Early Intubation and Increased Coronavirus Disease 2019 Mortality: A Propensity Score-Matched Retrospective Cohort Study.

OBJECTIVES: There has been controversy about the timing and indications for intubation and mechanical ventilation in novel coronavirus disease 2019. This study assessed the effect of early intubation and mechanical ventilation on all-cause, inhospital mortality for coronavirus disease 2019 patients. DESIGN: Multicenter retrospective cohort study. SETTING: Eleven municipal hospitals in New York City from March 1, 2020, to December 1, 2020. PATIENTS: Adult patients who tested positive for coronavirus disease 2019 in the emergency department were subsequently admitted. Patients with do-not-intubate orders at admission were excluded. INTERVENTIONS: Intubation within 48 hours of triage and intubation at any point during hospital stay. MEASUREMENTS AND MAIN RESULTS: Data from 7,597 coronavirus disease 2019 patients were included; of these, 1,628 (21%) were intubated overall and 807 (11%) were intubated within 48 hours of triage. After controlling for available confounders, intubation rates for coronavirus disease 2019 patients varied significantly across hospitals and decreased steadily as the pandemic progressed. After nearest neighbor propensity score matching, intubation within 48 hours of triage was associated with higher all-cause mortality (hazard ratio, 1.30 [1.15-1.48]; p < 0.0001), as was intubation at any time point (hazard ratio, 1.62 [1.45-1.80]; p < 0.0001). Among intubated patients, intubation within 48 hours of triage was not significantly associated with differences in mortality (hazard ratio, 1.09 [0.94-1.26]; p = 0.26). These results remained robust to multiple sensitivity analyses. CONCLUSIONS: Intubation within 48 hours of triage, as well as at any time point in the hospital course, was associated with increased mortality in coronavirus disease 2019 patients in this observational study.

Nicardipine: When high dose nitrates fail in treating heart failure.

Sympathetic Crashing Acute Pulmonary Edema (SCAPE) describes patients who present with acute hypertensive cardiogenic pulmonary edema. These patients present in respiratory distress, and requiring immediate medical and airway management. The treatment of SCAPE includes non-invasive positive pressure ventilation (NIPPV) to maintain oxygenation, and high dose nitrates to lower blood pressure and reduce afterload. We present a case report of a patient with refractory hypertension to high dose nitrates likely due to nitroglycerin resistance or an attenuated response. The addition of nicardipine led to marked clinical improvement, normalized blood pressure and spared the patient from endotracheal intubation and admission to the intensive care unit.

Emergency physicians in critical care: where are we now?

OBJECTIVE: Prior to 2011, emergency physicians who completed critical care (CC) fellowship were unable to obtain board certification in the United States. Three pathways for CC board certification have since been established. This study explores the training, practice, and perceived challenges of emergency medicine/critical care fellows and emergency medicine/critical care physicians in the United States. METHODS: Anonymous institutional review board-approved survey distributed via email through an online survey engine from April to December 2016. Participants were recruited through national organizations and independent interest groups. Emergency physicians who were in CC fellowship or had completed a CC fellowship and were in practice in the United States participated voluntarily. RESULTS: Of the 162 respondents, 152 were included (92 physicians, 60 fellows). Eighty-nine percent ranged from 31-50 years old. Among fellows, 90% desired a dual discipline practice. Among physicians, 63% split their time between the emergency department and ICU. Seventy-one percent of physicians reported working in academic institutions. Among physicians engaged in a dual practice, mean full-time equivalent (±SD) devoted to the ED was 0.37 (±0.22), mean full-time equivalent for ICU was 0.47 (±0.22), and mean full-time equivalent for protected academic time was 0.28 (±0.19). Emergency medicine/critical care fellows and emergency medicine/critical care physicians identified numerous challenges associated with duality. CONCLUSIONS: Since the advent of critical care board certification for emergency physicians in the United States, there has been an increasing number of emergency physicians pursuing CC fellowships and achieving CC board certification. Emergency medicine/critical care physicians are venturing into a variety of practice models, demonstrating that the employment landscape remains plastic. Not unexpectedly, emergency medicine/critical care fellows and emergency medicine/critical care physicians are encountering challenges intrinsic to their duality.

A multidisciplinary understanding of polarization.

This article aims to describe the last 10 years of the collaborative scientific endeavors on polarization in particular and collective problem-solving in general by our multidisciplinary research team. We describe the team's disciplinary composition-social psychology, political science, social philosophy/epistemology, and complex systems science-highlighting the shared and unique skill sets of our group members and how each discipline contributes to studying polarization and collective problem-solving. With an eye to the literature on team dynamics, we describe team logistics and processes that we believe make our multidisciplinary team persistent and productive. We emphasize challenges and difficulties caused by disciplinary differences in terms of terminology, units/levels of analysis, methodology, and theoretical assumptions. We then explain how work disambiguating the concepts of polarization and developing an integrative theoretical and methodological framework with complex systems perspectives has helped us overcome these challenges. We summarize the major findings that our research has produced over the past decade, and describe our current research and future directions. Last, we discuss lessons we have learned, including difficulties in a "three models" project and how we addressed them, with suggestions for effective multidisciplinary team research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE.

Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.

Scientific Networks on Data Landscapes: Question Difficulty, Epistemic Success, and Convergence.

A scientific community can be modeled as a collection of epistemic agents attempting to answer questions, in part by communicating about their hypotheses and results. We can treat the pathways of scientific communication as a network. When we do, it becomes clear that the interaction between the structure of the network and the nature of the question under investigation affects epistemic desiderata, including accuracy and speed to community consensus. Here we build on previous work, both our own and others', in order to get a firmer grasp on precisely which features of scientific communities interact with which features of scientific questions in order to influence epistemic outcomes. Here we introduce a measure on the landscape meant to capture some aspects of the difficulty of answering an empirical question. We then investigate both how different communication networks affect whether the community finds the best answer and the time it takes for the community to reach consensus on an answer. We measure these two epistemic desiderata on a continuum of networks sampled from the Watts-Strogatz spectrum. It turns out that finding the best answer and reaching consensus exhibit radically different patterns. The time it takes for a community to reach a consensus in these models roughly tracks mean path length in the network. Whether a scientific community finds the best answer, on the other hand, tracks neither mean path length nor clustering coefficient.

Polarization and Belief Dynamics in the Black and White Communities: An Agent-Based Network Model from the Data.

Public health care interventions-regarding vaccination, obesity, and HIV, for example-standardly take the form of information dissemination across a community. But information networks can vary importantly between different ethnic communities, as can levels of trust in information from different sources. We use data from the Greater Pittsburgh Random Household Health Survey to construct models of information networks for White and Black communities--models which reflect the degree of information contact between individuals, with degrees of trust in information from various sources correlated with positions in that social network. With simple assumptions regarding belief change and social reinforcement, we use those modeled networks to build dynamic agent-based models of how information can be expected to flow and how beliefs can be expected to change across each community. With contrasting information from governmental and religious sources, the results show importantly different dynamic patterns of belief polarization within the two communities.

What You Believe Travels Differently: Information and Infection Dynamics across Sub-networks.

In order to understand the transmission of a disease across a population we will have to understand not only the dynamics of contact infection but the transfer of health-care beliefs and resulting health-care behaviors across that population. This paper is a first step in that direction, focusing on the contrasting role of linkage or isolation between sub-networks in (a) contact infection and (b) belief transfer. Using both analytical tools and agent-based simulations we show that it is the structure of a network that is primary for predicting contact infection-whether the networks or sub-networks at issue are distributed ring networks or total networks (hubs, wheels, small world, random, or scale-free for example). Measured in terms of time to total infection, degree of linkage between sub-networks plays a minor role. The case of belief is importantly different. Using a simplified model of belief reinforcement, and measuring belief transfer in terms of time to community consensus, we show that degree of linkage between sub-networks plays a major role in social communication of beliefs. Here, in contrast to the case of contract infection, network type turns out to be of relatively minor importance. What you believe travels differently. In a final section we show that the pattern of belief transfer exhibits a classic power law regardless of the type of network involved.

Early complement activation increases in the brain in some aged normal subjects.

Complement activation is increased in Alzheimer's disease (AD) and may contribute to the development and progression of this disorder. To compare early complement activation between normal and AD brain specimens, C4d and iC3b concentrations were measured in hippocampus, entorhinal cortex, temporal cortex, parietal cortex, and cerebellum from aged normal and AD subjects n=10-14 for both), and in hippocampus and entorhinal cortex from younger normal subjects (n=5-6). C4d and iC3b levels increased 2.3- to 4.6-fold in AD versus aged normal specimens (all P <0.05), with lowest concentrations of these activation proteins generally in cerebellum. No significant differences were present between aged and younger normal C4d and iC3b levels in hippocampus or entorhinal cortex. However, the concentrations of these proteins were markedly increased in several aged normal specimens. Normal subject age was moderately associated with both C4d (r=0.49) and iC3b (r=0.53) concentrations in the hippocampus. Increased brain complement activation in some elderly individuals may promote the subsequent development of AD.