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Acute Management (acute + management)
Selected AbstractsThe Impact of Race on the Acute Management of Chest PainACADEMIC EMERGENCY MEDICINE, Issue 11 2003Arvind Venkat MD Abstract Objectives: African Americans with acute coronary syndromes receive cardiac catheterization less frequently than whites. The objective was to determine if such disparities extend to acute evaluation and noninterventional treatment. Methods: Data on adults with chest pain (N= 7,935) presenting to eight emergency departments (EDs) were evaluated from the Internet Tracking Registry of Acute Coronary Syndromes. Groups were selected from final ED diagnosis: 1) acute myocardial infarction (AMI), n= 400; 2) unstable angina/non,ST-elevation myocardial infarction (UA/NSTEMI), n= 1,153; and 3) nonacute coronary syndrome chest pain (non-ACS CP), n= 6,382. American College of Cardiology/American Heart Association guidelines for AMI and UA/NSTEMI were used to evaluate racial disparities with logistic regression models. Odds ratios (ORs) were adjusted for age, gender, guideline publication, and insurance status. Non-ACS CP patients were assessed by comparing electrocardiographic (ECG)/laboratory evaluation, medical treatment, admission rates, and invasive and noninvasive testing for coronary artery disease (CAD). Results: African Americans with UA/NSTEMI received glycoprotein IIb/IIIa receptor inhibitors less often than whites (OR, 0.41; 95% CI = 0.19 to 0.91). African Americans with non-ACS CP underwent ECG/laboratory evaluation, medical treatment, and invasive and noninvasive testing for CAD less often than whites (p < 0.05). Other nonwhites with non-ACS CP were admitted and received invasive testing for CAD less often than whites (p < 0.01). African Americans and other nonwhites with AMI underwent catheterization less frequently than whites (OR, 0.45; 95% CI = 0.29 to 0.71 and OR, 0.40; 95% CI = 0.17 to 0.92, respectively). A similar disparity in catheterization was noted in UA/NSTEMI therapy (OR, 0.53; 95% CI = 0.40 to 0.68 and OR, 0.68; 95% CI = 0.47 to 0.99). Conclusions: Racial disparities in acute chest pain management extend beyond cardiac catheterization. Poor compliance with recommended treatments for ACS may be an explanation. [source] Acute management,How should we intervene?CLINICAL CARDIOLOGY, Issue S1 2000Frederic Kontny M.D., PH.D. Abstract A crucial question in the acute management of the patient with unstable coronary artery disease (UCAD) is whether to carry out early intervention, performing angiography soon after presentation and following this with revascularization where appropriate, or whether to follow a noninvasive medical strategy as far as possible unless symptoms necessitate intervention. The body of literature addressing this question is sparse, but the recent Fast Revascularization during InStability in Coronary artery disease (FRISC II) study has provided new insights into the problem. Using a factorial design to randomize patients to invasive or noninvasive management strategies, and to short- or long-term treatment with the low-molecular-weight heparin (LMWH) dalteparin sodium (Fragmin®), it was shown in FRISC II that early invasive treatment (within 7 days), when combined with optimal medical pretreatment with dalteparin sodium, aspirin, and appropriate antianginal medication, is associated with improved clinical outcomes, relative to a "watchful waiting" approach based on noninvasive therapy. Thus, an early invasive approach following aggressive medical pretreatment should be the preferred strategy for patients with UCAD who present with signs of ischemia on the electrocardiogram or raised biochemical markers of myocardial damage at admission. [source] Shared Care in Geriatric Oncology: Primary Care Providers' and Medical/Oncologist's PerspectivesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2009Cynthia Owusu MD Existing literature lends support to the benefit of shared care in the management of chronic diseases, but there are limited data on the feasibility, cost-effectiveness, or benefits of shared care in oncology. A recent conference organized by the Aging and Cancer Program of the Case Comprehensive Cancer Center sought to explore the perceptions of physicians and other allied health professionals who attended the conference about shared care in the acute management of older patients with cancer using a case history presentation and an anonymous audience response system. Analyses of the audience response indicated that shared responsibility and enhanced information exchange in addition to the current level of communication between providers involved in the acute management of older patients with cancer is desirable. Studies exploring the feasibility and benefits of a shared care model in the management of older patients with cancer are needed. [source] Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approachJOURNAL OF CLINICAL NURSING, Issue 17 2009John X Rolley Aim., To evaluate the existing literature to inform nursing management of people undergoing percutaneous coronary intervention. Background., Percutaneous coronary intervention is an increasingly important revascularisation strategy in coronary heart disease management and can be an emergent, planned or rescue procedure. Nurses play a critical role in delivering care in both the independent and collaborative contexts of percutaneous coronary intervention management. Design., Systematic review. Method., The method of an integrative literature review, using the conceptual framework of the patient journey, was used to describe existing evidence and to determine important areas for future research. The electronic data bases CINAHL, Medline, Cochrane and the Joanna Briggs data bases were searched using terms including: (angioplasty, transulminal, percutaneous coronary), nursing care, postprocedure complications (haemorrhage, ecchymosis, haematoma), rehabilitation, emergency medical services (transportation of patients, triage). Results., Despite the frequency of the procedure, there are limited data to inform nursing care for people undergoing percutaneous coronary intervention. Currently, there are no widely accessible nursing practice guidelines focusing on the nursing management in percutaneous coronary intervention. Findings of the review were summarised under the headings: Symptom recognition; Treatment decision; Peri-percutaneous coronary intervention care, describing the acute management and Postpercutaneous coronary intervention management identifying the discharge planning and secondary prevention phase. Conclusions., Cardiovascular nurses need to engage in developing evidence to support guideline development. Developing consensus on nurse sensitive patient outcome indicators may enable benchmarking strategies and inform clinical trial design. Relevance to clinical practice., To improve the care given to individuals undergoing percutaneous coronary intervention, it is important to base practice on high-level evidence. Where this is lacking, clinicians need to arrive at a consensus as to appropriate standards of practice while also engaging in developing evidence. This must be considered, however, from the central perspective of the patient and their family. [source] The Role of Enoxaparin in Interventional Management of Patients with Acute Coronary SyndromesJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2003CINDY L. GRINES M.D., F.A.C.C. Interventional management strategies involving early angiography and percutaneous coronary intervention (PCI) are increasingly widespread in the management of patients with acute coronary syndromes (ACS). Notwithstanding the benefits of early intervention, there is a significant risk of postprocedural thrombotic complications and a need to optimize antithrombotic regimens for use before and during PCI. It is clear that the current standard therapy with unfractionated heparin (UFH) and aspirin can be improved upon, in terms of both efficacy and safety. The low-molecular-weight heparin(s) (LMWHs) offer pharmacologic and practical advantages over UFH. The LMWH enoxaparin has recently emerged as the anticoagulant of choice for the acute management of ACS. Enoxaparin has also demonstrated sustained benefits over UFH in patients proceeding to PCI, and as a procedural anticoagulant. Combination therapy with enoxaparin and a glycoprotein IIb/IIIa inhibitor may further improve the efficacy and safety of antithrombotic treatment during coronary interventions, as a result of the drugs' complementary mechanisms of action. Early clinical evidence supports the use of enoxaparin in combination with glycoprotein IIb/IIIa inhibitors in high-risk patients with ACS. Ongoing, large-scale, randomized controlled studies will help to clarify the role of enoxaparin in interventional cardiology, either as the primary anticoagulant or as part of a combination regimen, and to define optimal regimens for treatment. (J Interven Cardiol 2003;16:357,366) [source] Awake upper airway obstruction in children with spastic quadriplegic cerebral palsyJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 1-2 2006Dominic J Wilkinson Objective: Some children with severe cerebral palsy develop symptoms of upper airway obstruction (UAO) while awake. The aetiology, natural history and treatment of this complication have not previously been systematically described. This study documents a case series of children with severe cerebral palsy admitted to hospital because of severe awake UAO and reviews the relevant literature. Methods: The case records of children admitted to hospital with UAO while awake over an 8-month period were reviewed. Details of antecedent illness, comorbidities, acute management and follow up were collated. One case is presented in detail. Results: Eight children were admitted with UAO. Seven children required intensive care admission. One child died, and two underwent tracheostomy. Nasendoscopy showed pharyngeal collapse without anatomical obstruction in the majority. One child was discovered to have a brainstem malignancy. Conclusions: Upper airway obstruction is a potentially severe and life-threatening complication of cerebral palsy. In this series, a majority of children had obstruction related to pharyngeal hypotonia and collapse. This can lead to prolonged hospitalization and intensive care admission. It may raise difficult management issues. [source] Anaphylaxis during anaesthesia: diagnostic approachALLERGY, Issue 5 2007D. G. Ebo Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anaesthesiologist, and subsequent determination of the responsible agent(s) with strict avoidance of subsequent administration of all incriminated and/or cross-reacting compounds. However, correct identification of the causative compound(s) and safe alternatives is not always straightforward and, too often, not done. This review is not intended to discuss acute management of anaesthesia-related anaphylaxis but summarizes the major causes of anaphylaxis during anaesthesia and the diagnostic approach of this rare but potentially life-threatening complication. Apart from general principles about the diagnostic approach, history taking and importance of tryptase quantification, more specific confirmatory diagnostic procedures are organized on the basis of the major causes of perioperative anaphylactic reactions. [source] Emergency Department Sickle Cell Assessment of Needs and Strengths (ED-SCANS), a Focus Group and Decision Support Tool Development ProjectACADEMIC EMERGENCY MEDICINE, Issue 8 2010Paula Tanabe PhD ACADEMIC EMERGENCY MEDICINE 2010; 17:848,858 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, A decision support tool may guide emergency clinicians in recognizing assessment, analgesic and overall management, and health service delivery needs for patients with sickle cell disease (SCD) in the emergency department (ED). We aimed to identify data and process elements important in making decisions regarding evaluation and management of adult patients in the ED with painful episodes of SCD. Methods:, Qualitative methods using a series of focus groups and grounded theory were used. Eligible participants included adult clients with SCD and emergency physicians and nurses with a minimum of 1 year of experience providing care to patients with SCD in the ED. Patients were recruited in conjunction with annual SCD meetings, and providers included clinicians who were and were not affiliated with sickle cell centers. Groups were conducted until saturation was reached and included a total of two patient groups, three physician groups, and two nurse groups. Focus groups were held in New York, Durham, Chicago, New Orleans, and Denver. Clinician participants were asked the following three questions to guide the discussion: 1) what information would be important to know about patients with SCD in the ED setting to effectively care for them and help you identify patient analgesic, treatment, and referral needs? 2) What treatment decisions would you make with this information? and 3) What characteristics would a decision support tool need to have to make it meaningful and useful? Client participants were asked the same questions with rewording to reflect what they believed providers should know to provide the best care and what they should do with the information. All focus groups were audiotaped and transcribed. The constant comparative method was used to analyze the data. Two coders independently coded participant responses and identified focal themes based on the key questions. An investigator and assistant independently reviewed the transcripts and met until the final coding structure was determined. Results:, Forty-seven individuals participated (14 persons with SCD, 16 physicians, and 17 nurses) in a total of seven different groups. Two major themes emerged: acute management and health care utilization. Major subthemes included the following: physiologic findings, diagnostics, assessment and treatment of acute painful episodes, and disposition. The most common minor subthemes that emerged included past medical history, presence of a medical home (physician or clinic), individualized analgesic treatment plan for treatment of painful episodes, history of present illness, medical home follow-up available, patient-reported analgesic treatment that works, and availability of analgesic prescription at discharge. Additional important elements in treatment of acute pain episodes included the use of a standard analgesic protocol, need for fluids and nonpharmacologic interventions, and the assessment of typicality of pain presentation. The patients' interpretation of the need for hospital admission also ranked high. Conclusions:, Participants identified several areas that are important in the assessment, management, and disposition decisions that may help guide best practices for SCD patients in the ED setting. [source] Use of continuous positive airway pressure in the acute management of laryngeal paralysis in a catAUSTRALIAN VETERINARY JOURNAL, Issue 10 2008K Ticehurst Continuous positive airway pressure (CPAP) has been is used widely in humans to manage obstructive sleep apnoea syndrome, but it has not been widely used in animals. A brachycephalic cat, with previously undiagnosed laryngeal paralysis, that developed acute upper respiratory tract obstruction on recovery from anaesthesia, is presented. The condition was managed by CPAP, delivered via a facial mask. [source] Future perspectives in the acute management of head injury,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 7 2003P. J. Hutchinson Observations on one of the commonest reasons for admission to hospital [source] Sequential Analysis of Pretreatment Delays In Stroke ThrombolysisACADEMIC EMERGENCY MEDICINE, Issue 9 2010Tuukka Puolakka BM ACADEMIC EMERGENCY MEDICINE 2010; 17:965,969 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, The aim was to determine if an intensive restructuring of the approach to acute stroke improved time to thrombolysis over a 3-year study period and to determine whether delay modifications correlated with increased thrombolytic intervention or functional outcome. Methods:, The study examined the pretreatment process to define specific time intervals (delays) of interest in the acute management of 289 consecutive ischemic stroke patients who were transported by the emergency medical services (EMS) and received intravenous (IV) thrombolytic therapy in the emergency department (ED) of Helsinki University Central Hospital. Time interval changes of the 3-year period and use of thrombolytics was measured. Functional outcome, measured with the modified Rankin Scale (mRS) at 3 months, was assessed with multivariable statistical analysis. Results:, During implementation of the restructuring program from 2003 to 2005, the median total time delay from symptom onset to drug administration dropped from 149 to 112 minutes (p < 0.0001). Prehospital delays did not change significantly during the study period. The median delay in calling an ambulance remained at 13 minutes, and the total median prehospital delay stayed at 71 minutes. In-hospital delays decreased from 67 to 34 minutes (p < 0.0001). The median call delay was 25 minutes in patients with mild symptoms (National Institute of Health Stroke Scale [NIHSS] score < 7) and 8 minutes with severe symptoms (NIHSS > 15). In the multivariate model, stroke severity (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.78 to 0.88, p < 0.0001), age (OR = 0.57, 95% CI = 0.42 to 0.77, p < 0.0001), and in-hospital delay (OR = 0.47, 95% CI = 0.22 to 0.97, p = 0.04) were suggesting a good outcome. Conclusions:, Restructuring of the teamwork between the EMS personnel and the reorganized ED significantly reduced in-hospital, but not prehospital, delays. The present data suggest that a decreased in-hospital delay improves the accessibility of the benefits of thrombolysis. [source] Acute management,How should we intervene?CLINICAL CARDIOLOGY, Issue S1 2000Frederic Kontny M.D., PH.D. Abstract A crucial question in the acute management of the patient with unstable coronary artery disease (UCAD) is whether to carry out early intervention, performing angiography soon after presentation and following this with revascularization where appropriate, or whether to follow a noninvasive medical strategy as far as possible unless symptoms necessitate intervention. The body of literature addressing this question is sparse, but the recent Fast Revascularization during InStability in Coronary artery disease (FRISC II) study has provided new insights into the problem. Using a factorial design to randomize patients to invasive or noninvasive management strategies, and to short- or long-term treatment with the low-molecular-weight heparin (LMWH) dalteparin sodium (Fragmin®), it was shown in FRISC II that early invasive treatment (within 7 days), when combined with optimal medical pretreatment with dalteparin sodium, aspirin, and appropriate antianginal medication, is associated with improved clinical outcomes, relative to a "watchful waiting" approach based on noninvasive therapy. Thus, an early invasive approach following aggressive medical pretreatment should be the preferred strategy for patients with UCAD who present with signs of ischemia on the electrocardiogram or raised biochemical markers of myocardial damage at admission. [source] |