Nasogastric tube in mechanical ventilated patients: ETCO2 and pH measuring to confirm correct placement. A pilot study

Introduction

Nasogastric tube (NGT) placement is a procedure commonly performed in mechanically ventilated (MV) patients. Chest X-Ray is the diagnostic gold-standard to confirm its correct placement, with the downsides of requiring MV patients’ mobilization and of intrinsic actinic risk. Other potential methods to confirm NGT placement have shown lower accuracy compared to chest X-ray; end-tidal CO₂ (ETCO₂) and pH analysis have already been singularly investigated as an alternative to the gold standard. Aim of this study was to determine threshold values in ETCO₂ and pH measurement at which correct NGT positioning can be confirmed with the highest accuracy.

Materials & methods

This was a prospective, multicenter, observational trial; a continuous cohort of eligible patients was allocated with site into two arms. Patients underwent general anesthesia, orotracheal intubation and MV; in the first and second group we respectively assessed the difference between tracheal and esophageal ETCO₂ and between esophageal and gastric pH values.

Results

From November 2020 to March 2021, 85 consecutive patients were enrolled: 40 in the ETCO₂group and 45 in the pH group. The ETCO₂ ROC analysis for predicting NGT tracheal misplacement demonstrated an optimal ETCO₂ cutoff value of 25.5 mmHg, with both sensitivity and specificity reaching 1.0 (AUC 1.0, p < 0.001). The pH ROC analysis for predicting NGT correct gastric placement resulted in an optimal pH cutoff value of 4.25, with mild diagnostic accuracy (AUC 0.79, p < 0.001).

Discussion

In patients receiving MV, ETCO₂ and pH measurements respectively identified incorrect and correct NGT placement, allowing the identification of threshold values potentially able to improve correct NGT positioning.

Trial registration

NCT03934515 (www.clinicaltrials.gov).

New(spaper) evidence of a reduction in suicide mentions during the 19th century US gold rush

I analyze the relationship between state-level economic shocks and suicides using gold mined in the United States (US) between 1840 and 1860 as a large unexpected economic shock. Mined gold was an unexpected and large economic shock of up to 3.5% of GDP. This provides as good as random variation to the local economy that I use to estimate the effect of economic changes on suicides. Comprehensive mortality data by state and year does not exist for the US for 1840-1860. Thus, I use web-scraped data from a newspaper archive and use suicide mentions per 100,000 pages to proxy for suicides. Overall, results show that mined gold is linked with an apparent reduction in newspaper suicide mentions in line with previous research.

How did the 2008-11 financial crisis affect work-related common mental distress? Evidence from 393 workplaces in Great Britain

This paper analyses how the 2008-11 financial crisis relates to work-related common mental distress of those with continuous employment during the crisis. The literature connecting the 2008-11 financial crisis to common mental distress (anti-depressant drug use, suicide, etc.) generally estimates a negative effect. We used a sample of 393 workplaces from the 2011 Work and Employment Relations Study (WERS) for which employers and worker representatives agreed on that the crisis affected the workplace. WERS then provides detailed questions about how the financial crisis affected the workplace. We use these questions to show which crisis-induced work-changes are important for work-related common mental distress. In the British-context, increased workload and changes in nonfinancial benefits of work are most relevant worsening work-related common mental distress by 1.8 and 0.9 on a scale from 0-30 respectively.

Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England

OBJECTIVE

To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI).

DESIGN, SETTING, PARTICIPANTS

Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database.

OUTCOMES AND ANALYSIS

Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC).

RESULTS

Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews.

CONCLUSIONS

Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.

The impact of the UK National Minimum Wage on mental health

Despite an emerging literature, there is still sparse and mixed evidence on the wider societal benefits of Minimum Wage policies, including their effects on mental health. Furthermore, causal evidence on the relationship between earnings and mental health is limited. We focus on low-wage earners, who are at higher risk of psychological distress, and exploit the quasi-experiment provided by the introduction of the UK National Minimum Wage (NMW) to identify the causal impact of wage increases on mental health. We employ difference-in-differences models and find that the introduction of the UK NMW had no effect on mental health. Our estimates do not appear to support earlier findings which indicate that minimum wages affect mental health of low-wage earners. A series of robustness checks accounting for measurement error, as well as treatment and control group composition, confirm our main results. Overall, our findings suggest that policies aimed at improving the mental health of low-wage earners should either consider the non-wage characteristics of employment or potentially larger wage increases.

Catastrophic healthcare expenditure - drivers and protection: the Portuguese case

The objective of this paper is to assess the extent of catastrophic healthcare expenditure, which can lead to impoverishment, even in a country with a National Health Service, such as Portugal. The level of catastrophic healthcare expenditure will be identified before the determinants of these catastrophic payments are analyzed. Afterwards, the effects of existing exemptions to copayments in health care use will be tested and the relationship between catastrophe and impoverishment will be discussed. Catastrophe is calculated from the Portuguese Household Budget Surveys of 2000 and 2005, and then analyzed using logistic regression models. The results show that catastrophe due to healthcare out-of-pocket payments are a sizeable issue in Portugal. Exemptions from out-of-pocket expenses for medical care should be created to prevent vulnerable groups from facing catastrophic healthcare spending. These vulnerable groups include children, people with disabilities and individuals suffering from chronic conditions. Disability proxies offer straightforward policy options for an exemption for the elderly with recognized disabilities. An exemption of retired people with disabilities is therefore recommended to policymakers as it targets a vulnerable group with high risk of facing catastrophic healthcare expenditure.