San Francisco Medical Society

Estimating mortality risk in incarcerated adults is important for identifying individuals who may benefit from palliative care and compassionate release referrals. To develop and internally validate a 2-year mortality prediction model in incarcerated adults. Cohort study (February 1, 2018-February 1, 2020). Incarcerated adults aged ≥ 18years residing at a California Department of Corrections and Rehabilitation (CDCR) prison for ≥ 1year. Model predictors included demographics (e.g., age, sex), housing status (general housing vs. higher acuity infirmary bed vs. lower acuity infirmary bed), functional assessment (level of mobility restriction), healthcare utilization (e.g., hospitalizations and intensive care unit admissions in the previous year), and chronic conditions. The primary outcome was natural death at 2years, defined as death due to causes other than suicide, homicide, accidental injury, or drug overdose. Cox proportional hazards regression with LASSO for variable selection was used to develop the model. Model performance was assessed by discrimination (area under the receiver operating characteristic curve (AUC) at 2years) and calibration (plots of predicted and observed mortality). Classification metrics were assessed at clinically relevant thresholds. The final cohort included 89,430 adults (median age 40years (interquartile range = 20), 10.2% ≥ 60years, 30.6% Black, 41.4% Hispanic). At 2years, 506 (0.6%) individuals experienced a natural death. The optimism-corrected AUC at 2years after bootstrap internal validation was 0.926 (95% confidence interval (CI) = 0.915-0.938). The calibration plot at 2years suggested good calibration. At a 2-year mortality risk threshold of 5%, sensitivity, specificity, and positive predictive value were 47.6% (95% CI = 42.3-51.6%), 98.4% (95% CI = 98.2-98.4%), and 16.7% (95% CI = 14.3-18.5%), respectively. The mortality risk estimates from this model can help clinicians identify individuals who may most benefit from advance care planning discussions, palliative care services, and compassionate release referrals.

The environmental impact of holding in-person academic conferences and continuing medical education (CME) programs can be significant. In-person conferences provide a unique social and professional platform to engage in networking and foster professional development; however, there is an opportunity for hybrid and virtual platforms to provide CME for broader audiences looking to improve their clinical skills and strengthen their knowledge base. This study seeks to describe the reduction in carbon emissions associated with a webinar hosted by an online dermatology-focused medical education platform. This cross-sectional study used the location of deidentified virtual attendees of a webinar to predict the carbon emissions produced if attendees had instead traveled to the location of the most recent Integrative Dermatology Symposium (Sacramento, CA). Following collection of each virtual attendee's location, the mode of transportation was predicted on the basis of each participant's distance to the conference. The estimated carbon emissions were calculated for 576 participants. The total estimated, unadjusted carbon emissions for both attendees predicted to fly or drive was 370,100kg CO2. The emissions produced per participant from those expected to fly to an in-person CME after adjusting for all additional passengers on every flight were 4.5kg CO2. The emissions produced per participant from those expected to drive were 42.7kg CO2. The use of a virtual CME webinar led to a significant reduction in travel-related carbon dioxide emissions when compared to running the same program in-person event. When accounting for all passengers traveling via plane on any flight, driving to an event produced more emissions per participant than flying.

Non-steroidal anti-inflammatory drugs (NSAIDs) can cause kidney injury, especially in older adults. However, previously reported associations between NSAID use and kidney health outcomes are inconsistent and limited by reliance on serum creatinine-based GFR estimates. This analysis investigated the association of NSAID use with kidney damage in older adults using multiple kidney health measures. Cross-sectional and longitudinal analyses. Multicenter, community-based cohort. Two thousand nine hundred and ninty nine older adults in the Health ABC Study. A subcohort (n = 500) was randomly selected for additional biomarker measurements. Prescription and over-the-counter NSAID use ascertained by self-report. Baseline estimated glomerular filtration rate (eGFR) by cystatin C (cysC), urine albumin-to-creatinine ratio (ACR), kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18) were measured in 2,999 participants; alpha-1 microglobulin (α1m), neutrophil gelatinase-associated lipocalin (NGAL), propeptide type III procollagen (PIIINP), and uromodulin (UMOD) were measured in 500 participants. GFR was estimated three times over 10 years and expressed as percent change per year. Participants had a mean age of 74 years, 51% were female, and 41% African-American. No eGFR differences were detected between NSAID users (n = 655) and non-users (n = 2,344) at baseline (72 ml/min/1.73 m2 in both groups). Compared to non-users, NSAID users had lower adjusted odds of having ACR greater than 30 mg/g (0.67; 95% confidence interval (CI) = 0.51-0.89) and lower mean urine IL-18 concentration at baseline (-11%; 95% CI = -4% to -18%), but similar mean KIM-1 (5%; 95% CI = -5% to 14%). No significant differences in baseline concentrations of the remaining urine biomarkers were detected. NSAID users and non-users did not differ significantly in the rate of eGFR decline (-2.2% vs -2.3% per year). Self-reported NSAID use was not associated with kidney dysfunction or injury based on multiple measures, raising the possibility of NSAID use without kidney harm in ambulatory older adults. More research is needed to define safe patterns of NSAID consumption.

" Pursuit of Ecstasy: The MDMA Experience ." Journal of Psychoactive Drugs, 26(3), pp. 299–300

Most of the literature on massive transfusion concerns whole blood replacement, whereas clinically, packed red blood cells are commonly given. To determine when hemostatic abnormalities occur in patients resuscitated primarily with packed red blood cells and crystalloid, the cases of 39 consecutive patients who were transfused with 10 or more red blood cell units of any kind within 24 hours were reviewed. After transfusion with 20 or more units of red blood cell products of any kind (packed red blood cells, cell-saver units, or whole blood), 75% (3 of 4) of patients had platelet counts less than 50 x 10(9)/L, compared to 0 of 29 patients given less than 20 units (P less than 0.001). After transfusion of 12 units of relatively plasma-free red blood cell products (packed red blood cells or cell-saver units), 100% (8 of 8) of patients had prothrombin time prolonged by more than 1.5 times mid-range of normal, compared to 36% (5 of 14) of patients given less than 12 units (P = 0.012). These data confirm that patients massively transfused with red blood cells of any kind develop significant thrombocytopenia after 20 units. Importantly, probably clinically significant prothrombin time and partial thromboplastin time prolongations occurred consistently after transfusion of 12 units of relatively plasma-free red blood cells in unselected patients at an urban trauma hospital. These data suggest that coagulation factor replacement is necessary in patients who receive 12 or more units of packed red blood cells or cell-saver blood, and platelet replacement is necessary in patients who receive 20 or more units of any red blood cell product. A prospective study is needed to determine whether the expected abnormal clinical bleeding indeed occurs in patients with such laboratory coagulation abnormalities and to determine when plasma transfusion is indicated in patients massively transfused with red blood cells.

Medical Journal of AustraliaVolume 147, Issue 3 p. 156-157 Letter to the Editor The looming storm J.D. Hiekey FFARCS, J.D. Hiekey FFARCS The Medical Protection Society, 50 Hutt Street, Adelaide, SA, 5000Search for more papers by this author J.D. Hiekey FFARCS, J.D. Hiekey FFARCS The Medical Protection Society, 50 Hutt Street, Adelaide, SA, 5000Search for more papers by this author First published: 01 August 1987 https://doi.org/10.5694/j.1326-5377.1987.tb133337.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume147, Issue3August 1987Pages 156-157 RelatedInformation