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Background Droperidol is a first-generation antipsychotic medication that has been used for various indications in the emergency department (ED); however, its use has been controversial due to reports of QT prolongation and the risk of torsades de pointes (TdP). The aim of the study is to evaluate the safety of droperidol administration in the ED. Methods This was a retrospective study, conducted at an academic level I trauma center. System-generated reports were used to identify all droperidol administrations in the ED from the time that droperidol was reintroduced to the institutional formulary on July 1, 2019 through January 31, 2023. The major safety endpoint was a composite of the incidence of QTc interval prolongation, incidence of TdP, ventricular arrhythmia, or hypotension. Results A total of 327 administrations of droperidol were identified in 245 patients in the ED. The composite safety endpoint occurred in 30 (9.1%) administrations. None of these events were classified as “probable” or “definite” on the Naranjo adverse drug reaction probability scale. No episodes of TdP or serious ventricular arrhythmia were reported. Higher cumulative droperidol dose and creatinine clearance < 60 mL/min were associated with an increased odds of developing QTc prolongation (OR 1.27 [CI 1.04–1.56]) and (OR 1.01 [CI 1.0-1.02]), respectively. Conclusions The study supports the use of low dose droperidol for various indications in the ED. There were no serious adverse events reported that could be directly attributed to droperidol use; however, it is crucial to consider the potential dose dependent impact on QTc prolongation.

Objective:To evaluate the prevalence, risk factors, and clinical impact of delays in second doses of antibiotics in patients with sepsis.Design:Single-center, retrospective, observational study.Setting:Large teaching hospital.Patients:Adult patients who triggered an electronic sepsis alert in the emergency department (ED), received ≥2 doses of vancomycin or an antipseudomonal beta-lactam, and were discharged with an ICD-10 sepsis code.Methods:We assessed the prevalence of delays in second doses of antibiotics by ≥25% of the recommended dose interval and conducted multivariate regression analyses to assess for risk factors for delays and in-hospital mortality.Results:The cohort included 449 patients, of whom 123 (27.4%) had delays in second doses. In-hospital death occurred in 31 patients (25.2%) in the delayed group and 71 (21.8%) in the non-delayed group (p = 0.44). On multivariate analysis, only location in a non-ED unit at the time second doses were due was associated with delays (OR 2.75, 95% CI 1.20–6.32). In the mortality model, significant risk factors included malignant tumor, respiratory infection, and elevated Sequential Organ Failure Assessment (SOFA) score but not delayed second antibiotic doses (OR 1.19, 95% CI 0.69–2.05). In a subgroup analysis, delayed second doses were associated with higher mortality in patients admitted to non-intensive care units (ICUs) (OR 4.10, 95% CI 1.32–12.79).Conclusions:Over a quarter of patients with sepsis experienced delays in second doses of antibiotics. Delays in second antibiotic doses were not associated with higher mortality overall, but an association was observed among patients admitted to non-ICUs.

Background Intravenous (IV) insulin is commonly used for the management of hyperglycemia in critically ill patients. However, an assessment of real-world practices for the transition process from IV to Subcutaneous (SC) is lacking. Objective The objective of this study was to describe the real-world practice during insulin transition from IV to SC in intensive care unit (ICU) patients. Setting ICUs at a tertiary medical center. Methods This was a retrospective cohort study. Data were obtained from electronic medical records for all ICU patients for whom insulin infusions were ordered between Nov 2017–2018. Adult ICU patients were included if they were transitioned to a SC insulin regimen after spending at least 6 h on IV insulin infusion. Data collected include blood glucose readings, transition percentage, and the type of insulin regimen used after transition. Main outcome measure Assessment of the transition percentage and dysglycemic events during the insulin transition process from IV to SC. Results Two hundred patients with 4702 blood glucose checks were included. Of the included patients, 65% (130/200) were transitioned to a basal insulin-containing regimen. The median transition percentage in those patients was 45% [IQR: 28 – 69]. In the overall cohort, the number of patients who developed moderate and severe hypoglycemia was significantly higher prior to transition, while hyperglycemia was significantly higher after insulin transition. Conclusion We observed that patients were converted to SC therapy using a lower transition percentage than previously described. More data are needed to optimize the transition process in critically ill patients.

Neuroinflammatory diseases, such as multiple sclerosis, are characterized by invasion of the brain by autoreactive T cells. The mechanism for how T cells acquire their encephalitogenic phenotype and trigger disease remains, however, unclear. The existence of lymphatic vessels in the meninges indicates a relevant link between the CNS and peripheral immune system, perhaps affecting autoimmunity. Here we demonstrate that meningeal lymphatics fulfill two critical criteria: they assist in the drainage of cerebrospinal fluid components and enable immune cells to enter draining lymph nodes in a CCR7-dependent manner. Unlike other tissues, meningeal lymphatic endothelial cells do not undergo expansion during inflammation, and they express a unique transcriptional signature. Notably, the ablation of meningeal lymphatics diminishes pathology and reduces the inflammatory response of brain-reactive T cells during an animal model of multiple sclerosis. Our findings demonstrate that meningeal lymphatics govern inflammatory processes and immune surveillance of the CNS and pose a valuable target for therapeutic intervention.

Welfare measures from travel cost models net out variable costs such as travel expenses specific to each trip. Costs that are fixed in the short run, such as expenses for equipment that is used over multiple trips, are typically ignored and implicitly netted out. The resulting net value of recreation trips, or consumer surplus, is appropriate for long-run analysis when consumers can fully adjust their expenditures. However, in cases where some costs are difficult to adjust in the short run, such as when boat owners do not sell their boats in response to the transient effects of an oil spill, traditional consumer surplus measures underestimate the total welfare change. We explain this underestimation and show how to correct for it by adjusting traditional consumer surplus estimates upward. We illustrate our procedure using a model of recreational boating developed to assess damages from the Deepwater Horizon oil spill. In that case, accounting for boating fixed costs resulted in a 50% increase in estimated value relative to estimates of consumer surplus alone.