Plos One
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Observational Study
Determining factors for the increase in self-referrals to the Emergency Department of a rural hospital in Huelva (Spain).
To analyse the increase of self-referral patients at the Emergency Department of Riotinto District Hospital (in Huelva, Spain) during a short period. The study focused on patients' profiles to identify key factors that explained the increase of self-referrals. ⋯ Changes in the health system and in the time for patients to get to the reference hospital from their origin, affect the likelihood of self-referral to the emergency department. Once the patient's severity level was included, this variable, along with the time to get to the emergency department, modified the probability of self-referral to the emergency department. We found an increase in hospital services together with a reduction of resources in the primary care emergency system. This may have led to inefficiencies in the public health system, together with an increase in self-referrals and greater problems to service users.
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Different outcomes among patients hospitalized for bleeding after starting anticoagulation could influence choice of anticoagulant. We compared length of hospitalization, proportion of Intensive Care Unit (ICU) admissions, ICU length of stay, and 30- and 90-day mortality for adults with atrial fibrillation hospitalized for bleeding after starting warfarin, dabigatran, or rivaroxaban. ⋯ Rivaroxaban and dabigatran were associated with shorter hospitalizations; however, there were no differences in 30- and 90-day mortality. These findings suggest bleeding associated with the newer agents is not more dangerous than bleeding associated with warfarin.
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Observational Study
Immunoadsorption to remove ß2 adrenergic receptor antibodies in Chronic Fatigue Syndrome CFS/ME.
Infection-triggered disease onset, chronic immune activation and autonomic dysregulation in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) point to an autoimmune disease directed against neurotransmitter receptors. We had observed elevated autoantibodies against ß2 adrenergic receptors, and muscarinic 3 and 4 acetylcholine receptors in a subset of patients. Immunoadsorption (IA) was shown to be effective in removing autoantibodies and improve outcome in various autoimmune diseases. ⋯ IA can remove autoantibodies against ß2 adrenergic receptor and lead to clinical improvement. B cell phenotyping provides evidence for an effect of IA on memory B cell development. Data from our pilot trial warrants further studies in CFS/ME.
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Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation. On high-resolution manometry (HRM), impaired LES relaxation is defined by elevated integrated relaxation pressure (IRP). However, a new category of achalasia within the normal IRP range has been suggested. ⋯ The clinical presentation of achalasia has a gap between a HRM-defined impaired LES relaxation, with aging or disease progression considered reasons for a lowered LES pressure. POEM can be a feasible treatment option, even for cases of achalasia with a normal IRP. However, patients with severe LES fibrosis need more attention for the therapeutic indication.
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Upon admission to an intensive care unit (ICU), all patients should discuss their goals of care and express their wishes concerning life-sustaining interventions (e.g., cardiopulmonary resuscitation (CPR)). Without such discussions, interventions that prolong life at the cost of decreasing its quality may be used without appropriate guidance from patients. ⋯ Wikis and user-centered design can be used to adapt decision aids to users' needs and local contexts. Our wiki platform allows other centers to adapt our tools, reducing duplication and accelerating scale-up. Physicians need training in shared decision making skills about goals of care and in using the decision aid. A video version of the decision aid could clarify its purpose.