Sex position – I Videos Gratis http://ivideosgratis.org/ Fri, 08 Oct 2021 13:12:02 +0000 en-US hourly 1 https://wordpress.org/?v=5.8 https://ivideosgratis.org/wp-content/uploads/2021/09/icon-3-150x150.png Sex position – I Videos Gratis http://ivideosgratis.org/ 32 32 Majority leader refuses to state position on LGBTQ + bill https://ivideosgratis.org/majority-leader-refuses-to-state-position-on-lgbtq-bill/ https://ivideosgratis.org/majority-leader-refuses-to-state-position-on-lgbtq-bill/#respond Thu, 07 Oct 2021 18:24:43 +0000 https://ivideosgratis.org/majority-leader-refuses-to-state-position-on-lgbtq-bill/ Majority Leader in Parliament, Osei Kyei Mensah Bonsu • Majority leader says statement on LGBTQ + bill that has yet to be considered is damaging • The deputy for Suame maintains that his statement will be interpreted as the position of the House • A bill criminalizing LGBTQ + activities is currently before parliament The […]]]>

Majority Leader in Parliament, Osei Kyei Mensah Bonsu

• Majority leader says statement on LGBTQ + bill that has yet to be considered is damaging

• The deputy for Suame maintains that his statement will be interpreted as the position of the House

• A bill criminalizing LGBTQ + activities is currently before parliament

The Ghanaian majority leader in Parliament, Simon Osei Kyei-Mensah-Bonsu has refused to take a position on the LGBTQ + bill pending before the House.

When Ghana’s parliament meets on October 26, 2021, one of the first things it will consider in its activities is a bill that will unequivocally criminalize LGBTQ + activities if passed.

Ahead of the anticipated discussion of the bill by parliament, the house majority leader, in an interview with Okay FM monitored by GhanaWeb, declined to give his position on the bill which already divides the nation on the lines. Support.

“When we speak of parliament, the leader of the majority is the head of the house. So if I declare a position now, it will be interpreted as the position of Parliament, to mean either that the House is in favor of the bill or that we are against it, ”he said.

Kwame Nkrumah Tikese who is the host of the radio show, told the Suame MP that a statement by him can be clarified as personal, but the majority leader disagreed.

“Such statements could be very damaging,” replied Mr. Kyei Mensah.

The 38-page bill before Parliament, among others, states that persons of the same sex who have sex are “liable on summary conviction to a fine of at least seven hundred and fifty units. penalty and not more than five thousand penalty units, or imprisonment for not less than three years and not more than five years or both.

The bill targets people who “present themselves as lesbian, gay, transgender, transsexual, queer, pansexual, ally, non-binary identity or any other sexual or gender identity contrary to binary categories and female.

The bill also targets promoters and defenders of LGBTQ + rights, including “a person who, through the use of media, a technology platform, a technology account or any other means, produces, purchases, markets, broadcasts, broadcasts, publishes or distributes material for promotional purposes. an activity prohibited under the bill, or a person uses an electronic device, the Internet service, a film or any other device capable of electronic storage or transmission to produce, procure, market, broadcast, broadcast, publish or distribute material for the purpose of promoting an activity prohibited by the bill ”as well as a person who“ encourages, supports sympathy or a change of public opinion towards an act prohibited by the bill ”.

Within the framework of its provisions, the bill specifies that an offender can be sentenced to a term of imprisonment of at least six years or of not more than ten years of imprisonment.


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It’s “the most dangerous sex position in the world,” warns viral doctor https://ivideosgratis.org/its-the-most-dangerous-sex-position-in-the-world-warns-viral-doctor/ https://ivideosgratis.org/its-the-most-dangerous-sex-position-in-the-world-warns-viral-doctor/#respond Wed, 06 Oct 2021 16:17:00 +0000 https://ivideosgratis.org/its-the-most-dangerous-sex-position-in-the-world-warns-viral-doctor/ With cooler nights now, many couples may be tempted to warm things up in the bedroom. But there is one sex position men may want to avoid, given that a doctor goes viral to claim he is responsible for 50% of penile fractures. British surgeon Dr Karan Raj, who has 4.3 million followers on TikTok, […]]]>

With cooler nights now, many couples may be tempted to warm things up in the bedroom.

But there is one sex position men may want to avoid, given that a doctor goes viral to claim he is responsible for 50% of penile fractures.

British surgeon Dr Karan Raj, who has 4.3 million followers on TikTok, claims that the “reverse cowgirl” is the “most dangerous sex position in the world” because a man’s penis can slide and be crushed by his partner’s pubic bone during erratic periods. push.

In a viral video that has already racked up over 2.1 million views, Raj explains that a penis is technically boneless, but the word “fracture” is used to describe a tear in the tunica tunica – a piece of tissue that allows for the penis to become enlarged and erect.

Dr Karan Raj – a British surgical doctor with 4.3 million followers on TikTok – denounces “the world’s most dangerous sexual position”. The viral doc also has over 41,300 YouTube subscribers.
Jam PressVid/@dr.karanr

Men who tear their tunic albuginea usually need surgery to stitch up the tear. Those who don’t usually end up with erectile dysfunction and permanent curvature of their private part.

Raj, who previously went viral with COVID-19 prevention tips, even claimed that a penile fracture can make a man’s penis swell and look a bit like an eggplant.

Fans of The Doctor’s TikTok were disappointed with the news, with several gendered commentators revealing that the reverse cowgirl was their “favorite.”

However, others were so marked by the educational video that they vowed not to have sex in the hot position again.

“My husband is now afraid to come near me because of this!” One spectator wrote with humor.

Dr Raj even claimed that a broken penis can make a man's penis swell and look a bit like an eggplant.
Raj even claimed that a broken penis can make a man’s penis swell and look a bit like an eggplant.
Jam PressVid/@dr.karanr

Meanwhile, a man even claimed his penis fractured while having reverse sex with a cowgirl because he and his partner weren’t pushing in sync.

“I heard him crack!” the man confessed his member.

However, reverse cowgirl enthusiasts may not need to be so worried given that Raj’s claims are contradicted by a 2017 study published in the International Journal of Impotence Research.

This study did not name the reverse cowgirl among the most dangerous sex positions.

Instead, he said doggy style was the most common position for causing penile fractures, accounting for 41% of all cases.

In second place was the missionary, with the man at the top causing 25% of penile fractures – followed, in third place, by the woman at the top.

Fans of The Doctor's TikTok were disappointed with the news, with several gendered commentators revealing reverse cowgirl to be theirs. "favorite"
Fans of The Doctor’s TikTok were disappointed with the news, with several gendered commentators revealing that the reverse cowgirl was their “favorite.”
Jam PressVid/@dr.karanr

Fractures of the penis usually tear the tunica tunica horizontally, but in July, the British Medical Journal revealed the first documented case of a vertical fracture of the penis, suffered by a 40-year-old man during sexual intercourse.

The study did not specify what position the man was in, but it was reported that his “penis buckled against his partner’s perineum” – the area between the anus and the genitals – in due to an untimely push.

Subsequent MRI scans showed the man’s penis to have an inch (3 centimeters) vertical tear – rather than the more common horizontal variety.

Despite the unconventional nature of the fracture, surgeons were forced to treat the patient’s mutilated virility within 24 hours to avoid complications.

Meanwhile, in 2019, a horny man cut his member in half while wriggling with his girlfriend.

“It grew to the size of a bottle of wine. It was out of my control and scared me to death, ”the man said of his swollen member.

Fortunately, he too underwent successful surgery and made a full recovery without incident.


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Most dangerous sex position that increases risk of penile fractures revealed, NHS doctor says https://ivideosgratis.org/most-dangerous-sex-position-that-increases-risk-of-penile-fractures-revealed-nhs-doctor-says/ https://ivideosgratis.org/most-dangerous-sex-position-that-increases-risk-of-penile-fractures-revealed-nhs-doctor-says/#respond Wed, 06 Oct 2021 10:44:00 +0000 https://ivideosgratis.org/most-dangerous-sex-position-that-increases-risk-of-penile-fractures-revealed-nhs-doctor-says/ NHS doctor has revealed the most dangerous sex position for getting penile fractures. According to the doctor, who moonlights as a TikTok star, dating sessions using this style are the cause of 50% of horror injuries. 2 NHS doctor claims to know most dangerous sex position for penile fracturesCredit: Jam Press Dr Karan Rangarjan has […]]]>

NHS doctor has revealed the most dangerous sex position for getting penile fractures.

According to the doctor, who moonlights as a TikTok star, dating sessions using this style are the cause of 50% of horror injuries.

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NHS doctor claims to know most dangerous sex position for penile fracturesCredit: Jam Press

Dr Karan Rangarjan has revealed the position most likely to lead to a hospital run to his 4.3 million followers.

He announced that the reverse cowgirl is the riskiest – like there’s an “erratic thrust” during sex or if the two sides aren’t in sync, it can go horribly wrong.

The doctor explained that this is because the penis can slip and be crushed by their partner’s pubic bone, causing a fracture.

He warned that “over-enthusiastic sex could make your penis look like an eggplant.”

Although the penis is boneless, the word “fracture” is used to describe a tear in the tunica albuginea – a piece of fibrous tissue that connects the structure of the testicle and allows the penis to enlarge during an erection.

Patients who have a “penile fracture” and go untreated usually end up with erectile dysfunction, scarring, and permanent curvature for the rest of their lives.

The post has been viewed over 2.1 million times, racking up 189,200 likes.

Many of Dr. Karan’s supporters were devastated to learn that their preferred position could cause serious injury.

One of them said “this is my favorite position” followed by a sad face emoji.

Someone else commented, “They can just break, I heard … well now I can finally get revenge.”

Another viewer said: “My husband is now afraid to come near me because of this.”

Dr Karan hit back at people who wanted proof of these claims by saying that he knew it was true thanks to the “men coming to the emergency room with this problem.”

A cross section of the inside of a penis - the tunica tunica can tear and this causes the

2

A cross section of the inside of a penis – the tunica tunica can tear and this causes the “fracture”Credit: Jam Press
Doctor shares bloody details of man fractured penis during rampant sex session

Earlier this year, we recounted how a British man broke his penis vertically when he got deformed during sex.

Doctors have claimed that the man is the first known case to have damaged his penis in this way during sex.

The case study was 40 years old at the time and doctors said his penis “had buckled against his partner’s perineum (the area between the anus and the genitals).”

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Anti LGBTQ Bill: Our Position Has Nothing To Do With Our Personal Preference For Homosexuality – Akoto Ampaw https://ivideosgratis.org/anti-lgbtq-bill-our-position-has-nothing-to-do-with-our-personal-preference-for-homosexuality-akoto-ampaw/ https://ivideosgratis.org/anti-lgbtq-bill-our-position-has-nothing-to-do-with-our-personal-preference-for-homosexuality-akoto-ampaw/#respond Wed, 06 Oct 2021 02:46:11 +0000 https://ivideosgratis.org/anti-lgbtq-bill-our-position-has-nothing-to-do-with-our-personal-preference-for-homosexuality-akoto-ampaw/ A private lawyer and member of the Coalition of Lawyers, Academics and Other Professionals, said the Coalition’s appeal to Parliament to reject the Ghanaian Family Values ​​and Appropriate Human Sexual Rights Promotion Bill, 2021, no. has nothing to do with members’ personal preference for the same. sexual activities. Mr. Akoto Ampaw made this known during […]]]>

A private lawyer and member of the Coalition of Lawyers, Academics and Other Professionals, said the Coalition’s appeal to Parliament to reject the Ghanaian Family Values ​​and Appropriate Human Sexual Rights Promotion Bill, 2021, no. has nothing to do with members’ personal preference for the same. sexual activities.

Mr. Akoto Ampaw made this known during an interview with Evans Mensah on JoyNews‘PM Express.

According to him, the mandate of the coalition is to ensure that the rights of every citizen, whether homosexual or not, are protected, hence the recent initiative.

“Our position as a group is that every person who is a human being is entitled to certain basic rights and that what the bill does launches an attack on the rights of a particular group in our society.

“Our position has nothing to do with our personal preference or not for homosexual activities. Our position is a position of principle that we take to defend the rights of every person in Ghana and subject to the public interest, ”he said on Tuesday.

He further stated that the decision of two consenting adults in their sex life is of no concern to society and its people.

“We say that if two consenting adults have this relationship, it is not a social matter, even though I, Akoto Ampaw, may not like it.”

The Coalition of Lawyers, Academics and Other Professionals as well as the Human Rights Coalition have submitted two different memoranda calling for Parliament to reject the anti-LGBTQ bill.

The Human Rights Coalition petition signed by the Director of Policy and Advocacy at the Ghana Center for Democratic Development, Dr Kojo Pumpuni Asante, on behalf of 9 groups including the African Center for International Law and Accountability and the Alliance for equality and diversity, said the said bill. is in direct conflict with a number of fundamental freedoms and human rights protected by the Constitution.

In addition, the Coalition argues that the provisions of the bill are inconsistent with a number of international human rights instruments to which Ghana is a state party.

“It is the considered position of the Human Rights Coalition that the Ghanaian Human Sexual Rights and Family Values ​​Promotion Bill 2021 is hopelessly flawed, unconstitutional and unnecessary. It does not address any relevant cultural, socio-economic or political challenges facing the country, as private members’ bills were meant to address, ”he concluded.

The calling coalition of lawyers, academics and other professionals said the bill should be rejected by the Special Parliamentary Committee on Constitutional, Legal and Parliamentary Affairs, and by Parliament as a whole because it criminalizes dissenting opinions and expressions contrary to the words “freedom and justice” “which bear our coat of arms”.

But in response, Ningo Prampam MP Sam Nartey George, who is among eight lawmakers who officially introduced the bill to the House, said the majority of Ghanaians do not want to tolerate same-sex relationships or people with different sexual orientations.

“We’re not ready to tolerate it, that’s what we are, our people say they don’t want it. These personalities do not in any way hold the torch to the strength of the collective will of the majority of Ghanaians and their personal agendas will not override the desire of the majority of the population, ”he told Ayisha Ibrahim. on The Pulse.


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Violence: Zanu PF in pole position https://ivideosgratis.org/violence-zanu-pf-in-pole-position/ https://ivideosgratis.org/violence-zanu-pf-in-pole-position/#respond Tue, 05 Oct 2021 22:30:16 +0000 https://ivideosgratis.org/violence-zanu-pf-in-pole-position/ BY MIRIAM MANGWAYA / SIMBARASHE SITHOL Ruling party Zanu PF has become the main perpetrator of human rights violations following violence within the party during its internal elections that left some of its members hospitalized, according to a latest report released yesterday by the Zimbabwe Peace Project (ZPP). According to the ZPP report titled It’s […]]]>

BY MIRIAM MANGWAYA / SIMBARASHE SITHOL

Ruling party Zanu PF has become the main perpetrator of human rights violations following violence within the party during its internal elections that left some of its members hospitalized, according to a latest report released yesterday by the Zimbabwe Peace Project (ZPP).

According to the ZPP report titled It’s politics everywhere, the ruling party was responsible for 37% of human rights violations in September and claimed the life of one person.

In the report, 195 human rights violations, including assault, displacement, sexual harassment and illegal detention, were recorded.

Ordinary citizens were the majority of the victims.

The Police of the Republic of Zimbabwe (ZRP) comes second for human rights violations, with 31% of incidents attributed to it.

The ZPP said that in the past two years, according to trends seen in its findings, the ZRP had taken the lead in human rights violations, but for the first time in September, the ruling party was at the forefront.

This is attributed to clashes that erupted in various provinces as party members sought to consolidate their positions during the restructuring program ahead of an elective congress slated for 2022.

ZPP recorded 10 cases of intra-Zanu PF violence in September.

“Police of the Republic of Zimbabwe (ZRP) topped the list of human rights abuses over the past two years, but in September they passed the baton to Zanu PF, which contributed to more 37% of violations against 31% for the ZRP. ZPP said.

“Yet the ZRP’s contribution to human rights violations remains a source of concern as they as law enforcement officers are expected to be the torchbearers of a police approach. and public security centered on human rights.

“With the ruling party and the police leading the way as perpetrators of rights violations, levels of public safety and trust are compromised. “

The ZPP noted that Zanu PF party officials continued to abuse state resources for their party’s campaigns, as some members used police to fight in their corner during quarrels within the party.

In Buhera North, the ZPP said incumbent MP William Mutomba had to call Dorowa Police to disrupt an agricultural show his rival Philip Guyo sponsored.

“This month we have seen an increase in political activity from both the opposition and the ruling Zanu PF,” ZPP said.

“In most cases, the Zanu PF has succeeded and the main opposition MDC Alliance, whose operating space has been extremely limited, has also succeeded in rallying its supporters in some rural and urban areas and in some cases the party had to carry out activities at night. .

“It was a bloody weekend from September 24-26, 2021 in the Zanu PF party as party supporters and contenders for positions engaged in bloody fighting in Harare, Manicaland, Mashonaland West and Midlands provinces.”

However, acting Zanu PF spokesperson Michael Bimha said NewsDay yesterday that violence and shoving for posts was proof of the party’s popularity.

He said that although there have been reports of some clashes within the party, its members have been abused by other parties, but the cases have not been documented.

“The government is very concerned about human rights violations and has established the Zimbabwe Human Rights Commission which has the power to monitor the human rights situation even within the party within Zanu PF power, ”Bimha said.

“We have not yet received any complaints from the commission that we are committing rights violations. When it comes to the use of state resources, the ruling party is a separate entity from the government, so it has no control over what happens in state institutions. If the police showed up at the Zanu PF events, the responsible authorities would have seen fit to send personnel there.

The ZPP said there had been an increase in political activity across the country ahead of the 2023 elections, resulting in violence and called for restraint and tolerance among political members.

Meanwhile, Bindura police rushed to a Zanu PF restructuring meeting yesterday and beat up party members, allegedly in retaliation for the assault on one of their colleagues by a ruling party member. Sunday.

Police, who wore riot gear, used tear gas before assaulting ruling party officials led by Shamva chairman Phamhidzayi Chirimuuta.

Chirimuuta said NewsDay that the police severely beat the members and arrested young people who were still in custody.

Mashonaland Central’s acting police spokesperson, Deputy Inspector Naison Dhliwayo, was not responding to calls.

Follow us on Twitter @NewsDayZimbabwe


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Senior Professor position, employment in School of Applied Psychology, Counseling and Family Therapy with Antioch University in Seattle https://ivideosgratis.org/senior-professor-position-employment-in-school-of-applied-psychology-counseling-and-family-therapy-with-antioch-university-in-seattle-2/ https://ivideosgratis.org/senior-professor-position-employment-in-school-of-applied-psychology-counseling-and-family-therapy-with-antioch-university-in-seattle-2/#respond Fri, 01 Oct 2021 01:09:35 +0000 https://ivideosgratis.org/senior-professor-position-employment-in-school-of-applied-psychology-counseling-and-family-therapy-with-antioch-university-in-seattle-2/ Main faculty position School of Applied Psychology, Counseling and family therapy The School of Applied Psychology, Counseling and Family Therapy at Antioch University in Seattle invites applications for a full-time faculty position in our APA-accredited Psychology Doctoral Program (PsyD) in Psychology clinical. The mission of our Psy.D. The program, founded in 2004, is to educate […]]]>

Main faculty position

School of Applied Psychology,

Counseling and family therapy

The School of Applied Psychology, Counseling and Family Therapy at Antioch University in Seattle invites applications for a full-time faculty position in our APA-accredited Psychology Doctoral Program (PsyD) in Psychology clinical. The mission of our Psy.D. The program, founded in 2004, is to educate students to become informed and effective practitioner-researchers and agents of change in a diverse world with a strong emphasis on social justice. The core faculty participate fully in the academic and governance functions of the program, school and university. Primary responsibilities include transporting the equivalent of 24 quarter units per year; student mentoring (including thesis, clinical supervision and academic counseling); actively participate in program, school and university committees and functions; maintain a program of scholarships, professional and community services. Ideal candidates would be qualified to teach personality theory, qualitative research, clinical training courses, and adult development. Preference will be given to applicants who have teaching experience at the postgraduate level and who have an active clinical practice. We desire a proven history of active participation in teaching, clinical practice, supervision and research. Social justice is at the heart of our agenda, as evidenced by our unique APA program competence. We are looking for a colleague to join our faculty who will share this goal and who can demonstrate their commitment to these ideals. Our ideal colleague will help us continue to foster diversity, excellence in education and training, as well as a welcoming and rewarding ministerial culture for community members with diverse identities. All qualified applicants are encouraged to apply.

Founded in 1852, Antioch established itself as an innovative education from its inception, and in the 1920s Antioch became synonymous with radical transformations in higher education. Today Antioch University Seattle, along with the other four campuses and two campus-wide programs make up Antioch University, are proud of our progressive heritage and continue to promote innovative programs in higher education. The Psy.D. The program continues this tradition of innovative education while upholding the highest professional standards in clinical psychology and valuing contextual theory and diversity. To learn more about our program, our unique history, and our student-centered educational philosophy, visit https://www.antioch.edu/seattle/degrees-programs/psychology-degree/clinical-psychology-psyd/

Qualifications:

Applicants must have a minimum of a doctorate in clinical psychology (Ph.D. or Psy.D.) and hold a bachelor’s or undergraduate degree in Washington State as a clinical psychologist with a minimum of two years of post-graduate experience. Graduates of APA accredited doctoral programs with APA accredited internships are preferred.

Equivalent education / experience may replace minimum qualifications, except where there are legal requirements, such as as license / certification / registration

Application process

Complete and submit the following documents:

• Cover letter

• CV or curriculum vitae

• Names, addresses (including e-mail addresses) and telephone numbers of four references. References will not be

contacted without the prior consent of the candidate.

Choose an option to submit your documents:

E-mail: hr.aus@antioch.edu OR by mail: search for Faculty c / o Human Resources, 2400 Third Avenue, Suite 200, Seattle, WA 98121.

The University of Antioch offers equal opportunities to all qualified applicants and does not discriminate on the basis race, color, sex, descent, religion, national origin, sexual orientation, family status or disability in matters affecting employment or providing access to programs.

To obtain accommodations to complete the application process and / or if you are selected for an interview, please contact the Human Resources Department at 206-268-4022. TTY: 206-728-5745.


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Best sleeping position for gallbladder pain https://ivideosgratis.org/best-sleeping-position-for-gallbladder-pain/ https://ivideosgratis.org/best-sleeping-position-for-gallbladder-pain/#respond Thu, 30 Sep 2021 18:56:15 +0000 https://ivideosgratis.org/best-sleeping-position-for-gallbladder-pain/ The gallbladder is a small digestive organ that stores bile. Bile is what your body uses to digest fat, and it’s usually released from your gallbladder into your small intestine. When the chemical balance of the bile is upset, the bile can crystallize into small deposits of protein called gallstones. Gallstones can block the bile […]]]>

The gallbladder is a small digestive organ that stores bile. Bile is what your body uses to digest fat, and it’s usually released from your gallbladder into your small intestine.

When the chemical balance of the bile is upset, the bile can crystallize into small deposits of protein called gallstones. Gallstones can block the bile ducts and cause what is sometimes called a gallbladder attack or biliary colic.

It is estimated that more than 20 million Americans have had or will develop gallstones. These attacks can cause severe pain symptoms in the upper abdomen. Sometimes this pain lasts for hours.

Resting or sleeping in certain positions can help relieve gallbladder pain. There are also home strategies you can try while you wait to see if the pain goes away. We’ll cover the best sleeping positions during a gallbladder attack, what to avoid when you’re in pain, and how to know when to seek emergency help.

When you experience gallbladder pain, you should sleep on your left side.

Sleeping or resting on your left side allows your gallbladder to contract and expand freely until the obstruction in your bile ducts is cleared. The theory is that it can help resolve the pain.

While this is conventional wisdom, keep in mind that most of the evidence is anecdotal. There is currently no research that compares the pain level of different incline positions when you have gallbladder pain.

If you are suffering from any type of gallbladder pain, you may want to avoid sleeping on your right side. This is because your liver and gallbladder are both located on the right side of your body. Sleeping on your right side can contract your gallbladder and make it harder for a gallbladder to pass through. The added pressure of sleeping on your right side can even make gallbladder pain worse.

You can also avoid sleeping on your back or stomach. These positions may not be comfortable until the pain from your blocked bile duct has passed.

There are other pain remedies you can try when you have pain from a blocked bile duct.

  • Lying on your left side, try a warm compress to reduce pressure and soothe pain. A hot water bottle or heating pad may work well for this purpose.
  • Drink soothing peppermint tea to relieve pain and calm gallbladder spasms.
  • Consider taking a magnesium supplement or mixing magnesium powder with lukewarm water. Magnesium can help empty your gallbladder and relieve attacks of the gallbladder.

Gallbladder pain may be a sign that you need medical help. Call a doctor or go to the emergency room if you notice any of the following symptoms along with your gallbladder pain.

Gallbladder pain is relatively common and is usually caused by gallstones blocking the bile ducts. Resting or sleeping on your left side can help manage gallstone pain if you have a blocked bile duct.

You can also try other home remedies for pain relief. Serious symptoms should not be ignored and could indicate a health emergency. Talk to a doctor if you are concerned about gallstones and gallbladder pain.


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TD accuses former Kerry judge of abusing his position https://ivideosgratis.org/td-accuses-former-kerry-judge-of-abusing-his-position/ https://ivideosgratis.org/td-accuses-former-kerry-judge-of-abusing-his-position/#respond Wed, 29 Sep 2021 16:23:25 +0000 https://ivideosgratis.org/td-accuses-former-kerry-judge-of-abusing-his-position/ The Taoiseach believes that the allegations against a former judge in Kerry have not been fully addressed. Three women came forward alleging that the former judge behaved inappropriately after appearing in court. People Before Profit TD for Dublin South-West, Paul Murphy used Dáil privilege to appoint James O’Connor, retired Kerry District Court Judge. In July, […]]]>

The Taoiseach believes that the allegations against a former judge in Kerry have not been fully addressed.

Three women came forward alleging that the former judge behaved inappropriately after appearing in court.

People Before Profit TD for Dublin South-West, Paul Murphy used Dáil privilege to appoint James O’Connor, retired Kerry District Court Judge.

In July, Deputy Murphy informed Taoiseach Micheál Martin of allegations that James O’Connor had abused his judicial position to persistently and wholly inappropriately prosecute a vulnerable woman who was before his court on a justice law case. family for a sexual relationship.

Deputy Murphy says he was contacted by another woman, called Miss B, over the summer, who was also sued by James O’Connor after she appeared in family court qu ‘he chaired:

MP Paul Murphy said there is clearly a repeated pattern of abuse here and asked what the government will do to prevent this from happening again.

The Garda Mediation Commission investigated one of the complaints, but no further action was taken.

Taoiseach Micheál Martin said the government is not engaging in the operational side of the prosecution, but serious issues have been raised here:

James O’Connor has not publicly commented on the allegations.


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VVD wants to change government position that monarch in same-sex marriage must relinquish throne https://ivideosgratis.org/vvd-wants-to-change-government-position-that-monarch-in-same-sex-marriage-must-relinquish-throne/ https://ivideosgratis.org/vvd-wants-to-change-government-position-that-monarch-in-same-sex-marriage-must-relinquish-throne/#respond Tue, 28 Sep 2021 08:50:00 +0000 https://ivideosgratis.org/vvd-wants-to-change-government-position-that-monarch-in-same-sex-marriage-must-relinquish-throne/ The VVD wants to change a government position dating back to 2000 that a monarch who wants to marry a same-sex partner must relinquish the throne. The ruling party has been reminded of this position by a new book on Crown Princess Amalia and has asked interim Prime Minister Mark Rutte about it, reports RTL […]]]>

The VVD wants to change a government position dating back to 2000 that a monarch who wants to marry a same-sex partner must relinquish the throne. The ruling party has been reminded of this position by a new book on Crown Princess Amalia and has asked interim Prime Minister Mark Rutte about it, reports RTL Nieuws.

Political lawyer Peter Rehwinkel wrote about this government position in his new book ‘Amalia, from plicht roept’. In 2000, then Secretary of State for Justice Job Cohen made the reservation on behalf of the cabinet that an heir to the throne would have to relinquish the throne if he wanted to marry a same-sex partner. He considered that royalty is hereditary, and that this would be impossible in same-sex marriage “because it is certain in advance that no child can be born from such a marriage”.

This government position has not been discussed since, until VVD parliamentarians wrote a letter to Rutte on Tuesday. “Do you think this matches the standards and values ​​of the Netherlands in 2021? They want to know. They also want to know to what extent children from a marriage between an heir to the throne and a same-sex partner are eligible for the monarchy, according to the broadcaster.

Parliamentarians asked the prime minister to respond within two weeks.


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Impact on Adult Pneumonia Burden Estimates https://ivideosgratis.org/impact-on-adult-pneumonia-burden-estimates/ https://ivideosgratis.org/impact-on-adult-pneumonia-burden-estimates/#respond Tue, 28 Sep 2021 04:23:17 +0000 https://ivideosgratis.org/?p=276 Study Design: Retrospective database review. Methods: Data from the 2014 National Inpatient Sample of the Healthcare Cost and Utilization Project, a population-weighted, 20% sample of all US community hospitalizations, were analyzed for all pneumonia hospitalizations in adults aged 18 to 64 years and 65 years or older. Number of hospitalizations, hospital stay length, direct medical […]]]>

Study Design: Retrospective database review.

Methods: Data from the 2014 National Inpatient Sample of the Healthcare Cost and Utilization Project, a population-weighted, 20% sample of all US community hospitalizations, were analyzed for all pneumonia hospitalizations in adults aged 18 to 64 years and 65 years or older. Number of hospitalizations, hospital stay length, direct medical costs, in-hospital mortality, patient discharge disposition, illness severity, and likelihood of dying were evaluated based on the diagnosis field of pneumonia as a discharge diagnosis (eg, first, second, third, or further).

Results: In 2014, an estimated 2.4 million US adult hospitalizations were associated with pneumonia in any of the discharge diagnosis positions (33%-35% in first, 33%-36% in second, and 29%-34% in further positions). When estimates were based only on hospitalizations with pneumonia in the first diagnosis field, approximately 66% of hospitalizations, 78% of hospital days, 87% of in-hospital deaths, 76% and 73% of transfers to short-term hospitals and skilled nursing facilities, 68% of discharges with home health care services, and 82% of direct medical costs were excluded.

Conclusions: Pneumonia hospitalizations were associated with substantial health care resource utilization and in-hospital mortality. Relying only on pneumonia in the first hospital diagnosis field may potentially underestimate the burden associated with pneumonia hospitalizations.

Am J Manag Care. 2021;27(8):e261-e268. https://doi.org/10.37765/ajmc.2021.88727

_____

Takeaway Points

Commonly estimated pneumonia burden among US adults is based primarily on hospitalizations with pneumonia in the first discharge diagnosis field. This study generated estimates including hospitalizations with pneumonia in any diagnosis field.

  • There is substantial health care resource utilization and in-hospital mortality associated with pneumonia hospitalizations.
  • Estimates of disease burden were lower when relying solely on pneumonia in the first hospital diagnosis field vs including pneumonia coded in any diagnosis field.
  • For more sensitive estimates of incidence rates and disease burden, all appropriate hospitalizations, regardless of the discharge diagnosis field in which pneumonia is coded, may be used.

_____

The burden of US adult hospitalizations for pneumonia is substantial. Many studies have used administrative claims data to determine the number of these hospitalizations, with annual estimates of 1200 to 2000 pneumonia hospitalizations per 100,000 persons 65 years and older and more than 4000 per 100,000 among those 85 years and older.1-3 Evaluating hospital discharge administrative data is critical in assessing the public health impact of disease prevention strategies, particularly against pneumococcal disease.1,2 Nevertheless, most studies using administrative data are limited to pneumonia coded as the primary diagnosis (first diagnosis field [DF] of hospital discharge) or extend the definition only to septicemia or respiratory failure coded as the primary diagnosis with pneumonia coded as the secondary or higher DF.1-6 Thus, patients with pneumonia in the second or higher discharge DF are generally excluded from pneumonia burden estimates, but the impact of this practice on estimates is not well researched.

Coding practices vary based on several considerations (eg, administrative considerations, billing, training, experience, local practice), affecting the assigned position of pneumonia discharge DFs. Notably, studies using administrative databases can find different incidence rates (IRs) depending on which discharge DF positions are included; other outcomes may also be affected.6,7 For example, CMS uses only primary diagnoses when estimating hospital 30-day risk-standardized mortality rates associated with pneumonia and reimburses hospitals according to those rates.7,8 Patients with pneumonia can also present with sepsis or respiratory failure, which are increasingly used as primary diagnoses.6,7 Presumably these patients have higher mortality risk, so their exclusion may falsely lower pneumonia mortality. Using nationally representative databases, we assessed overall IRs of pneumonia hospitalization and effects of different discharge DFs for pneumonia coding.

METHODS

Study Design and Data Sources

Pneumonia hospitalizations and corresponding hospital length of stay (LOS); direct medical costs; hospital discharge disposition, including in-hospital case fatality rate (CFR); illness severity; and mortality risk were estimated using National Inpatient Sample (NIS) data (described in the eAppendix [available at ajmc.com]9-11). Data from 2014 were analyzed, as the International Classification of Diseases codes changed from the Ninth Revision, Clinical Modification (ICD-9-CM) to the Tenth Revision, Clinical Modification (ICD-10-CM) in September 2015. US Census Bureau population projections were used for age-group population estimates using July 2014 projected population estimates.12

Identification of Pneumonia Hospitalizations

For the purposes of this study, a pneumonia-associated hospitalization was defined as any hospitalization with a pneumonia diagnosis ICD-9-CM code (480.xx-486.xx or 487.0) in any discharge DF; codes were selected based on previously published research.1 Each hospitalization in the NIS database contained 30 or fewer discharge DFs. Because NIS has a complex sample design (oversampling, uneven selection probabilities, nonresponses), nationally representative estimates were generated using Healthcare Cost and Utilization Project (HCUP) variance calculations and sample weights.10 The criteria used for identification and classification of pneumonia-related hospitalizations are summarized in Figure 1.

Outcomes and Data Analysis

Age-specific IRs for the overall US population were calculated as hospitalizations per 100,000 persons per year. Age group–specific estimates were obtained by dividing the number of all pneumonia hospitalizations by the US Census population estimates for 2014 (199,030,227 and 46,243,211 adults aged 18-64 years and ≥ 65 years, respectively; hereafter, they are referred to as younger and older adults).

IRs and frequency distributions of pneumonia hospitalizations were analyzed by diagnostic position in which pneumonia was first coded. Because of similar frequency distribution, all outcomes of interest were grouped by whether the pneumonia diagnosis code occurred in the first, second, or any further discharge DF. Hospital LOS, direct medical costs, hospital discharge disposition, illness severity, and mortality risk were described similarly.

HCUP provides information on charges for each hospitalization and cost to charge ratios.11 Hospitalization charges were converted into hospitalization costs using HCUP cost to charge ratio. Direct medical costs of pneumonia hospitalization were initially estimated in 2014 US$ and converted to 2018 US$ using the Consumer Price Index of medical care increase over this time (11.3%).13 Mean values per hospitalization and cumulative totals were calculated for hospital LOS and costs.

Patient hospital discharge disposition was assessed and described with frequency distributions. A patient could have died in the hospital (in-hospital CFR); been transferred to a short-term care facility, skilled-nursing facility (SNF), or intermediate-care facility (ICF); been discharged with home health care; received routine discharge; been discharged against medical advice; or been discharged (alive) with undefined destination.10

Several analyses were performed to characterize the conditions associated with pneumonia across different discharge DFs. First, the top 10 ICD-9-CM codes occurring in the first DF when pneumonia occurred in the second or any other DF were assessed. Further analyses were used to determine the most common ICD-9-CM codes within the first 5 discharge DFs and All Patient Refined Diagnosis–Related Groups (APR-DRGs) associated with pneumonia hospitalizations in the first, second, or any other discharge DFs; most common ICD-9-CM codes and APR-DRGs were predefined as those occurring in at least 1% of all pneumonia hospitalizations. Lastly, we evaluated the prevalence of ventilator-associated hospital-acquired pneumonia (VAP; ICD-9-CM code 99731) and pneumonitis due to inhalation of food or vomitus (aspiration pneumonia; ICD-9-CM code 5070) occurring with pneumonia in the first, second, or any other discharge DF.

Each HCUP hospitalization included information on overall illness severity (ie, loss of function and mortality risk levels) using a 3M proprietary classification-independent system, which considers presence and seriousness of underlying comorbidities.14 Frequency distribution of illness severity and likelihood of dying were calculated using pneumonia discharge DF positions.

Comparing Alternative Criteria for Identifying Pneumonia-Associated Hospitalizations

We compared our approach for classifying any pneumonia-associated hospitalization with that followed by Griffin and colleagues.1 Both studies used the same ICD-9-CM codes for pneumonia. Our study included any hospitalization with a pneumonia code in any discharge DF as a proxy for a pneumonia-associated hospitalization. Griffin and colleagues1 identified pneumonia hospitalizations as those with pneumonia coded in the first DF or pneumonia coded in any field if septicemia, meningitis, or empyema was the primary diagnosis.

Analyses were performed using SAS software version 9.4 (SAS Institute). Ethical conduct within the study is summarized in the eAppendix.

RESULTS

Pneumonia Hospitalizations

In 2014, approximately 2.4 million acute hospitalizations of US adults included pneumonia diagnosis at discharge. Of these, 38% (~900,000 hospitalizations) and 62% (~1.5 million hospitalizations) occurred in younger and older adults, respectively. Annual overall pneumonia hospitalization incidences in younger and older adults were 453 and 3185 per 100,000 persons, respectively (Figure 2).

Among all possible hospital discharge diagnoses, pneumonia was within the first 6 DFs in 90% of all pneumonia hospitalizations (Figure 2). Pneumonia was coded in the first or second DF position in approximately one-third each of all pneumonia hospitalizations (Table 1). Overall, 34% of younger adults and 29% of older adults had a pneumonia diagnosis in any further discharge DF (ie, beyond second position).

LOS and Costs

The mean LOS of all hospitalizations with pneumonia included in any discharge DF was 8.4 and 7.3 days in younger and older adults, respectively (Table 1). Pneumonia hospitalizations were associated with approximately 18.3 million hospital days, 41.5% of which occurred among younger adults and 58.5% of which occurred among older adults. The lowest mean LOS and the lowest number of total hospital days were observed when pneumonia was in the first DF.

Mean direct medical costs of all hospitalizations with pneumonia included in any discharge DF (2018 US$) were $24,637 in younger adults and $18,360 in older adults (Table 1). The estimated cost associated with pneumonia hospitalizations in 2014 was $48.3 billion (2018 US$); 45% of these costs were attributable to younger adults and 55% to older adults. Among younger adults, 15%, 25%, and 60% of total costs were attributable to patients with pneumonia in the first, second, or any other discharge DF, respectively, vs 21%, 31%, and 49% for older adults. The available data were not sufficient to determine the relative contributions of pneumonia vs other associated conditions to either LOS, total hospital days, or direct medical costs.

Patient Disposition After Hospitalization

Mean in-hospital CFRs of all pneumonia hospitalizations were 5.7% among younger adults and 8.9% among older adults (Table 2). There were 182,730 pneumonia-associated in-hospital deaths in younger (28.1%) and older (71.9%) adults (Table 2). Of in-hospital deaths in younger adults, 9%, 19%, and 72% had pneumonia in the first, second, or any other discharge DF, respectively, vs 15%, 28%, and 57% in older adults.

Hospital discharge disposition after pneumonia hospitalization among younger and older adults included transfers to another short-term hospital (3.7% and 3.0%, respectively) or SNF/ICF (15.1% and 34.9%), and discharge as routine (61.0% and 33.7%) or to home with home health care services (12.2% and 18.9%) (Table 2). Few patients were discharged against medical advice. As with other outcomes, the percentage of transfers was lowest when the pneumonia diagnosis was primary (Table 2).

ICD-9-CM Codes and APR-DRGs Associated With Pneumonia Hospitalizations

Septicemia was the most common condition noted in the first DF for hospitalizations associated with pneumonia in the second DF (24.2%) or any other DF (28.2%) (eAppendix Table 1). Eight of the 10 most common conditions noted in the first DF (including septicemia, chronic obstructive pulmonary disease, congestive heart failure, and respiratory failure) were similarly prevalent regardless of whether pneumonia was listed in the second DF or any other DF.

The 5 most common nonpneumonia conditions associated with pneumonia listed in any DF (excluding hypertension) were respiratory failure, septicemia, acute renal failure, exacerbation of obstructive pulmonary disease, and acute and chronic respiratory failure/congestive heart failure (both occurring with approximately the same frequency) (eAppendix Table 2). At least 1 of these conditions was reported along with 51.7% of hospitalizations with pneumonia listed in the first DF, 86.4% of hospitalizations with pneumonia listed in the second DF, and 99.9% of hospitalizations with pneumonia listed in any other DF.

Three APR-DRGs (all defined as “simple pneumonia”) accounted for 87.6% of all hospitalizations associated with pneumonia listed in the first DF (including 39.4% with complicating or comorbid conditions, 30% with major complicating or comorbid conditions, and 18.2% without complicating or comorbid conditions) (eAppendix Table 3). In contrast, these 3 APR-DRGs were very rarely associated with pneumonia listed in the second or any other DF; rather, septicemia was most commonly associated with pneumonia in the second DF (27.0%) or in any other DF (30.9%). VAP and aspiration pneumonia were associated with 0.2% and 1.2% of all pneumonia hospitalizations, respectively (eAppendix Table 4).

Severity and Likelihood of Dying

In both age groups, the percentage of patients with major to extreme illness increased with pneumonia discharge diagnosis position, including 46.6%, 71.9%, and 93.2% of younger patients and 56.3%, 80.9%, and 94.7% of older patients with pneumonia in the first, second, and any other DFs, respectively (Table 3). Likewise, the percentage classified as having a major to extreme likelihood of dying upon discharge also increased with pneumonia discharge position in both younger and older adults.

Alternative Criteria for Identifying Pneumonia-Associated Hospitalizations

Compared with the criteria used by Griffin and colleagues,1 our study criteria identified 81% more pneumonia-associated hospitalizations in adults 18 years and older (ie, 2.37 million vs 1.31 million hospitalizations) (eAppendix Table 5).

DISCUSSION

We found that although 90% of pneumonia hospitalizations were identified in the first 6 DFs, just one-third were in the first DF. Consequently, claims-based estimates focusing only on the first DF underestimate pneumonia hospitalization burden. Excluding patients with nonprimary pneumonia coded positions from studies using administrative claims may also exclude many of the most severe pneumonia hospitalizations, as secondary diagnoses were associated with higher LOS, costs, and CFRs and sicker patients overall compared with primary diagnoses.

The overall incidence of pneumonia hospitalization in younger adults (453/100,000) in the current analysis was higher than IRs previously reported when examining pneumonia only as a primary discharge diagnosis or when included with septicemia or respiratory failure (septicemia, meningitis, empyema in the study by Griffin and colleagues) as the primary diagnosis (80-370/100,000).1,2,5 The IR among older adults (3185/100,000) was also higher than reported rates using a more limited case definition (~850-1400/100,000).2,4 Using clinical and radiographic data instead of discharge codes for all hospitalized adult residents in Louisville, Kentucky, a prospective population-based cohort study estimated annual incidences of community-acquired pneumonia (CAP) closer to those reported here (327/100,000 and 2093/100,000 for adults aged 18-64 and ≥ 65 years, respectively).15 This study extrapolated data to the US population to estimate 1.7 million annual CAP hospitalizations or 1.5 million unique CAP hospitalizations (ie, excluding rehospitalizations).

Mean LOS per pneumonia hospitalization was similar to LOS reported in a previous study3 and was higher among younger vs older adults (8.4 vs 7.3 days). The difference in overall mean LOS between younger and older adults was primarily driven by shorter LOS for older vs younger adults associated with pneumonia in the third or higher DF. This result may have occurred because of a higher mortality rate among older adults (thus shortening their hospital stay), because older adults were more likely than younger adults to be transferred to a different acute or subacute care facility to complete their care, or because health care professionals more readily hospitalized older adults with less severe presentations.

Compared with previous studies, the primary economic impact of including pneumonias in additional DFs derived from increasing the total number of included fields rather than increasing the cost per episode. For example, previous studies that included pneumonia only in the first DF or combined pneumonia with primary septicemia or respiratory failure found direct medical costs for pneumonia of $22,354 per episode among persons aged 18 to 64 years3 and $16,689 to $18,942 (cost/episode)3 or $13,825 (in-hospital cost)4 among those 65 years or older. Similarly, our study found mean direct medical costs of $24,637 for younger adults and $18,360 for older adults. Decreased costs associated with older vs younger adults may have been due to the shorter mean LOS in the older population.

Additionally, compared with an earlier study, the impact of our study for pneumonia mortality burden was primarily related to the increase in pneumonias identified rather than differences in pneumonia CFR. We found an in-hospital CFR associated with any pneumonia diagnosis of 8.9% in older adults, within the 7.0% to 11.5% range for those 65 years and older reported previously.1 For younger adults, we found an in-hospital CFR of 5.7%, higher than the 2.2% to 4.9% range for ages 18 to 64 years reported previously.1 Both our study and earlier studies may underestimate the long-term impact of pneumonia on early mortality. For example, a study of US Medicare beneficiaries 65 years or older reported a 1-year 16.3% CFR difference for patients with pneumonia (30.8%) compared with otherwise similar patients without pneumonia (14.5%).16

Our strategy to identify pneumonia-associated hospitalizations was more sensitive than that of another study that relied on administrative data.17 Similarly, our approach was more sensitive than those of other studies that limited hospitalizations to only those with pneumonia coded in the primary DF or additionally included only a limited number of alternative primary diagnoses (eg, septicemia or respiratory failure) combined with pneumonia coded in any other discharge DF.1-6 These studies attempted to focus on what they considered to be the most likely hospitalizations for CAP instead of all pneumonia-associated hospitalizations.

In estimating pneumonia burden, some researchers have limited the case definition to CAP by excluding individuals who within 14 days preceding the pneumonia hospitalization were discharged from a long-term care facility, had a previous hospitalization, or required mechanical ventilation, as these patients may have had hospital-acquired pneumonia (HAP), VAP, or aspiration pneumonia.3,4 The ICD-9-CM classification system does not include specific codes for HAP, so we were unable to evaluate its prevalence among hospitalizations in our study, but very small percentages of pneumonia hospitalizations were associated with VAP or aspiration pneumonia. Moreover, distinguishing between CAP and these additional categories may be less relevant when considering public health interventions to combat pneumonia. Some strategies may be setting-specific, whereas others (eg, vaccination) may affect any setting. Future research is needed to define the etiologic agents of HAP and VAP because these categories might contribute to overall burden and are more likely to result in severe outcomes, such as intensive care unit admission. Furthermore, although VAP is relatively uncommon, HAP constitutes a substantial proportion of all pneumonia cases, with a 2010 cross-sectional 1-day survey of a sample of US hospitals projecting 186,000 HAP cases annually.18 An administrative database analysis of all pneumonia-associated hospitalizations (ie, any discharge diagnosis) among New York City residents 18 years or older from 2010 to 2014 found that 54.3% were CAP, 30.2% were health care–associated pneumonia (no longer a guideline-recommended definition19; also community acquired), and 14.0% and 1.6% were HAP and VAP, respectively.20

Reasons for placing pneumonia in different DFs are unclear; however, our data suggest a possible answer. When pneumonia was coded in the first DF in our study, patients were less likely to have severe complications from either the pneumonia itself or an underlying comorbid condition, and patients were more likely to have an APR-DRG of simple pneumonia. This is logical because pneumonia generally involves straightforward treatment, so regardless of whether pneumonia was the original reason for hospitalization, health care providers are likely to spend more time managing an underlying comorbid condition than the pneumonia itself.

Our results argue against the methodology of estimating the pneumonia burden by excluding pneumonias coded outside the first discharge DF (or associated with sepsis or respiratory failure). Pneumonias occurring in the second or higher DF because of underlying comorbidities were associated with the most severe pneumonia hospitalizations, and therefore excluding these cases from burden estimates will potentially omit the subset of pneumonias that are most relevant and critical to prevent.

Our study did not assess the performance of the ICD-9-CM classification for pneumonia hospitalizations. Although some studies report that sensitivity may be suboptimal,21,22 the ICD-9-CM classification has shown high positive predictive value (PPV) (88%) when using a single DF to identify pneumonia, even in ambulatory settings.23 Notably, in a study evaluating children younger than 19 years hospitalized with CAP, which used ICD-9-CM codes similar to those used in our study, expanding the discharge DFs to identify pneumonia from the first to any discharge field increased sensitivity from 71.0% to 99.7% but reduced specificity from 90.9% to 75.7% and reduced PPV from 80.1% to 67.9%17; the trade-offs among sensitivity, specificity, and other performance characteristics warrant further research. We can examine how performance characteristics could affect our estimates if we assume that the above PPVs reported in children are valid for adults in our study (and that pneumonia hospitalizations in adults have high negative predictive value). In this case, we applied PPVs of 80.1% and 67.9%, for hospitalizations and costs for pneumonia in the first or in any DF, respectively, to our 2014 estimates. Our estimates of 808,165 and 2,373,030 pneumonia hospitalizations in the first and in any DF, and corresponding associated medical costs of $8.8 billion and $48.4 billion, respectively, would result in 647,340 and 1,611,287 pneumonia hospitalizations in the first and in any DF, and in $7.1 billion and $32.8 billion in corresponding associated medical costs, respectively. As this example shows, even after adjusting for PPVs, including pneumonia in any DF increases the accuracy of assessing hospital pneumonia burden and cost compared with using pneumonia only in the first DF. Specifically, for our study, PPV-adjusted pneumonia hospitalizations and associated costs of pneumonia in any DFs were 2.0 and 3.7 times, respectively, higher than the unadjusted estimates based on pneumonia diagnosis only in the first DF.

Our study was based on hospitalizations in 2014, the final entire year using the ICD-9-CM classification system. The 2015 year was a transition year, with the last quarter introducing the ICD-10-CM classification. NIS data for subsequent years were not available at the time of this study. To guide future studies under the ICD-10-CM classification, as a starting point, the ICD-10-CM codes used in a study in Finland to identify pneumonia-related hospitalizations were J10.0, J11.0, J12-J18, J85.1, and J86.24 The use of specific ICD-10-CM codes for pneumonia will likely become an important area of research in the near future.

Data regarding LOS, total hospital days, mortality rates, discharge disposition, and direct medical costs in our study cannot be attributed to pneumonia specifically because most patients with pneumonia hospitalizations had additional diagnoses that likely contributed to these outcomes. The degree to which outcomes were affected by pneumonia may vary considerably. For example, chronic obstructive pulmonary disease or congestive heart failure may have been precipitated by a pneumonia episode, in which case pneumonia would be the primary driver of associated outcomes. Alternatively, pneumonia may have been an incidental and relatively trivial component of hospitalization. These distinctions can potentially be explored in more robust analyses, including chart review or a control population; one example is a claims-based study of Medicare beneficiaries 65 years and older, in which the incremental direct medical cost of pneumonia during 1 year of follow-up was $15,682 (~$22,500 in 2018 US$) higher for patients with pneumonia in the first DF than for matched control patients without pneumonia.16 However, regardless of whether pneumonia is the cause of the outcomes measured here, the outcomes are nevertheless an accurate reflection of pneumonia hospitalizations complicated by multiple diagnoses regardless of whether pneumonia is included in the first discharge DF.

Our data demonstrate that hospitalizations associated with pneumonia in any discharge DF can have enormous financial consequences. The total cost of adult hospitalizations with pneumonia (primarily simple pneumonia) reported in the first discharge DF in 2014 was $8.8 billion, similar to costs reported for 2013 in an HCUP analysis ($9.5 billion for all ages).25 When we included hospitalizations with any pneumonia diagnosis, estimated 2014 costs were $48.3 billion, representing more than 12% of all US hospitalization costs in 2013.25 Although many of these costs would likely have accrued without the pneumonia, it is likely that a substantial proportion of the economic burden could have been avoided if pneumonia were prevented. Furthermore, during the COVID-19 pandemic, access to routine immunization has experienced major challenges.26 Actions to improve delays in routine vaccination may free up scarce health care resources, including hospital and intensive care unit beds and mechanical ventilation, during the COVID-19 pandemic.27

Limitations

Our study did not attempt to disentangle what part of the total cost of a pneumonia-associated hospitalization was due to pneumonia or due to other underlying conditions that may have triggered or further complicated the hospitalization. This is difficult to assess. Some methodologies, such as recycled predictions, have been used in attempts to separate the potential incremental cost of a diagnosis in the context of multiple diagnoses that were part of a hospital discharge.28 Nevertheless, although we did not estimate the extent of the role of pneumonia in the cost of a pneumonia-related hospitalization, avoiding a hospitalization for pneumonia or avoiding a pneumonia episode in the course of a hospitalization would have prevented or reduced the medical cost associated with the hospitalization.

CONCLUSIONS

Pneumonia hospitalization burden reflected in administrative claims data for hospital discharges depends largely on inclusion criteria. In our analysis, IRs and human and economic burdens when including pneumonias coded in any DF were markedly higher than rates based only on primary pneumonia diagnoses. For an acute condition such as pneumonia, we propose that IR estimates should include all appropriate hospitalizations regardless of the discharge DF in which pneumonia is coded. We are unaware of any scientific rationale for including only pneumonias coded in the first discharge DF.

Additionally, because illness severity and hospitalization were lower in patients hospitalized with pneumonia in the first discharge DF than in other positions, focusing solely on this group underestimates pneumonia burden. We have demonstrated that hospitalizations with pneumonia coded in the second or higher DFs were associated with tremendous health care utilization and direct medical costs, in fact accounting for the majority of all costs attributed to pneumonia hospitalizations. The extent to which pneumonia contributed to the reported outcomes, as well as the extent to which the reported outcomes could have been mitigated by preventive intervention (eg, vaccination against influenza or pneumococcal disease), should be investigated in future studies. Similar to estimated IR, these studies should evaluate the contribution of pneumonia to economic burden regardless of the discharge DF.

Author Affiliations: Vaccines Medical Development and Medical/Scientific Affairs, Pfizer Inc, New York, NY (JAS), and Collegeville, PA (JMM, EC, DLS, BDG, REI); Pfizer Summer Graduate Program (ET, VH), New York, NY; Department of Clinical and Administrative Pharmacy Science, College of Pharmacy, Howard University (ET), Washington, DC; Harvard T.H. Chan School of Public Health (VH), Boston, MA; Patient and Health Impact, Vaccines, Pfizer Inc (JV), Collegeville, PA.

Source of Funding: Pfizer Inc.

Author Disclosures: Drs Suaya, McLaughlin, Chilson, Vietri, Swerdlow, Gessner, and Isturiz are current or former employees of Pfizer Inc and as employees receive company stocks and/or stock options; Pfizer Inc has a pneumococcal vaccine, but this paper is not product specific. Drs Tilahun and Harrison were contractors with Atrium Staffing as summer graduate students and do not hold stock or stock options in Pfizer Inc.

Authorship Information: Concept and design (JAS, ET, VH, JMM, EC, JV, DLS, BDG, REI); acquisition of data (JAS, ET, VH); analysis and interpretation of data (JAS, ET, VH, JMM, EC, JV, DLS, BDG, REI); drafting of the manuscript (JAS, ET, VH, JMM, EC, DLS, BDG, REI); critical revision of the manuscript for important intellectual content (JAS, ET, VH, JMM, EC, JV, DLS, BDG, REI); statistical analysis (JAS, ET, VH, BDG); provision of patients or study materials (ET, VH); obtaining funding (JAS, REI); and supervision (JMM, BDG).

Address Correspondence to: Jose A. Suaya, MD, PhD, MPH, Vaccines Medical Development and Medical/Scientific Affairs, Pfizer Inc, 235 E 42nd St, New York, NY 10017. Email: JSuaya@brandeis.edu.

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