (95% CI 0.3 to 0.9)). The risk of dying from HIV/AIDS in urban population was 54% less likely than their rural counterparts (AOR: 0.46 (95% CI 0.2 to 0.9)). CONCLUSION: TB and HIV/AIDS interventions are needed to target vulnerable populations to reduce premature mortality from these diseases in PNG.

Non-communicable diseases attributed mortality and associated sociodemographic factors in Papua New Guinea: Evidence from the Comprehensive Health and Epidemiological Surveillance System.

BACKGROUND: Papua New Guinea (PNG) is undergoing an epidemiological transition with increased mortality from NCDs. This study examined NCDs-attributed mortality and associated sociodemographic factors in PNG. METHOD: Using WHO 2016 instrument, 926 verbal autopsy (VA) interviews were conducted in six major provinces from January 2018 to December 2020. InterVA-5 tool was used to assign causes of death (COD). Multivariable logistic regression analysis was performed to identify sociodemographic factors associated with mortalities from emerging and endemic NCDs. FINDING: NCDs accounted for 47% of the total deaths, including 20% of deaths attributed to emerging NCDs and 27% of deaths due to endemic NCDs. Leading CODs from emerging NCDs were identified including cardiac diseases, stroke, and diabetes. The risk of dying from emerging NCDs was significantly lower among populations under age 44y compared with population aged 75+y (OR: 0.14 [0.045-0.433]; p-value: 0.001). People living in urban areas were twice likely to die from emerging NCDs than those in rural areas (OR: 1.92 [1.116-3.31]; p-value: 0.018). People in Madang province were 70% less likely to die from emerging NCDs compared to those from East New Britain province (OR: 0.314 [0.135-0.73]; p-value: 0.007). Leading CODs from endemic NCDs included digestive neoplasms, respiratory neoplasms, and other neoplasms. Only children aged 0-4y had significant lower risk of dying from endemic NCDs compared to the population aged 75+y (OR: 0.114 [95% CI: 0.014-0.896]; p-value: 0.039). CONCLUSION: Public health interventions are urgently needed, prioritizing urban population and those aged over 44y to reduce premature mortality from NCDs.

Measuring Wasting and Stunting Prevalence Among Children Under 5 Years of Age and Associated Risk Factors in Papua New Guinea: New Evidence From the Comprehensive Health and Epidemiological Surveillance System.

Background: Papua New Guinea (PNG) has undergone a significant health transition, with the prevalence of non-communicable diseases increasing. Many children under 5 years of age suffer from the burden of malnutrition. While wasting and stunting still remain high, children who are overweight and obese are reportedly increasing. Objective: This study reports the prevalence of wasting, stunting, underweight, and overweight children under five in PNG and explores potential household and maternal socioeconomic factors associated with malnutrition. Method: Data were drawn from the Comprehensive Health and Epidemiological Surveillance System (CHESS) in PNG. Height and weight were directly measured, and wasting, stunting, overweight, and underweight statistics were determined using the 2006 WHO Standard Growth Standards. Household and maternal factors were assessed with parent interviews conducted by trained data collectors. Multivariate logistic regression analyses were conducted to report associations between selected socioeconomic correlates and child malnutrition outcomes. Result: The prevalence of wasting, stunting, underweight, and overweight children was 13.8, 46.5, 18.2, and 18%, respectively. Children from households with food shortage were more likely to be wasted than those from households without such an experience [OR: 1.43 (95% CI: 0.93-2.21)]. Children from the poor quintile were more likely to be stunted than those from the richest quintile [OR: 1.2 (95% CI: 0.79-1.82)]. Other factors associated with wasting included living in an urban vs. rural area [OR: 1.36 (0.77-2.4)], middle household wealth quintile vs. richest quintile [OR: 0.77 (0.38-1.55)], mothers in union with a man vs. mother unmarried or live in union [OR: 0.76 (0.4-1.42)], and male children vs. female [OR: 0.77 (0.53-1.11)]. Factors associated with stunting included residing in urban vs. rural areas [OR: 1.13 (0.8-1.6)], mother in union vs. single mother [OR: 0.86 (0.59-1.24)], and mothers with preparatory/elementary vs. mothers with vocational/college education [OR: 0.15 (0.02-1.01)]. Conclusion: An integrated approach is needed to comprehensively address the household socioeconomic factors at the household level, contributing to the improvement of child health and development in PNG.

Breastfeeding Rate, Food Supplementation, Dietary Diversity Among Children Aged 6-59 Months, and Associated Factors in Papua New Guinea.

Background: Along the socioeconomic changes in the past decades, Papua New Guinea (PNG) has undergone significant food transition. Little is known about the influence of household and maternal socioeconomic demographic factors on dietary intake and diversity among children under 5 years of age (CU5). Objective: This study aimed to examine breastfeeding rate, food supplementation, dietary intake, and diversity among children aged 6-59 months and to identify associations with household and maternal socioeconomic demographic factors in PNG. Method: Data from 2,943 children were extracted from the Comprehensive Health and Epidemiological Surveillance System database, operated by the PNG Institute of Medical Research and used to estimate breastfeeding rate, food supplementation, and dietary intake of CU5 in a typical week. Dietary diversity score (DDS) was used as a proxy indicator to measure nutrient adequacy. Associations of DDS with household and maternal socioeconomic and demographic factors were examined using multivariate logistic regression analysis. Result: The breastfeeding rate among children aged 6-8 months was 85% (70% in urban and 90% in rural sectors), and 50% of children of this age group were fed with supplementary foods. Twenty percent of children aged 6-23 months were currently breastfed and received solid, semisolid, and soft foods three times or more per day. Forty-eight percent of children aged 6-59 months had a total DDS below the average level (23 scores). Place of residence, mother's education, and household wealth were associated with dietary diversity among studied children. Children in urban areas are 10% more likely to have a lower level of total DDS than those in rural areas (OR: 1.11 [0.79-1.56]; p-value: 0.5). Children whose mothers had a primary education level were 1.6-fold more likely to have a lower level of total DDS than children whose mothers had vocational training or college education (OR: 1.63 [0.68-3.92]; p-value: 0.28). Children from the poorest households were 1.2-fold more likely to have a lower DDS than those from the richest households (OR: 1.22 [0.79-1.87]; p-value: 0.37). Discussion: A range of factors has been identified, contributing to the eating behaviors among CU5 in PNG, in which mother's education and household wealth are among the most important determinants of childhood dietary diversity as they have a direct effect on accessibility to and affordability of a variety of foods at the household level. Conclusion: Evidence-based integrated and comprehensive approaches are needed to improve women education and household wealth, contributing to the improvement of food diversity among young children in PNG.

Impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and adverse events of special interest in patients with rheumatoid arthritis or spondyloarthritis: a systematic analysis of the literature and meta-analysis.

OBJECTIVES: To systematically review the impact of tapering targeted therapies (bDMARDs or JAKis) on the risk of serious infections and severe adverse events (SAEs) in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) in remission or low disease activity (LDA) state. MATERIALS AND METHODS: A meta-analysis based on a systematic review of PubMed, Embase, Cochrane, until August 2019, as well as relevant databases of international conferences, was used to evaluate the risk difference (RD) at 95% confidence interval (95% CI) of incidence density of serious infections, SAEs, malignancies, cardiovascular adverse events (CV AEs), or deaths after tapering (dose reduction or spacing) compared to continuation of targeted therapies. RESULTS: Of the 1957 studies initially identified, 13 controlled trials (9 RA and 4 SpA trials) were included in the meta-analysis. 1174 patient-years were studied in the tapering group (TG) versus 1086 in the usual care group (UC). There were 1.7/100 patient-year (p-y) serious infections in TG versus 2.6/100 p-y in UC (RD (95% CI) 0.01 (0.00 to 0.02), p = 0.13) and 7.4/100 p-y SAEs in TG versus 6.7/100 p-y in UC (RD 0.00 (- 0.02 to 0.02), p = 0.82). The risk of malignancies, CV AEs, or deaths did not differ between the tapering and the usual care groups. Subgroup analysis (RA and SpA) detected no significant differences between the two groups. CONCLUSION: We could not show significant impact of tapering bDMARD or JAKi over continuation concerning the risk of serious infections, SAEs, malignancies, CV AEs, or deaths in RA and SpA patients in remission or LDA state.

What drives intentional overdose with non-prescription drugs? A cross-sectional study.

BACKGROUND: Use of overdosage of Non-Prescription Drugs (NPD) among university students is a serious public health issue. However, there are no extensive studies that measured the prevalence of taking more than the recommended dose of NPD and/or identified the risk associated with this behavior among university students. OBJECTIVES: This study was undertaken to assess the prevalence and associated risks of self-overdosage with NPDs in university students in United Arab Emirates (UAE). METHODS: A cross-sectional survey-based study was conducted from January to April 2014, among 2875 students in three randomly selected universities. A structured and validated questionnaire was used to collect the responses of the students. SPSS version 20 was used to analyze the data. RESULTS: Out of 2875 students, only 2355 surveys were fully answered, returned back and included in the present study. Of 2355, more than half (1348; 57.2%) the participants reported using Oral NPD (ONPD) in the past 90 days before conducting the study and were asked to complete the survey. Only 290 (22%) of a total 1348 participants reported taking more than the recommended dose of ONPD in the previous three months before conducting the study. Analgesic/antipyretic (223, 16.5%) and anti-allergic (67, 4.9%) drugs were more than other classes of the ONPD, reported to be taken in a dose, more than the recommended dosage. The most common justifications for taking more than the recommended dose of ONPD among respondents were severe symptoms (6%), the belief that the recommended dose would not be sufficient to relieve the symptom (5%), the belief that a stronger dose would relieve the symptoms faster (11%), and previous experience (4%). Our results identified three risk factors for taking more than the recommended dose of NPD. High frequently drug-users of daily use (OR=3.494, 95% CI: 1.677-7.279) (P<0.001), and students from non-medical colleges had higher odds of taking more than the recommended dosage as compared to students from medical colleges (OR=1.486, 95% CI: 1.060-2.085, P-value<0.05). Furthermore\re, participants with a poly-pharmacy behavior had higher odds of taking overdosage of ONPD than single NPD users (OR=1.918, 95% CI: 1.440-2.555) (P<0.001). CONCLUSION: There are a sizable proportion of university students that use overdosage of NPD, but it is more serious issue when it comes to non-medical student. There is a need for educational programs designed to increase awareness among all university students and to motivate them not to use overdosage of NPD. Further studies are also required to investigate additional explanatory variables that could influence the practice of overdosage with NPD.

The Accuracy of an Electronic Pulmonary Embolism Severity Index Auto-Populated from the Electronic Health Record: Setting the stage for computerized clinical decision support.

BACKGROUND: The Pulmonary Embolism (PE) Severity Index identifies emergency department (ED) patients with acute PE that can be safely managed without hospitalization. However, the Index comprises 11 weighted variables, complexity that can impede its integration into contextual workflow. OBJECTIVE: We designed a computerized version of the PE Severity Index (e-Index) to automatically extract the required variables from discrete fields in the electronic health record (EHR). We tested the e-Index on the study population to determine its accuracy compared with a gold standard generated by physician abstraction of the EHR on manual chart review. METHODS: This retrospective cohort study included adults with objectively-confirmed acute PE in four community EDs from 2010-2012. Outcomes included performance characteristics of the e-Index for individual values, the number of cases requiring physician editing, and the accuracy of the e-Index risk category (low vs. higher). RESULTS: For the 593 eligible patients, there were 6,523 values automatically extracted. Fifty one of these needed physician editing, yielding an accuracy at the value-level of 99.2% (95% confidence interval [CI], 99.0%-99.4%). Sensitivity was 96.9% (95% CI, 96.0%-97.9%) and specificity was 99.8% (95% CI, 99.7%-99.9%). The 51 corrected values were distributed among 47 cases: 43 cases required the correction of one variable and four cases required the correction of two. At the risk-category level, the e-Index had an accuracy of 96.8% (95% CI, 95.0%-98.0%), under-classifying 16 higher-risk cases (2.7%) and over-classifying 3 low-risk cases (0.5%). CONCLUSION: Our automated extraction of variables from the EHR for the e-Index demonstrates substantial accuracy, requiring a minimum of physician editing. This should increase user acceptability and implementation success of a computerized clinical decision support system built around the e-Index, and may serve as a model to automate other complex risk stratification instruments.

Dissociation of lexical syntax and semantics: evidence from focal cortical degeneration.

The question of whether information relevant to meaning (semantics) and structure (syntax) relies on a common language processor or on separate subsystems has proved difficult to address definitively because of the confounds involved in comparing the two types of information. At the sentence level syntactic and semantic judgments make different cognitive demands, while at the single word level, the most commonly used syntactic distinction (between nouns and verbs) is confounded with a fundamental semantic difference (between objects and actions). The present study employs a different syntactic contrast (between count nouns and mass nouns), which is crossed with a semantic difference (between naturally occurring and man-made substances) applying to words within a circumscribed semantic field (foodstuffs). We show, first, that grammaticality judgments of a patient with semantic dementia are indistinguishable from those of a group of age-matched controls, and are similar regardless of the status of his semantic knowledge about the item. In a second experiment we use the triadic task in a group of age-matched controls to show that similarity judgments are influenced not only by meaning (natural vs. manmade), but also implicitly by syntactic information (count vs. mass). Using the same task in a patient with semantic dementia we show that the semantic influences on the syntactic dimension are unlikely to account for this pattern in normals. These data are discussed in relation to modular vs. nonmodular models of language processing, and in particular to the semantic-syntactic distinction.

Validation of a single screening question for problem drinking.

OBJECTIVE: The researchers hoped to confirm the sensitivity and specificity of a single screening question for problem drinking: "When was the last time you had more than X drinks in 1 day?", where X=4 for women and X=5 for men. STUDY DESIGN: Cross-sectional study. POPULATION: Adult patients presenting to 3 emergency departments in Boone County, Missouri, for care within 48 hours of an injury. OUTCOMES MEASURED: The answers to the question were coded as never, more than 12 months ago, 3 to 12 months ago, and within the past 3 months. Problematic drinking was defined as either hazardous drinking (identified by a 29-day retrospective interview) or a past-year alcohol use disorder (defined by questions from the Diagnostic Interview Schedule). RESULTS: There was a 70% participation rate. Of 2517 interviewed patients: 29% were hazardous drinkers; 20% had a past-year alcohol use disorder; and 35% had either or both. Considering "within the last 3 months" as positive, the sensitivity of the single question was 86%, and the specificity was 86%. In men (n=1432), sensitivity and specificity were 88% and 81%; in women, 83% and 91%. Using the 4 answer options for the question, the area under the receiver-operating characteristic curve was 0.90. Controlling for age, sex, tobacco use, injury severity, and breath alcohol level in logistic regression models changed the findings minimally. CONCLUSIONS: A single question about the last episode of heavy drinking has clinically useful sensitivity and specificity in detecting hazardous drinking and alcohol use disorders.

Diphenhydramine for the prevention of akathisia induced by prochlorperazine: a randomized, controlled trial.

STUDY OBJECTIVES: The utility of intravenous prochlorperazine as an antiemetic agent and abortive therapy for headache may be limited by the frequent occurrence of akathisia, the distressing effects of which have been shown to disrupt patient care. We tested the hypothesis that adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine. METHODS: This randomized, double-blind, placebo-controlled trial was conducted in the emergency department of an academic tertiary care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of 100 adult patients who received 10 mg of intravenous prochlorperazine for the treatment of nausea/vomiting or headache. Subjects were randomly assigned to receive a 2-minute infusion of prochlorperazine with either 50 mg of diphenhydramine or placebo. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. To measure the influence of treatment on sedation, the subjects noted, on a 100-mm visual analog scale, their degree of sedation before and after treatment. RESULTS: Akathisia developed in 18 (36%) of 50 subjects in the control group and in 7 (14%) of 50 subjects in the diphenhydramine group, a 61% relative reduction. The addition of adjunct diphenhydramine resulted in an absolute reduction of 22% in the incidence of akathisia (95% confidence interval [CI] 6% to 38%; P = .01). The odds ratio for akathisia with the use of adjuvant diphenhydramine was 0.39 (95% CI 0.18 to 0.85). Mean sedation scores increased 12 mm after infusion of prochlorperazine alone (95% CI 3 to 21 mm) compared with a 33-mm increase after infusion of prochlorperazine with adjuvant diphenhydramine (95% CI 24 to 42 mm). The 12-mm difference between the groups was statistically significant (95% CI 9 to 34 mm, P < .001). CONCLUSION: Adjuvant diphenhydramine reduces the incidence of akathisia induced by prochlorperazine and is associated with an increase in sedation.

Slow infusion for the prevention of akathisia induced by prochlorperazine: a randomized controlled trial.

The utility of intravenous prochlorperazine (PCZ) in the treatment of nausea, vomiting, and headache may be limited by the akathisia that occurs frequently with the recommended 2-min infusion rate. We tested the hypothesis that decreasing the rate of PCZ infusion to 15 min reduces the incidence of akathisia at 1 hour. This double-blinded, randomized, controlled trial was conducted in the Emergency Department of an academic tertiary-care medical center with an annual census of 95,000 emergency patient visits. We enrolled a convenience sample of adult patients who received 10 mg i.v. PCZ for the treatment of nausea, vomiting, or headache. Subjects were randomized to receive either a 2-min infusion of PCZ (10 mg) followed by a 15-min infusion of saline, or a 2-min infusion of saline followed by a 15-min infusion of prochlorperazine. The incidence of akathisia at 1 hour was measured by using explicit diagnostic criteria. One hundred sixty patients were randomly enrolled into two groups, which were comparable with respect to age, gender, weight, and complaint. Akathisia developed in 31 of 84 patients (36.9%) who received the 2-min infusion of PCZ and in 18 of 76 patients (23.7%) who received the 15-min infusion of PCZ (p = 0.07), a 36% (95% CI, -5% to 61%) relative reduction. The delta from pre-infusion to postinfusion scores between the two groups was not significant (p = 0.19). We conclude that slowing the rate of PCZ infusion does not decrease akathisia.

Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department.

STUDY OBJECTIVE: We evaluate the effectiveness and safety of an outpatient clinical care pathway for the initial treatment of acute proximal lower-extremity deep venous thrombosis (DVT) with low molecular weight heparin (LMWH) managed by the emergency department of 2 affiliated community hospitals. METHODS: This observational, retrospectively defined, population-based study with 39(1/2) months of preintervention analysis and 32(1/2) months of postintervention analysis was conducted in 2 suburban EDs of a large group model health maintenance organization. Our outpatient DVT clinical care pathway used careful patient selection and multidisciplinary follow-up. Ninety-six patients before the intervention and 178 patients after the intervention met eligibility criteria for the pathway. Adverse events during the first 2 weeks of treatment included symptomatic pulmonary embolism (PE), progressive DVT, minor and major bleeding, and death. RESULTS: Demographic and baseline clinical characteristics of the 2 groups were similar. Five (5.2%) of 96 preintervention subjects (95% confidence interval [CI] 2.4 to 8.1) developed adverse events compared with 5 (2.8%) of 178 postintervention subjects (95% CI 1.5 to 4.1; difference between groups 2.4%; P =.50). In each group, 1 (1.0% versus 0.6%) subject developed a PE, 2 (2.1% versus 1.1%) developed progressive symptoms of progressive DVT, and 2 (2.1% versus 1.1%) developed minor bleeding. Major bleeding occurred in 1 (1.0%) preintervention subject and no postintervention subjects. No patient in either cohort died. CONCLUSION: Managed by the ED, an outpatient DVT clinical care pathway using careful patient selection and an integrated multidisciplinary approach can provide a similar degree of effectiveness and safety as customary inpatient therapy.