ED patients with LEP experienced both increased rates of diagnostic testing and of hospital admission. Research is needed to examine why these differences occurred and if they represent inefficiencies in care.

This cohort study analyzes the trends in filled naloxone prescriptions during the COVID-19 pandemic in the United States and compare these to opioid prescriptions and overall prescriptions.

As many as 1 in 10 patients experience dyspnea at hospital admission but the relationship between dyspnea and patient outcomes is unknown. We sought to determine whether dyspnea on admission predicts outcomes.We conducted a retrospective cohort study in a single, academic medical center. We analysed 67 362 consecutive hospital admissions with available data on dyspnea, pain, and outcomes. As part of the Initial Patient Assessment by nurses, patients rated “breathing discomfort” using a 0 to 10 scale, (10=“unbearable”). Patients reported dyspnea at the time of admission and recalled dyspnea experienced in the 24 h prior to admission. Outcomes included in-hospital mortality, 2-year mortality, length of stay, need for rapid response system activation, transfer to the intensive care unit, discharge to extended care, and 7- and 30-day all cause readmission to the same institution.Patients who reported any dyspnea were at an increased risk of death during that hospital stay; the greater the dyspnea, the greater the risk of death (dyspnea=0, 0.8% in-hospital mortality; dyspnea=1–3, 2.5% mortality; dyspnea ≥4, 3.7% mortality, p<0.001). After adjustment for patient comorbidities, demographics, and severity of illness, increasing dyspnea remained associated with inpatient mortality (dyspnea 1–3, aOR 2.1, 95% CI 1.7–2.6; dyspnea ≥4, aOR 3.1, 95% CI 2.4–3.9). Pain did not predict increased mortality. Patients reporting dyspnea also used more hospital resources, were more likely to be readmitted, and were at increased risk of death within 2 years (dyspnea=1–3 adjusted HR 1.5, 95% CI 1.3–1.6; dyspnea ≥4 adjusted HR 1.7, 95% CI 1.5–1.8).We found that dyspnea of any rating was associated with an increased risk of death. Dyspnea can be rapidly collected by nursing staff, which may allow for better monitoring or interventions that could reduce mortality and morbidity.

Dyspnea is a common symptom among all hospitalized patients. Routine documentation of dyspnea is feasible in a large tertiary care center.

BackgroundResearch has shown that tobacco smoke contains substances of microbiological origin such as ergosterol (a fungal membrane lipid) and lipopolysaccharide (LPS) (in the outer membrane of Gram-negative bacteria). The aim of the present study was to compare the amounts of ergosterol and LPS in the tobacco and mainstream (MS) and sidestream (SS) smoke of some popular US cigarettes.MethodsWe measured LPS 3-hydroxy fatty acids and fungal biomass biomarker ergosterol in the tobacco and smoke from cigarettes of 11 popular brands purchased in the US. University of Kentucky reference cigarettes were also included for comparison.ResultsThe cigarette tobacco of the different brands contained 6.88-16.17 (mean 10.64) pmol LPS and 8.27-21.00 (mean 14.05) ng ergosterol/mg. There was a direct correlation between the amounts of ergosterol and LPS in cigarette tobacco and in MS smoke collected using continuous suction; the MS smoke contained 3.65-8.23% (ergosterol) and 10.02-20.13% (LPS) of the amounts in the tobacco. Corresponding percentages were 0.30-0.82% (ergosterol) and 0.42-1.10% (LPS) for SS smoke collected without any ongoing suction, and 2.18% and 2.56% for MS smoke collected from eight two-second puffs.ConclusionsTobacco smoke is a bioaerosol likely to contain a wide range of potentially harmful bacterial and fungal components.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. While the primary risk factor for COPD is cigarette smoke exposure, vitamin D deficiency has been epidemiologically implicated as a factor in the progressive development of COPD-associated emphysema. Because of difficulties inherent to studies involving multiple risk factors in the progression of COPD in humans, we developed a murine model in which to study the separate and combined effects of vitamin D deficiency and cigarette smoke exposure. During a 16-week period, mice were exposed to one of four conditions, control diet breathing room air (CD-NS), control diet with cigarette smoke exposure (CD-CSE), vitamin D deficient diet breathing room air (VDD-NS) or vitamin D deficient diet with cigarette smoke exposure (VDD-CSE). At the end of the exposure period, the lungs were examined by a pathologist and separately by morphometric analysis. In parallel experiments, mice were anesthetized for pulmonary function testing followed by sacrifice and analysis. Emphysema (determined by an increase in alveolar mean linear intercept length) was more severe in the VDD-CSE mice compared to control animals and animals exposed to VDD or CSE alone. The VDD-CSE and the CD-CSE mice had increased total lung capacity and increased static lung compliance. There was also a significant increase in the matrix metalloproteinase-9: tissue inhibitor of metalloproteinases-1 (TIMP-1) ratio in VDD-CSE mice compared with all controls. Alpha-1 antitrypsin (A1AT) expression was reduced in VDD-CSE mice as well. In summary, vitamin D deficiency, when combined with cigarette smoke exposure, seemed to accelerate the appearance of emphysemas, perhaps by virtue of an increased protease-antiprotease ratio in the combined VDD-CSE animals. These results support the value of our mouse model in the study of COPD.

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IMPORTANCE Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care.OBJECTIVE To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines.