Month Period (month + period)

Distribution by Scientific Domains

Selected Abstracts

The Financial Impact of Ambulance Diversions and Patient Elopements

Thomas Falvo DO
Abstract Objectives Admission process delays and other throughput inefficiencies are a leading cause of emergency department (ED) overcrowding, ambulance diversion, and patient elopements. Hospital capacity constraints reduce the number of treatment beds available to provide revenue-generating patient services. The objective of this study was to develop a practical method for quantifying the revenues that are potentially lost as a result of patient elopements and ambulance diversion. Methods Historical data from 62,588 patient visits to the ED of a 450-bed nonprofit community teaching hospital in central Pennsylvania between July 2004 and June 2005 were used to estimate the value of potential patient visits foregone as a result of ambulance diversion and patients leaving the ED without treatment. Results The study hospital may have lost $3,881,506 in net revenue as a result of ambulance diversions and patient elopements from the ED during a 12-month period. Conclusions Significant revenue may be foregone as a result of throughput delays that prevent the ED from utilizing its existing bed capacity for additional patient visits. [source]

Fragrance contact allergic patients: strategies for use of cosmetic products and perceived impact on life situation

Susan Hovmand Lysdal
Background: Fragrance ingredients are a common cause of contact allergy. Very little is known about these patients' strategies to manage their disease and the effect on their daily lives. Objectives: To investigate if patients with diagnosed fragrance contact allergy used scented products, how they identified tolerated products, and if fragrance allergy affected their daily living. Method: One hundred and forty-seven patients diagnosed with fragrance contact allergy in a 20-month period were included and received a postal questionnaire concerning the subjects of the study. One hundred and seventeen (79.6%) replied. Results: In total, 53/117 (45.3%) responded that they had found some scented products that they could tolerate. Thirty-seven (31.6%) had not tried to find any scented products and 26 (22%) had tried but could not find any. The methods most often used were trying different products and reading the ingredient label. Of the total respondents, 17.1% reported sick-leave due to fragrance allergy and 45.3% found that fragrance allergy significantly affected their daily living. Conclusion: Many patients with fragrance contact allergy succeeded in finding some scented products, which they could tolerate, e.g. by use of ingredient labelling, but a significant proportion had continued skin problems. Almost half of the patients perceived that fragrance allergy significantly affected their daily lives. [source]

Photopatch testing , a retrospective review using the 1 day and 2 day irradiation protocols

R. J. Batchelor
Photopatch testing is indicated in the investigation of patients with eczematous eruptions, affecting mainly light-exposed sites and in those who give a history of worsening of their condition with sun exposure. 3 different protocols are described by the British Photodermatology Group (Br J Dermatol 1997:136:371,376), 1 of which includes irradiation of allergens 1 day after application and 2 using irradiation of allergens 2 days after application. There is no evidence for superiority of any of these protocols. We reviewed the records of all patients who underwent photopatch testing in Leeds over a 50-month period, who had had the allergens applied in triplicate with 1 set irradiated after 1 day occlusion and another after 2 days. The control was occluded for 2 days. Readings were performed at 2 days and 4 days. 15 of 74 patients photopatch tested during this period had 49 positive results between them. 43 of these were felt to be of current relevance to their clinical problem. 34 of the positive results were indicative of photoallergy. Additional photoallergic reactions were detected following 2 days occlusion and irradiation compared with 1 day occlusion (16 versus 5). In conclusion, our case series suggests that 2 days occlusion before irradiation of allergens is more sensitive at detecting photoallergy. [source]


CRIMINOLOGY, Issue 4 2009
Does the death penalty save lives? In recent years, a new round of research has been using annual time-series panel data from the 50 U.S. states for 25 or so years from the 1970s to the late 1990s that claims to find many lives saved through reductions in subsequent homicide rates after executions. This research, in turn, has produced a round of critiques, which concludes that these findings are not robust enough to model even small changes in specifications that yield dramatically different results. A principal reason for this sensitivity of the findings is that few state-years exist (about 1 percent of all state-years) in which six or more executions have occurred. To provide a different perspective, we focus on Texas, a state that has used the death penalty with sufficient frequency to make possible relatively stable estimates of the homicide response to executions. In addition, we narrow the observation intervals for recording executions and homicides from the annual calendar year to monthly intervals. Based on time-series analyses and independent-validation tests, our best-fitting model shows that, from January 1994 through December 2005, evidence exists of modest, short-term reductions in homicides in Texas in the first and fourth months that follow an execution,about 2.5 fewer homicides total. Another model suggests, however, that in addition to homicide reductions, some displacement of homicides may be possible from one month to another in the months after an execution, which reduces the total reduction in homicides after an execution to about .5 during a 12-month period. Implications for additional research and the need for future analysis and replication are discussed. [source]

Trials update in wales

A. Fiander
Three ongoing studies will be presented and discussed. Prevalence of Human Papillomavirus Infection in a South Wales Screening population Methods: A total of 10 000 consecutive, anonymous liquid based cytology screening samples were collected over a five month period in 2004. Age, cytology result and social deprivation score was provided for each specimen. The methodology was chosen to ensure inclusion of all women attending routine cervical screening, avoiding potential constraints associated with obtaining individual informed consent. The liquid based cytology samples were processed and reported by the receiving cytology laboratory and the residual specimens sent to the HPV Research Laboratory, Wales College of Medicine, where they were processed and stored at -80C until analysis. High risk and low risk HPV Typing was undertaken using PCR , EIA (Jacobs et al 1997). Full high risk typing was performed on HPV positive specimens. Results: The study population had a mean age of 38 years with 92% negative, 5% borderline and 3% dyskaryotic cytology. The average social deprivation score was 17.4 (based upon the Welsh Index of multiple deprivation). The following results will be presented: HPV prevalence by age. HPV prevalence by cytology result. Type specific HPV prevalence in single and multiple infection. Conclusion: This study represents the largest type specific HPV Prevalence Study in the UK to date. As such it will form a useful base line against which to access performance of marketed HPV tests and evaluating the impact following implementation of HPV vaccination. [Funded by Welsh Office for Research and Development] CRISP , 1 Study (Cervical Randomized Intervention Study Protocol -1) Background: Indole-3-carbinol (I3C) and Diindolylmethane (DIM) are found in cruciferous vegetables and have been identified as compounds that could potentially prevent or halt carcinogenesis. I3C spontaneously forms DIM in vivo during acid digestion. I3C has been shown to prevent the development of cervical cancer in HPV 16 transgenic mice and both I3C and DIM have been shown to promote cell death in cervical cancer cell models. DIM is the major active bi-product of I3C and preliminary data indicate that DIM is active in cervical dysplasia and may be better tolerated than I3C. Aim: To investigate chemoprevention of high grade cervical neoplasia using Diindolylmethane (DIM) supplementation in women with low grade cytological abnormalities on cervical cytology. Objectives: To observe any reduction in the prevalence of histological proven high-grade cervical intraepithelial neoplasia (CIN) after 6 months of supplementation. ,,To observe any reduction in the prevalence of cytological abnormalities. ,,To observe any changes in the clinical appearance of the cervix. To assess acceptability and monitor any side effects of DIM supplementation. ,,To assess whether any benefit is seen in relation to Human Papillomavirus (HPV) status including HPV Type, Viral load and integration. Methods: This is a double blind randomized placebo-controlled trial involving 600,700 women with low grade cytological abnormalities on a cervical smear. Randomization is in the ratio of 2 : 1 in favour of active medication. Women with first mildly dyskaryotic smear or second borderline smear are eligible. They are asked to take two capsules daily for 6 months. At the end of 6 months they undergo repeat cervical cytology, HPV testing and colposcopy. Results: A progress report will be given for this ongoing study. [Funded: - Cancer Research UK] Type Specific HPV Infection in Welsh Cervical Cancers Background: Whilst there have been numerous studies of HPV infection associated with cervical cancer and on prevalence of Human Papillomavirus in diverse populations there have been no studies of these variables in the same population. Against a background of prophylactic HPV vaccination it is important to assess potential protection against cervical cancer within a given population. The most comprehensive analysis of HPV type specific cervical cancer is a meta-analysis published by the IARC in 2003. This however included only three UK based studies, totalling 118 cases, 75 of which were only investigated by HPV type PCR for four high risk types. None of this data was presented with associated population based prevalence data. Therefore, the research objectives for this study in combination with the first study above, are as follows: To determine the frequency of specific HPV types in cervical cancers in Wales. To compare the distribution of specific HPV types amongst cervical cancers with their prevalence in the general population. This will allow accurate delineation of the relationship between prevalence of specific HPV types in the general population and their association with clinically relevant disease. This information is a pre-requisite to assess the potential impact of prophylactic vaccination against HPV infection in Wales. Methods: Welsh Cervical Cancer specimens from 2000,2005 will be identified from pathology departments within Wales. The pathology of each tumour will be reviewed by a single Gynaecological Pathologist. The age of the patient and pathological features of the tumour will be noted. DNA will be extracted from the paraffin sections and HPV typed by PCR-EIA. Results: A progress report will be given for this ongoing study. [Funded by Welsh Office for Research and Development] [source]

A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine

I. Cormac
Cormac I, Brown A, Creasey S, Ferriter M, Huckstep B. A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapine. Objective:, To investigate the effect of a complete smoking ban on a group of psychiatric inpatients maintained on the antipsychotic medication clozapine. Method:, Retrospective data on clozapine dose and plasma levels were collected from a three month period before and a six month period after the introduction of the smoking ban. Results:, Before the ban only 4.2% of patients who smoked had a plasma clozapine level ,1000 ,g/l but after the ban this increased to 41.7% of the sample within the six month period following the ban despite dose reductions. Conclusion:, Abrupt cessation of smoking is associated with a potentially serious risk of toxicity in patients taking clozapine. Plasma clozapine levels must be monitored closely and adjustments made in dosage, if necessary, for at least six months after cessation. [source]

Laser Hair Removal: Long-Term Results with a 755 nm Alexandrite Laser

Sorin Eremia MD
Background. Hypertrichosis is a common problem for which laser hair removal is becoming the treatment of choice. Optimal wavelength, pulse duration, spot size, fluence, and skin cooling parameters for various skin types have not yet been firmly established. Objective. To evaluate the long-term efficacy and safety of a 3-msec 755 nm alexandrite laser equipped with a cryogen cooling device for patients with Fitzpatrick skin types I,V. Methods. Eighty-nine untanned patients with skin types I,V underwent a total of 492 treatments of laser hair removal over a 15-month period. Each patient in the study underwent a minimum of three treatment sessions spaced 4,6 weeks apart (mean treatments 5.6). Retrospective chart review and patient interviews were used to establish hair reduction results. Treatment sites included the axillae, bikini, extremities, face, and trunk. A 3-msec pulse width, 755 nm alexandrite laser equipped with a cryogen spray cooling device was used in this study. Spot sizes of 10,15 mm were used. A spot size of 10 mm was used for fluences greater than 40 J/cm2, a spot size of 12 mm was used for fluences of 35,40 J/cm2, and spot sizes of 12 and 15 mm were used for fluences less than 30 J/cm2. Fluences ranging from 20 to 50 J/cm2 (mean fluence 36 J/cm2) were used. Results. The patients had a mean 74% hair reduction. Skin type I patients had an average of 78.5% hair reduction using a mean fluence of 40 J/cm2 (35,50 J/cm2) and a 10,12 mm spot size (12 mm in more than 95% of treatments). Skin type II patients had a mean 74.3% hair reduction using a mean fluence of 38 J/cm2 (30,40 J/cm2) and a 12,15 mm spot size. Skin type III patients had a mean 73.4% hair reduction using a mean fluence of 37 J/cm2 (25,40 J/cm2) and a 12,15 mm spot size. Skin type IV patients had a mean 71.0% hair reduction using a mean fluence of 31 J/cm2 (25,35 J/cm2) and a 12,15 mm spot size. A patient with skin type V had a 60% hair reduction using a mean fluence of 23 J/cm2 (20,25 J/cm2) and a 12,15 mm spot size. The efficiency of hair removal directly correlates significantly with the fluence used. Rare side effects included transient postinflammatory hyperpigmentation (n = 9; 10%), burn with blisters (n = 1; 1%), and postinflammatory hypopigmentation (n = 2; 2%). All complications resolved without permanent scarring. Conclusion. The 3-msec cryogen cooling-equipped alexandrite laser can safely and effectively achieve long-term hair removal in patients with skin types I,V. The best results are achieved in untanned patients with skin types I,IV. [source]

Magnetic resonance imaging findings in a population-based cohort of children with cerebral palsy

The purpose of this study was to investigate the frequency and spectrum of magnetic resonance imaging (MRI) abnormalities in a population of children with cerebral palsy (CP) who were born in the years 2000 and 2001 in Victoria, Australia. In 2000 and 2001, 221 children (126 males, 95 females; mean age 6y [SD 7mo], range 5,7y) with CP, excluding those with CP due to postneonatal causes (6% of all cases), were identified through the Victorian Cerebral Palsy Register. All medical records were systematically reviewed and all available brain imaging was comprehensively evaluated by a single senior MRI radiologist. MRI was available for 154 (70%) individuals and abnormalities were identified in 129 (84%). The study group comprised 88% with a spastic motor type CP; the distribution was hemiplegia in 33.5%, diplegia in 28.5%, and quadriplegia in 37.6% of children. Overall, pathological findings were most likely to be identified in children with spastic hemiplegia (92%) and spastic quadriplegia (84%). Abnormalities were less likely to be identified in non-spastic motor types (72%) and spastic diplegia (52%). The most common abnormalities identified on MRI were periventricular white matter injury (31%), focal ischaemic/haemorrhagic lesions (16%), diffuse encephalopathy (14%), and brain malformations (12%). Dual findings were seen in 3% of patients. This is the first study to document comprehensively the neuroimaging findings of all children identified with CP born over a consecutive 24-month period in a large geographical area. [source]

Predictors of glycaemic control in indigent patients presenting with diabetic ketoacidosis

M. Maldonado
Aim:, To derive predictors of good glycaemic control in patients presenting with diabetic ketoacidosis (DKA) followed prospectively in a specialized clinic. Methods:, One hundred and sixty-one adult patients were admitted during a 31-month period and followed for at least 12 months. After 1 year, the patients were classified into three groups: good control (GC) (HbA1c , 7%), intermediate control (IC) (HbA1c 7,9%) and poor control (PC) (HbA1c > 9%). Characteristics of patients in the three groups were compared both at baseline and during follow-up. Results:, At 12 months, 36% of the patients were classified as GC, 27% as IC and 37% as PC. GC patients had higher fasting serum C-peptide levels 0.7 0.54 compared to 0.38 0.29 and 0.16 0.21 nmol/l, respectively, for the IC and PC patients (p < 0.0001). A higher proportion GC patient had a C-peptide level greater than 0.33 nmol/l than that for IC and PC patients (86, 61 and 19%, respectively; p < 0.0001). Exogenous insulin was safely discontinued in 50, 30 and 3% of patients, respectively, in the GC, IC and PC groups (p < 0.0001). Compliance with life-style interventions was higher in the GC than that in IC and PC patients (87, 41 and 5%, respectively; p < 0.0001). In the logistic regression analysis, predictors of good glycaemic control were having baseline fasting serum C-peptide value ,0.33 mmol/l, OR: 3.01 (95% CI 1.07,8.55, p = 0.03) and compliance with life-style interventions OR 12.66 (95% CI 3.73,51.57, p = 0.0001). Conclusion:, Among adult patients with DKA, significant predictors of good glycaemic control are preserved ,-cell function and compliance with life-style modifications. [source]

Long-term review of driving potential following bilateral panretinal photocoagulation for proliferative diabetic retinopathy

S. A. Vernon
Abstract Aim To determine the necessity for repeated Driver and Vehicle Licensing Agency (DVLA) visual field testing in people with diabetes who have had bilateral panretinal photocoagulation (PRP) for proliferative diabetic retinopathy. Methods A questionnaire survey was conducted of driving history in a cohort of people with diabetes who had been treated with bilateral PRP for proliferative retinopathy between 1988 and 1990. In addition, all similarly eligible subjects attending the diabetic retinal review clinic over a 12-month period who had had laser between 1991 and 2000 were questioned as to their driving status. Results Forty-five surviving patients from the 1988,1990 cohort were eligible and 25 returned the questionnaire (55%). Eight had never driven and 15 (13 with Type 1 diabetes) still held a valid licence, having passed the DVLA field test on a number of occasions. Neither of the two patients who had stopped driving reported failing the DVLA field test as the reason for stopping. All 12 of the patients directly questioned in the clinic were still driving and had passed at least one repeat DVLA test. Conclusions People with Type 1 diabetes who have no further laser treatment for proliferative diabetic retinopathy can expect to retain their UK driving licence for at least 15 years following small-burn PRP, provided they maintain sufficient acuity. [source]

Low-risk HLA genotype in Type 1 diabetes is associated with less destruction of pancreatic B-cells 12 months after diagnosis

M. Spoletini
Abstract Aims The role of human leukocyte antigen (HLA) genes in the susceptibility to Type 1 diabetes (T1DM) is well known. However, we do not know whether the degree of pancreatic B-cell destruction depends on different HLA genetic risk. The aim of this study was to analyse the influence of DRB1* and DQB1* genes on the rate of pancreatic B-cell loss in a prospective series of 120 consecutive newly diagnosed T1DM subjects in the first 12 months after diagnosis. Methods Patients were typed for HLA-DRB1* and DQB1* loci by a reverse line blot assay using an array of immobilized sequence-specific oligonucleotide probes. C-peptide, insulin requirement and glycated haemoglobin (HbA1c) were determined at diagnosis and every 3 months for 12 months. The variance of C-peptide as evidence of B-cell loss during follow-up was analysed using the general linear model for repeated-measures procedure. Results Fasting C-peptide in T1DM subjects with low HLA genetic risk was significantly higher when compared with subjects with moderate or high HLA genetic risk from time of diagnosis up to 12 months (P = 0.007 and P = 0.0002, respectively). Nonetheless, the changes in C-peptide levels over a 12-month period did not differ significantly between T1DM subjects with different HLA genetic risks. Conclusions Low-risk HLA genotype in T1DM is associated with less destruction of pancreatic B-cells up to 12 months after diagnosis. These results are useful when designing trials for therapies aimed to prevent the progression of B-cell destruction in recent-onset T1DM. [source]

Joint liaison psychiatry,diabetes clinic: a new specialist service

C. Mitchell
Summary Aims Specialist diabetes clinics have an established role in prevention and management of complications. As psychological problems are usually treated separately from diabetes centres, the role of a specialist psychiatrist within a teaching hospital was assessed. The aims of the study were to describe referral patterns, specific psychiatric conditions and treatments offered. Results During weekly outpatient sessions over a 12-month period, 31 patients were referred with a wide range of psychiatric diagnoses. One-third of patients were seen on the day and two-thirds within 2 weeks of referral. Treatments included anti-depressant medication, counselling and cognitive behaviour therapy. Successful discharge was obtained in 10 subjects and eight were undergoing continued treatment. Conclusions The range of specific diagnoses requiring psychiatric supervision supported the role of specifically trained personnel as seen in a joint liaison psychiatry,diabetes service. Keywords diabetes mellitus, joint clinic, liaison psychiatry [source]

The effect of preoperative weight loss and body mass index on postoperative outcome in patients with esophagogastric carcinoma

J. Skipworth
SUMMARY Studies have shown that weight loss is associated with adverse outcomes in all treatment modalities for esophagogastric carcinoma. Because of the increased prevalence of obesity and the effectiveness of perioperative nutrition, a number of patients are now obese or have normal body mass index (BMI) at the time of treatment. We investigated the relationship between weight loss, BMI, and outcome of surgery for patients with esophagogastric carcinoma. Data were collected over a 38-month period for all patients diagnosed with operable esophagogastric cancer at two UK centers. All patients underwent resection by a single Consultant Upper Gastrointestinal Surgeon and the use of perioperative jejunal feeding was universal. Ninety-three patients (57 male) underwent esophagogastric resection; 48 had no preoperative weight loss (34 with a BMI > 25 and 14 with a BMI < 25). Forty-five patients had preoperative weight loss (20 with BMI > 25 and 25 with BMI < 25). There was no significant difference in complication rates, median hospital stay, or mortality between the four groups. A significantly higher number of patients displaying preoperative weight loss were found to have stage III disease, but difference in survival of up to 3 years did not reach statistical significance on multivariate analysis. Preoperative weight loss and low BMI did not significantly influence the complication rate, perioperative mortality rate, length of hospital stay, or short-term prognosis. We conclude that preoperative weight loss can not be reliably used as an independent predictor of poor outcome in patients undergoing surgery for esophagogastric carcinoma. However, patients with preoperative weight loss and low BMI are more likely to have advanced disease. [source]

Spatial dynamics of supercolonies of the invasive yellow crazy ant, Anoplolepis gracilipes, on Christmas Island, Indian Ocean

K. L. AbbottArticle first published online: 19 DEC 200
ABSTRACT Key to the management of invasive species is an understanding of the scope of an invasion, the rate of proliferation and the rate at which invaded habitats become degraded. This study examines the spatial dynamics of high-density supercolonies of the invasive yellow crazy ant, Anoplolepis gracilipes, on Christmas Island, Indian Ocean, and the associated impacts at their boundaries. Since the early 1990s, A. gracilipes supercolonies have occupied over 30% of the 10,000 ha of rainforest on Christmas Island. Thirty-four discrete high-density supercolonies formed between 1989 and 2003, ranging in size across nearly three orders of magnitude from 0.9 to 787 ha. Supercolonies boundaries are diffuse, and ants were observed in low densities in some cases up to 200 m from the main high-density supercolony. The 13 boundaries examined were all dynamic over a 10,20 observation month period: nine boundaries expanded, and the maximum rate of spread was 0.5 m day,1. Across boundary transition zones, between high-density supercolonies and intact rainforest, yellow crazy ants reduced other ant species richness, occupied red crab burrows and killed resident red crabs, which was the trigger for ,invasional meltdown' on Christmas Island. The highly variable and unpredictable nature of A. gracilipes boundaries poses a challenge for incorporation into a predictive framework, as well as for their management. [source]

Daily to seasonal cross-shore behaviour of quasi-persistent intertidal beach morphology

S. Quartel
Abstract In this study, an intertidal bar and trough system on the beach of Noordwijk, The Netherlands was monitored over a 15-month period in order to examine the daily to seasonal sequential cross-shore behaviour and to establish which conditions force or interrupt this cyclic bar behaviour. The beach morphology (bars and troughs) was classified from low-tide Argus video images based on surface composition. From the classified images, time series of the landward boundary of the bar and of the trough were extracted. The time series of the alongshore-averaged boundary positions described sawtooth motion with a period between 1 and 4 months, comprising gradual landward migration followed by abrupt seaward shifts. The abrupt seaward shift appeared to be a morphological reset induced by storm events, which lasted at least 30 h with a large average root-mean-square wave height (,2 m) and offshore surge level (,05 m), and a small trough (<20 m wide) in the pre-storm beach morphology. The time series of the boundary positions exhibited very little longer (seasonal) scale variability, but somewhat larger smaller (daily) scale variability. The bar boundary was found to be more dynamic than the trough boundary. Copyright 2007 John Wiley & Sons, Ltd. [source]

Transcatheter Intracardiac Echocardiography-Assisted Closure of Interatrial Shunts: Complications and Midterm Follow-Up

Gianluca Rigatelli M.D.
Objective: It has been suggested that intracardiac echocardiography (ICE) improves the safety and effectiveness of transcatheter device-based closure of interatrial shunts, but the impact of this technique on midterm follow-up is unknown. We sought to prospectively evaluate midterm follow-up results of ICE-aided transcatheter closure of interatrial shunts in adults. Methods: Over a 48-month period, we prospectively enrolled 140 consecutive patients (mean age 43 15. 5 years, 98 females) who had been referred to our center for catheter-based closure of interatrial shunts. All patients were screened with transesophageal echocardiography (TEE) before the operation. Patients who met the inclusion criteria underwent ICE study and attempted closure. Immediate success rates, predischarge occlusion rates, complication rates, as well as fluoroscopy and procedural times, patients' radiological exposure, midterm complication rates, and midterm occlusion rates were evaluated. Results: One hundred patients out of 140 (71.4%) underwent an attempt at transcatheter closure. After ICE study and measurements, the TEE-planned device type and size was changed in 31 patients with patent foramen ovale whereas the TEE-planned device size was changed in 41 patients with atrial septal defect (globally 72%). Procedural success rate, predischarge occlusion rate, and complication rate were 99, 90.7, and 12%, respectively. On mean follow-up of 36.6 14.8 months the follow-up occlusion rate was 96.5%. No aortic erosion or device thrombosis was observed. Conclusions: ICE-guided interatrial shunt transcatheter closure is safe and effective and appears to have excellent midterm results thus avoiding the complications caused by device oversizing, such as aortic erosion and device thrombosis. [source]

Impact of Scribes on Performance Indicators in the Emergency Department

Rajiv Arya MD
Abstract Objectives:, The objective was to quantify the effect of scribes on three measures of emergency physician (EP) productivity in an adult emergency department (ED). Methods:, For this retrospective study, 243 clinical shifts (of either 10 or 12 hours) worked by 13 EPs during an 18-month period were selected for evaluation. Payroll data sheets were examined to determine whether these shifts were covered, uncovered, or partially covered (for less than 4 hours) by a scribe; partially covered shifts were grouped with uncovered shifts for analysis. Covered shifts were compared to uncovered shifts in a clustered design, by physician. Hierarchical linear models were used to study the association between percentage of patients with which a scribe was used during a shift and EP productivity as measured by patients per hour, relative value units (RVUs) per hour, and turnaround time (TAT) to discharge. Results:, RVUs per hour increased by 0.24 units (95% confidence interval [CI] = 0.10 to 0.38, p = 0.0011) for every 10% increment in scribe usage during a shift. The number of patients per hour increased by 0.08 (95% CI = 0.04 to 0.12, p = 0.0024) for every 10% increment of scribe usage during a shift. TAT was not significantly associated with scribe use. These associations did not lose significance after accounting for physician assistant (PA) use. Conclusions:, In this retrospective study, EP use of a scribe was associated with improved overall productivity as measured by patients treated per hour (Pt/hr) and RVU generated per hour by EPs, but not as measured by TAT to discharge. ACADEMIC EMERGENCY MEDICINE 2010; 17:490,494 2010 by the Society for Academic Emergency Medicine [source]

Metoprolol CR/XL Improves Systolic and Diastolic Left Ventricular Function in Patients with Chronic Heart Failure

Torstein Hole M.D.
Aims: To investigate whether metoprolol controlled release/extended release (CR/XL) once daily would improve diastolic and systolic left ventricular function in patients with chronic heart failure and decreased ejection fraction. Methods: In an echocardiographic substudy to the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF), 66 patients were examined three times during a 12-month period blinded to treatment group, assessing left ventricular dimensions and ejection fraction, and Doppler mitral inflow parameters, all measured in a core laboratory. Results: In the metoprolol CR/XL group left ventricular ejection fraction increased from 0.26 to 0.31 (P = 0.009) after a mean observation period of 10.6 months, and deceleration time of the early mitral filling wave (E) increased from 189 to 246 ms (P = 0.0012), time velocity integral of E-wave increased from 8.7 to 11.2 cm (P = 0.018), and the duration of the late mitral filling wave (A) increased from 122 to 145 ms (P = 0.014). No significant changes were seen in the placebo group regarding any of these variables. Conclusion: Metoprolol CR/XL once daily in addition to standard therapy improved both diastolic and systolic function in patients with chronic heart failure and decreased ejection fraction. (ECHOCARDIOGRAPHY, Volume 21, April 2004) [source]

Therapeutic Yield and Outcomes of a Community Teaching Hospital Code Stroke Protocol

Andrew W. Asimos MD
Objectives: To describe the experience of a community teaching hospital emergency department (ED) Code Stroke Protocol (CSP) for identifying acute ischemic stroke (AIS) patients and treating them with tissue plasminogen activator (tPA) and to compare outcome measures with those achieved in the National Institute of Neurological Disorders and Stroke (NINDS) trial. Methods: This study was a retrospective review from a hospital CSP registry. Results: Over a 56-month period, CSP activation occurred 255 times, with 24% (n= 60) of patients treated with intravenous (IV) tPA. The most common reasons for thrombolytic therapy exclusion were mild or rapidly improving symptoms in 37% (n= 64), intracerebral hemorrhage (ICH) in 23% (n= 39), and unconfirmed symptom onset time for 14% (n= 24) of patients. Within 36 hours of IV tPA treatment, 10% (NINDS = 6%) of patients (n= 6) sustained a symptomatic ICH (SICH). Three months after IV tPA treatment, 60% of patients had achieved an excellent neurologic outcome, based on a Barthel Index of ,95 (NINDS = 52%), while mortality measured 12% (NINDS = 17%). Among IV tPA-treated patients, those developing SICH were significantly older and had a significantly higher mean initial glucose value. Treatment protocol violations occurred in 32% of IV tPA-treated patients but were not significantly associated with SICH (Fisher's exact test). Conclusions: Over the study period, the CSP yielded approximately one IV tPA-treated patient for every four screened and, despite prevalent protocol violations, attained three-month functional outcomes equal to those achieved in the NINDS trial. For community teaching hospitals, ED-directed CSPs are a feasible and effective means to screen AIS patients for treatment with thrombolysis. [source]

Fast track: Has it changed patient care in the emergency department?

Paul Kwa
Abstract Objective: To determine whether the introduction of a designated fast-track area altered the time to care and patient flow in an Australian mixed adult and paediatric ED. Methods: Retrospective cohort study of all patients presenting to the ED between 08.00 and 22.00 hours, during a 6 month period before and after the opening of a fast-track area. Data were stratified according to Australasian Triage Scale (ATS) category, and comparisons were made for performance indicators, waiting time, length of stay and did-not-waits. Results: During its operational hours, fast track managed 14.9% of all patients presenting to the ED. There was a significant increase in the proportion of all ATS 4 patients seen within their target times (77.8% to 79.9%, P < 0.001). There was a trend towards improved performance in ATS categories 2, 3 and 5. Median patient waiting times were significantly decreased in ATS 4 (24 to 22 min, P < 0.001) and ATS 5 (27 to 25 min, P < 0.05), but increased in ATS 2 (3 to 4 min, P < 0.05). No deterioration in performance or waiting time for ATS 1 was shown. There was a decreasing trend in the proportion of patients who did not wait to be assessed by a doctor in ATS categories 4 and 5. These improvements occurred despite a 12% increase in patient attendances and no change in medical staffing levels. Conclusions: Fast track in an Australian mixed ED can help meet the demand of increasing patient attendances, allowing lower-acuity patients to be seen quickly without a negative impact on high-acuity patients. [source]

A Comparison of Trauma Intubations Managed by Anesthesiologists and Emergency Physicians

Joseph S. Bushra MD
Although airway management by emergency physicians has become standard for general emergency department (ED) patients, many believe that anesthesiologists should manage the airways of trauma victims. Objectives: To compare the success and failure rates of trauma intubations performed under the supervision of anesthesiologists and emergency physicians. Methods: This was a prospective, observational study of consecutive endotracheal intubations (ETIs) of adult trauma patients in a single ED over a 46-month period. All ETIs before November 26, 2000, were supervised by anesthesiologists (34 months), and all ETIs from November 26, 2000, onward were supervised by emergency physicians (12 months). Data regarding clinical presentation, personnel involved, medications used, number of attempts required, and need for cricothyrotomy were collected. Study outcomes were: 1) successful intubation within two attempts, and 2) failure of intubation. Failure was defined as inability to intubate, resulting in successful intubation by another specialist, or cricothyrotomy. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to compare results between groups. Results: There were 673 intubations during the study period. Intubation within two attempts was accomplished in 442 of 467 patients (94.6%) managed by anesthesiologists, and in 196 of 206 of patients (95.2%) managed by emergency physicians (OR = 1.109, 95% CI = 0.498 to 2.522). Failure of intubation occurred in 16 of 467 (3.4%) patients managed by anesthesiologists, and in four of 206 (1.9%) patients managed by emergency physicians (OR = 0.558, 95% CI = 0.156 to 1.806). Conclusions: Emergency physicians can safely manage the airways of trauma patients. Success and failure rates are similar to those of anesthesiologists. [source]

Influence of isolation on the recovery of pond mesocosms from the application of an insecticide.


Abstract The immediate response and recovery of the macrobenthic communities of nonisolated and isolated freshwater outdoor 9 m3 mesocosms following an acute stress caused by the addition of deltamethrin were studied over a 14-month period. To discriminate between internal and external recovery mechanisms, half of the treated ponds were covered by 1-mm mesh lids that restricted aerial recolonization. Both structural (abundance of the different taxonomic groups) and functional (litter breakdown) parameters were monitored. Insects were broadly reduced in numbers by deltamethrin addition. In general, noninsect groups were not affected or increased in abundance in deltamethrin-treated ponds, probably because of relative insensitivity to deltamethrin, reduced predation, and lower competition for food. No major change in litter breakdown rates were seen, probably because of functional redundancy among the macrobenthic community. Chironominae larvae recovered in open, treated mesocosms 62 d after deltamethrin addition and most insect groups recovered 84 d after the treatment date. However, the presence of lids significantly reduced insect recovery rate, suggesting that it largely depends on the immigration of winged forms (i.e., external recovery) from surrounding non- or less affected systems. These results indicate that the recovery time of macrobenthic communities in an affected natural pond would depend on spatial characteristics of the landscape and also the season that exposure occurs. Isolated ecosystems would display posttreatment insect recovery dynamics very different from highly connected ones, evolving toward alternate pseudoequilibrium states, possibly with lower biodiversity but with preserved functionality. Consequences for higher tier risk assessment of pesticides are discussed. [source]

Concentrations and partitioning of polychlorinated biphenyls in the surface waters of the southern Baltic Sea,seasonal effects

Kilian E.C. Smith
Abstract In the marine environment, the partitioning of hydrophobic organic contaminants, such as polychlorinated biphenyls (PCBs), between the dissolved and suspended matter phases in the water column plays a fundamental role in determining contaminant fate (e.g., air,water exchange or food-chain uptake). Despite the pronounced seasonality in physical, chemical, and biological conditions in temperate marine ecosystems, little is known about the seasonality in organic contaminant partitioning behavior. Surface water from the western Baltic Sea was sampled regularly during an 18-month period between February 2003 and July 2004. The concentrations of seven PCB congeners were determined in the dissolved and particulate organic carbon (POC) phases. An inverse relationship was found between KPOC (i.e., the ratio between the POC-normalized PCB concentration [pg/kg POC] and the dissolved concentration [pg/L]) and temperature. The decrease in the water temperature of 20C between summer and winter resulted in an increase in KPOC by a factor of approximately five. The POC-normalized PCB concentrations were higher in winter than in summer by a factor of 9 to 20. This reflected the higher KPOC and somewhat greater PCB concentrations in the dissolved phase, and it could have consequences for bioaccumulation of these chemicals in aquatic food webs. The results demonstrate a clear seasonality in contaminant partitioning in the temperate marine environment that should be accounted for when interpreting field data or modeling contaminant fate. [source]

Underdosing of Midazolam in Emergency Endotracheal Intubation

Mark J. Sagarin MD
Objectives: To determine whether midazolam, when used as an induction agent for emergency department (ED) rapid-sequence intubation (RSI), is used in adequate and recommended induction doses (0.1 to 0.3 mg/kg), and to compare the accuracy of the dosing of midazolam for ED RSI with the accuracy of dosing of other agents. Methods: The authors conducted a systematic query of a prospectively collected database of ED intubations using the National Emergency Airway Registry data, gathered in 11 participating EDs over a 16-month period. A data form completed at the time of emergency department intubation (EDI) enabled analysis of patients' ages, weights, and indications for EDI, as well as the techniques and drugs used to facilitate EDI. Data were analyzed to determine whether midazolam is used in recommended doses during RSI. Patients intubated with midazolam alone were compared with patients who received other induction agents for RSI. Results: Of 1,288 patients entered in the study, 1,023 (79%) underwent RSI. Of the 888 RSI patients with an age recorded, midazolam was used as the sole induction agent in 140 (16%). The mean (SD) dosages of midazolam used in RSI were 2.6 (1.7) mg in children (age , 18) and 3.7 (2.5) mg in adults (age ,19); the mean (SD) dosages by weight were 0.08 (0.04) mg/kg in children and 0.05 (0.03) mg/kg in adults. More than half (56%) of the children, and nearly all (92%) of the adults, received dosages lower than the minimum recommended dosage (0.1 mg/kg). Of patients who received barbiturates, only 21% of children and 21% of adults received a dose lower than the minimum recommended. When combined with another induction agent, midazolam was dosed similarly to when it was used alone: mean adult doses were 3.1 (1.2) mg and 0.04 (0.02) mg/kg. Conclusions: Underdosing of midazolam during ED RSI is frequent, and appears to be related to incorrect dosage selection, rather than to a deliberate intention to reduce the dose used. [source]

The Costs of Childhood Epilepsy in Italy: Comparative Findings from Three Health Care Settings

EPILEPSIA, Issue 5 2001
R. Guerrini
Summary: ,Purpose: To determine the direct costs of epilepsy in a child neurology referral population, stratified by disease, duration, and severity, comparing three different health care settings [i.e., teaching or clinical research (CR) hospitals, general hospitals, and outpatient services]. Methods: Patients were accepted if they had confirmed epilepsy and were resident in the center catchment area. Eligible subjects were grouped in the following categories: (a) newly diagnosed patients; (b) patients with epilepsy in remission; (c) patients with active non,drug-resistant epilepsy; and (d) those with drug-resistant epilepsy. Over a 12-month period, data regarding the consuming of all resources (i.e., consultations, tests, hospital admissions, drugs), were collected for each patient. Using the Italian National Health Service tariffs, the unit cost of each resource was calculated and indicated in Euros, the European currency. Results: A total of 189 patients was enrolled by two teaching-CR hospitals, two general hospitals, and two outpatient services. The patients were evenly distributed across the four categories of epilepsy. The mean annual cost per person with epilepsy was 1,767 Euros. Drug-resistant epilepsy was the most expensive category (3,268 Euros) followed by newly diagnosed epilepsy (1,907 Euros), active non,drug-resistant epilepsy (1,112 Euros), and epilepsy in remission (844 Euros). Costs were generally highest in teaching-CR hospitals and lowest in outpatient services. Hospital services were the major cost in all epilepsy groups, followed by drugs. Conclusions: The cost of epilepsy in children and adolescents in Italy tends to vary significantly depending on the severity and duration of the disease Hospitals services and drugs are the major sources of costs. The setting of health care plays a significant role in the variation of the costs, even for patients in the same category of epilepsy. [source]

Oral endoscopy as an aid to diagnosis of equine cheek tooth infections in the absence of gross oral pathological changes: 17 cases

Summary Reasons for performing study: Removal of cheek teeth in all but the aged horse or pony is a serious undertaking with potentially deleterious sequellae. Rigid endoscopy permits detailed examination of the oral cavity and erupted dental tissues and has the potential to assist in the correct identification of the diseased tooth. Objectives: To document oral endoscopic findings associated with infected equine cheek teeth in cases without gross oral pathological changes and thereby determine the usefulness of rigid oral endoscopy as an aid to diagnosis of such infections. Methods: Records of all cases of equine cheek tooth removal attempted under standing sedation over a 38 month period were examined. Cases were excluded from the study if apical infection was associated with gross dental fracture, malalignment, diastema/periodontal pocketing or supernumerary teeth. Endoscopic and radiographic findings were analysed and correlated to diseased tooth location. Results: Seventeen cases of apical dental infection fitting the inclusion criteria (nonresponsive to antibiotics and with no gross oral abnormality of the affected arcade) were identified in which oral endoscopy was used as an aid to diagnosis. In 15 (88%) of the 17 cases, oral endoscopy revealed abnormalities specific to the infected tooth. Focal gingival recession (10/17 cases) was the most common visible abnormality associated with infected teeth. Conclusions: In the majority of cases of apical infection of equine cheek teeth there is visible intraoral evidence implicating the affected tooth. Potential relevance: Oral endoscopy facilitates detailed examination of the mouth and should be considered along with radiography as an important aid to diagnosis in cases of equine dental infection. [source]

Post mortem survey of dental disorders in 349 donkeys from an aged population (2005,2006).

Part 1: Prevalence of specific dental disorders
Summary Reasons for performing study: Donkey dental disorders are being recognised with increased frequency worldwide and have important welfare implications; however, no detailed investigations of dental disorders in donkeys appear to have been published. Objectives: To determine the prevalence of specified dental disorders in donkeys by performing a prospective post mortem study on donkeys that were subjected to euthanasia or died for other reasons at the Donkey Sanctuary, UK. Methods: Post mortem examinations were performed on 349 donkeys over an 18 month period, 2005,2006. The presence and extent of specified dental disorders were recorded and these data analysed to determine their prevalence and common locations. 45Results: A high prevalence (93%) of disorders was noted in the population with a median age of 31 years. In particular, cheek teeth diastemata (85% prevalence) were very common, often associated with advanced periodontal disease. Other disorders observed included missing teeth (in 55.6% of donkeys), displaced teeth (43%), worn teeth (34%), local overgrowths (15%), focal sharp overgrowths (3%) and dental-related soft tissue injuries (8%). Conclusions and potential relevance: Aged donkeys have a high prevalence of significant dental disease, especially cheek teeth diastemata. These findings highlight the importance of routine dental examinations and prophylactic dental treatments to improve the dental health and welfare of donkeys. [source]

Developmental aspects of distal limb conformation in the horse: the potential consequences of uneven feet in foals

Summary Reasons for performing study: Distal limb conformation is generally accepted to be an important item with respect to performance and soundness in mature horses, but little is known about the developmental aspects. Objectives: To gain insight into the development of distal limb conformation and to assess the possible consequences of uneven feet in foals. Methods: Conformation of the distal front limbs of 23 Warmblood foals was scored visually and measured using radiographs, at ages 27 and 55 weeks. At the same ages, pressure measurements were made under both front feet. Results: At both ages the hoof-pastern axis was broken-backwards on radiographs, but only occasionally recognised as such, when scored by eye. Over time, the hoof angle decreased, while both the angles of the dorsal and solar surfaces of the distal phalanx (P3) increased and the parallelism between hoof wall and P3 improved. The foals with uneven feet at age 27 weeks showed a significant difference in distal limb loading that persisted until age 55 weeks. Conclusions: The alignment of the distal limb in the sagittal plane increased in a 6 month period. Visual assessment was not sensitive enough to appreciate this. The growth processes in the distal limb could not compensate for existing unevenness and ensuing asymmetrical limb loading. Potential relevance: Foals have a different conformation of the distal limb from mature horses, which should be taken into account when interpreting radiographs. Unevenness of the feet resulted in asymmetrical loading of the proximal and distal interphalangeal joint, which might lead to increased susceptibility to overload injuries and decreased performance at mature age. [source]

Acoustic Features of Female Chacma Baboon Barks

ETHOLOGY, Issue 1 2001
Julia Fischer
We studied variation in the loud barks of free-ranging female chacma baboons (Papio cynocephalus ursinus) with respect to context, predator type, and individuality over an 18-month period in the Moremi Game Reserve, Botswana. To examine acoustic differences in relation to these variables, we extracted a suite of acoustic parameters from digitized calls and applied discriminant function analyses. The barks constitute a graded continuum, ranging from a tonal, harmonically rich call into a call with a more noisy, harsh structure. Tonal barks are typically given when the signaler is at risk of losing contact with the group or when a mother and infant have become separated (contact barks). The harsher variants are given in response to large predators (alarm barks). However, there are also intermediate forms between the two subtypes which may occur in both situations. This finding is not due to an overlap of individuals' distinct distributions but can be replicated within individuals. Within the alarm bark category, there are significant differences between calls given in response to mammalian carnivores and those given in response to crocodiles. Again, there are intermediate variants. Both alarm call types are equally different from contact barks, indicating that the calls vary along different dimensions. Finally, there are consistent, significant differences among different individuals' calls. However, individual identity in one call type cannot directly be inferred from knowledge of the individuals' call characteristics in the other. In sum, the barks of female baboons potentially provide rich information to the recipients of these signals. The extent to which baboons discriminate between alarm and contact barks, and classify calls according to context and/or acoustic similarity will be described in a subsequent paper. [source]

An evidence-based specialist breast nurse role in practice: a multicentre implementation study

National breast cancer centre's specialist breast nurse project team
The objective of this study was to examine the feasibility, implementation, acceptability and impact of an evidence-based specialist breast care nurse (SBN) model of care in Australia. Primary data were collected from four diverse Australian breast cancer treatment centres over a 12-month period. The design was a multicentre demonstration project. Information about the provision of care and patient needs was collected through prospective logs. Structured interviews were conducted with women who received the SBN intervention (N = 167) and with a control group of women treated prior to the intervention period (N = 133). Health professionals (N = 47) were interviewed about their experience of the SBN. Almost all women had contact with an SBN at five scheduled consultations and 67% of women in the intervention group requested at least one additional consultation with the SBN. Women in the intervention group were more likely to receive hospital fact sheets and to be told about and participate in clinical trials. Ninety-eight per cent of women reported that the availability of an SBN would affect their choice of hospital, with 48% indicating that they would recommend only a hospital with a SBN available. Health professionals reported that SBNs improved continuity of care, information and support for the women, and resulted in more appropriate referrals and use of the time of other members of the team. In conclusion, the SBN model is feasible and acceptable within diverse Australian treatment centres; there is evidence that some aspects of care were improved by the SBN. [source]