Evaluating the 0–10 Point Pain Scale on Adolescent Opioid Use in US Emergency Departments

Objective: To evaluate trends in national emergency department (ED) adolescent opioid use in relation to reported pain scores. Methods: A retrospective, cross-sectional analysis on National Hospital Ambulatory Medical Care Survey (NHAMCS) data was conducted on ED visits involving patients aged 11–21 from 2008–2017. Crude observational counts were extrapolated to weighted estimates matching total population counts. Multivariate models were used to evaluate the role of a pain score in the reported use of opioids. Anchors for pain scores were 0 (no pain) and 10 (worst pain imaginable). Results: 31,355 observations were captured, which were extrapolated by the NHAMCS to represent 162,515,943 visits nationwide. Overall, patients with a score of 10 were 1.35 times more likely to receive an opioid than patients scoring a 9, 41.7% (CI95 39.7–43.8%) and 31.0% (CI95 28.8–33.3%), respectively. Opioid use was significantly different between traditional pain score cutoffs of mild (1–3) and moderate pain (4–6), where scores of 4 were 1.76 times more likely to receive an opioid than scores of 3, 15.5% (CI95 13.7–17.3%) and 8.8% (CI95 7.1–10.6%), respectively. Scores of 7 were 1.33 times more likely to receive opioids than scores of 6, 24.7% (CI95 23.0–26.3%) and 18.5% (CI95 16.9–20.0%), respectively. Fractures had the highest likelihood of receiving an opioid, as 49.2% of adolescents with a fracture received an opioid (CI95 46.4–51.9%). Within this subgroup, only adolescents reporting a fracture pain score of 10 had significantly higher opioid use than adjacent pain scores, where fracture patients scoring a 10 were 1.4 times more likely to use opioids than those scoring 9, 82.2% (CI95 76.1–88.4%) and 59.8% (CI95 49.0–70.5%), respectively. Conclusions: While some guidelines in the adult population have revised cut-offs and groupings of the traditional tiers on a 0–10 point pain scale, the adolescent population may also require further examination to potentially warrant a similar adjustment.

Smoking Cessation Behaviors and Reasons for use of Electronic Cigarettes (EC) and Heated Tobacco Products (HTP) Among Romanian Adults: Implications for Comprehensive Tobacco Control Policy

We report cessation behaviors, reasons for use of EC and HTP and association of their use with quit attempts and smoking intensity using Romania Global Adult Tobacco Survey 2018. Weighted estimates of EC and HTP by cigarette smoking (CS) status were assessed. ‘Quit attempts’, ‘intention to quit’, reasons for lack of intention to quit among current CS and reasons for current use of EC and HTP were estimated. Association of ‘ever use’ of EC and HTP with cigarette smoking intensity and quit attempts was explored using binary logistic regression. Of the total 4571 surveyed, 1243 (27.3%) were current CS, 300 (24.4%) made quit attempt in the past 12 months. Only 38 (12.5%) and 26 (8.6%) had used EC and HTP as an aid to quit. Among current CS, 512 (41.2%) had no intention to quit. Reasons for this were, ‘enjoy smoking’ (86.1%), ‘reduce stress’ (65.9%) and ‘staying alert’ (46.3%). Awareness and use of EC and HTP was significantly higher among current CS. ‘Dual use’ of EC and HTP with CS was manifolds higher than stand-alone use. Reasons for current use of EC and HTP were ‘enjoyment’, and ‘use in places where smoking was prohibited’.

Heat Kernels Estimates for Hermitian Line Bundles on Manifolds of Bounded Geometry

We consider a family of semiclassically scaled second-order elliptic differential operators on high tensor powers of a Hermitian line bundle (possibly, twisted by an auxiliary Hermitian vector bundle of arbitrary rank) on a Riemannian manifold of bounded geometry. We establish an off-diagonal Gaussian upper bound for the associated heat kernel. The proof is based on some tools from the theory of operator semigroups in a Hilbert space, results on Sobolev spaces adapted to the current setting, and weighted estimates with appropriate exponential weights.

Early Coronary Angiography Is Associated with Improved 30-Day Outcomes among Patients with out-of-Hospital Cardiac Arrest

We evaluated the association between early coronary angiography (CAG) and outcomes in resuscitated out-of-hospital cardiac arrest (OHCA) patients, by linking data from the Singapore Pan-Asian Resuscitation Outcomes Study, with a national registry of cardiac procedures. The 30-day survival and neurological outcome were compared between patients undergoing early CAG (within 1-calender day), versus patients not undergoing early CAG. Inverse probability weighted estimates (IPWE) adjusted for non-randomized CAG. Of 976 resuscitated OHCA patients of cardiac etiology between 2011–2015 (mean(SD) age 64(13) years, 73.7% males), 337 (34.5%) underwent early CAG, of whom, 230 (68.2%) underwent PCI. Those who underwent early CAG were significantly younger (60(12) vs. 66(14) years old), healthier (42% vs. 59% with heart disease; 29% vs. 44% with diabetes), more likely males (86% vs. 67%), and presented with shockable rhythms (69% vs. 36%), compared with those who did not. Early CAG with PCI was associated with better survival and neurological outcome (adjusted odds ratio 1.91 and 1.82 respectively), findings robust to IPWE adjustment. The rates of bleeding and stroke were similar. CAG with PCI within 24 h was associated with improved clinical outcomes after OHCA, without increasing complications. Further studies are required to identify the characteristics of patients who would benefit most from this invasive strategy.

Women, Younger Clinicians’, and Caregivers’ Experiences of Burnout and Well-being During COVID-19 in a US Healthcare System

Background The COVID-19 pandemic brought rapid changes to the work and personal lives of clinicians. Objective To assess clinician burnout and well-being during the COVID-19 pandemic and guide healthcare system improvement efforts. Design A survey asking about clinician burnout, well-being, and work experiences. Participants Surveys distributed to 8141 clinicians from June to August 2020 in 9 medical groups and 17 hospitals at Sutter Health, a large healthcare system in Northern California. Main Measures Burnout was the primary outcome, and other indicators of well-being and work experience were also measured. Descriptive statistics and multivariate logistic regression analyses were performed. All statistical inferences were based on weighted estimates adjusting for response bias. Key Results A total of 3176 clinicians (39.0%) responded to the survey. Weighted results showed 29.2% reported burnout, and burnout was more common among women than among men (39.0% vs. 22.7%, p<0.01). In multivariate models, being a woman was associated with increased odds of reporting burnout (OR=2.19, 95% CI: 1.51–3.17) and being 55+ years old with lower odds (OR=0.54, 95% CI: 0.34–0.87). More women than men reported that childcare/caregiving was impacting work (32.9% vs. 19.0%, p<0.01). Even after controlling for age and gender, clinicians who reported childcare/caregiving responsibilities impacted their work had substantially higher odds of reporting burnout (OR=2.19, 95% CI: 1.54–3.11). Other factors associated with higher burnout included worrying about safety at work, being given additional work tasks, concern about losing one’s job, and working in emergency medicine or radiology. Protective factors included believing one’s concerns will be acted upon and feeling highly valued. Conclusions This large survey found the pandemic disproportionally impacted women, younger clinicians, and those whose caregiving responsibilities impacted their work. These results highlight the need for a holistic and targeted strategy for improving clinician well-being that addresses the needs of women, younger clinicians, and those with caregiving responsibilities.

HIV Prevalence in Migrant Groups Based on Country of Origin: A Systematic Review on Data Obtained between 1993 and 2020

The prevalence of internationally displaced people has been rising steadily within the last decade, creating enormous groups of migrants vulnerable to communicable diseases. This study aims to investigate HIV prevalence in migrant groups based on country of origin and present these results as weighted estimates on HIV prevalence based on geographical origin. Furthermore, HIV prevalence by country of origin is compared to WHO estimated prevalence in these countries. A systematic literature search has been conducted, and risk of bias in the included studies has been assessed. A ratio termed the Migration/Origin ratio, expressing weighted estimates on HIV prevalence among migrants by country of origin compared to the WHO estimated HIV prevalence in the country of origin, was constructed to compare the yields of this study to WHO prevalence estimates. Based on the search strategies covering the years 1990 to February 2021, 2295 articles were identified. The articles were screened by title and/or abstract, and retrieved articles were screened by full manuscript, leading to a final inclusion of 49 studies. HIV prevalence among migrants originating from the Middle East was 0.11%, Southeast Asia 1.50%, Eastern Europe 0.44%, Latin America 0.74%, North-, East-, West-, Central- and Southern Africa 1.90%, 3.69%, 2.60%, 3.75% and 3.92%, respectively. The overall Migration/Origin ratio was 2.1. HIV prevalence among migrants originating from countries with a high HIV prevalence was generally higher than among the autochthonous population. Several HIV prevalence estimates among migrants according to country of origin varied from WHO estimates.

Weighted Estimates for Iterated Commutators of Riesz Potential on Homogeneous Groups

In this paper, we study the two weight commutators theorem of Riesz potential on an arbitrary homogeneous group H of dimension N. Moreover, in accordance with the results in the Euclidean space, we acquire the quantitative weighted bound on homogeneous group.