To examine the extent to which advanced meditative practices might alter body metabolism and the electroencephalogram (EEG), we investigated three Tibetan Buddhist monks living in the Rumtek monastery in Sikkim, India. In a study carried out in February 1988, we found that during the practice of several different meditative practices, resting metabolism (VO2) could be both raised (up to 61%) and lowered (down to 64%). The reduction from rest is the largest ever reported. On the EEG, marked asymmetry in alpha and beta activity between the hemispheres and increased beta activity were present. From these three case reports, we conclude that advanced meditative practices may yield different alterations in metabolism (there are also forms of meditation that increase metabolism) and that the decreases in metabolism can be striking.

IntroductionAntimicrobial prescribing in the emergency department is predominantly empiric, with final microbiology results either unavailable or reported after most patients are discharged home. Systematic follow-up processes are needed to ensure appropriate antimicrobial therapy at this transition of care. The objective of this study was to assess the impact of a culture follow-up (CFU) program on the frequency of emergency department (ED) revisits within 72 h and hospital admissions within 30 days compared to the historical standard of care (SOC). Additionally, infection characteristics and antimicrobial therapy were compared.MethodsA single group, pre-test post-test quasi-experimental study was conducted comparing a retrospective SOC group to a prospective CFU group. CFU was implemented using computerized decision-support software and a multidisciplinary team of pharmacists and emergency physician staff.ResultsOver the four-month intervention period the CFU group evaluated 197 cultures and modified antimicrobial therapy in 25.5%. The rate of combined ED revisits within 72 h and hospital admissions within 30 days was 16.9% in the SOC group and 10.2% in the CFU group (p = 0.079). When evaluating the uninsured population alone, revisits to the ED within 72 h were reduced from 15.3% in the SOC group to 2.4% in the CFU group (p = 0.044).ConclusionImplementation of a multidisciplinary CFU program was associated with a reduction in ED revisits within 72 h and hospital admissions within 30 days. One-fourth of patients required post-discharge intervention, representing a large need for antimicrobial stewardship expansion to ED practice models.Electronic supplementary materialThe online version of this article (doi:10.1007/s40121-014-0026-x) contains supplementary material, which is available to authorized users.

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Haemangiomas are relatively common in the head and neck region, but cases in the temporal bone are rare. Hemangioma of the external auditory canal (EAC) is a rare otologic entity. Up till now (till 2013), only 18 cases of hemangioma EAC have been reported in the English literature. It is commonly classified as capillary or cavernous hemangioma. According to the literature, this case represents the fourth patient with capillary hemangioma of the EAC. A 22-year-old male presented to our department with a 3 years history of right-sided aural fullness, mild pain and decreased hearing. There was no history of ear discharge, pulsatile tinnitus, vertigo and local trauma. Otomicroscopic and otoendoscopic examination revealed a smooth surface, reddish pulsatile mass arising from the right postero-superior portion of bony canal wall, which measured about 1 cm in diameter, obstructing 2/3rd of the EAC. The tympanic membrane was not seen. No facial nerve dysfunction was observed. Patient had moderate conductive hearing loss in right ear on audiology. HRCT temporal bone showed soft tissue mass involving the right EAC and middle ear. The lesion was excised via a postaural approach under general anesthesia. The tumor was a reddish, soft mass and measured 1.6 9 1.7 9 2.8 cm. The histopathologic assessment indicated a capillary hemangioma.

The alterations in serum levels of T3, T4, TSH and TBG, TSH response to 100 mug iv TRH, and urinary excretion of T3 and T4 were studied in 8 healthy men at sea level (SL), on days 1, 2, 4, 8 and 16 after arrival by air at high altitude (3,700 m, HA), and during days 5 to 7 after their return to SL. No significant alterations in serum levels of TSH and TBG or TSH response to TRH were observed during exposure to HA or on return to SL. There was, however, an acute elevation in both serum total T3 and T4. Serum total T3 from a mean basal+/-SE value of 128+/-13 ng/dl increased to 320+/-18 on day 1 and remained significantly elevated at 225+/-48 up to day 8 after arrival at high altitude. Similarly serum total T4 increased from basal level of 9+/-0.92 mug/dl to 15.2+/-1.2 and remained elevated till day 16 and it was 11+/-1.19 mug/dl during days 5 to 7 after return to SL. The urinary excretion of both T3 and T4 was decreased. These changes perhaps were the result of complex physiologic adjustments on acute exposure to high altitude, like shrinkage of the T3 and T4 distribution pools, altered binding capacities of thyroid hormones binding proteins, and a reduction in clearance of thyroid hormones from the plasma compartment; and were probably not suggestive of an enhanced thyroid activity. Their actual significance in high altitude adaptation in man is not clearly understood.

Background Outpatient parenteral antimicrobial therapy (OPAT) is a widely-used safe and cost-effective treatment strategies. Most public and private insurance providers require prior authorization (PA) for OPAT, yet impact of the inpatient PA process is not known. This study aimed to characterize discharge barriers and PA delays associated with high-priced OPAT antibiotics. Methods IRB-approved study of adult patients discharged with high-priced OPAT antibiotics from January to December 2017. Antibiotics included: daptomycin, ceftaroline, ertapenem, and the novel beta-lactam beta-lactam inhibitor combinations. Patients with an OPAT PA delay were compared to patients without. Primary endpoint: total direct hospital costs from the start of treatment. Secondary outcomes: discharge delay and 30-day readmission or mortality. Results Two-hundred patients included: 141 (71%) no OPAT delay vs 59 (30%) OPAT delay. More patients with a PA delay were discharged to a sub-acute care facility compared to an outpatient setting: 37 (63%) vs 52 (37%), p=0.001. Discharge delays and median total direct hospital costs were higher in patients with OPAT delays: 31 (53%) vs 21 (15%), p<0.001; and $19,576 vs (IQR 10,056-37,038) vs $7,770 (IQR 3,031-13,974), p<0.001. In a multiple variable regression, discharge to a sub-acute care facility was associated with an increased odds of discharge delay while age over 64 years was associated with a decreased odds of discharge delay. Conclusions OPAT with high-priced antibiotics requires significant care coordination. PA delays for these antibiotics are common and contribute to discharge delays. OPAT transitions of care represent an opportunity to improve patient are and address access barriers.

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