Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prospects for the control of neglected tropical diseases by mass drug administration

The prospects for the control of neglected tropical diseases, including soil-transmitted helminthiasis, shistosomiasis, lymphatic filariasis, onchocerciasis and trachoma, through mass drug administration, are exemplified by the elimination of the trachoma as a public-health problem in Morocco. In spite of this and other striking successes, mass drug administration programs are faced with major challenges resulting from suboptimal coverage and lack of efficacy. At current suboptimal coverage rates, programs may need prolongation for an extended period, increasing costs and undermining sustainability. Community participation through health education and information appears to be crucial to improve coverage and to achieve sustainability. Implementation of complementary measures, such as vector control, improved hygiene and environmental sanitation, are important to further control transmission and to prevent re-emergence of the infection and, again, may only be achieved effectively through community-based initiatives. To reduce costs and to relieve pressure on the health system, combining neglected tropical disease programs in areas where diseases coexist and integration with existing control programs for malaria, tuberculosis and HIV/AIDS is advocated. The risk of developing drug resistance is of particular concern in view of the lack of alternative drugs, and reduced treatment efficacy due to emerging resistance is evident for the soil-transmitted helminths and onchocerciasis. Given the risk for the development of drug resistance and the need for a high degree of participation, close attention should be paid to the monitoring of the coverage and efficacy of the different program components.     

Bacterial meningitis: an update of new treatment options

The outcome of bacterial meningitis critically depends on the rapid initiation of bactericidal antibiotic therapy and adequate management of septic shock. In community-acquired meningitis, the choice of an optimum initial empirical antibiotic regimen depends on the regional resistance patterns. Pathogens resistant to antibacterials prevail in nosocomial bacterial meningitis. Dexamethasone is recommended as adjunctive therapy for community-acquired meningitis in developed countries. In comatose patients, aggressive measures to lower intracranial pressure <20 mmHg (in particular, external ventriculostomy, osmotherapy and temporary hyperventilation) were effective in a case–control study. Although many experimental approaches were protective in animal models, none of them has been proven effective in patients. Antibiotics, which are bactericidal but do not lyse bacteria, and inhibitors of matrix metalloproteinases or complement factor C5 appear the most promising therapeutic options. At present, vaccination is the most efficient method to reduce disease burden. Palmitoylethanolamide appears promising to enhance the resistance of the brain to infections.     

Imaging choices in occult hip fracture

Background: Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people. Objectives: In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Discussion: Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3–4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging. Conclusion: We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.     

Systematic Reviews Published in the April 2012 Issue of the Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD but monthly online. The April 2012 issue (second DVD for 2012) contains 5045 complete reviews, 2182 protocols for reviews in production, and 17,084 short summaries of systematic reviews published in the general medical literature. In addition, there are citations of 674,000 randomized controlled trials, and 15,400 cited papers in the Cochrane methodology register. The health technology assessment database contains just over 11,000 citations. One hundred and seventeen new reviews have been published in the last 3 months of which 12 have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.186. Readers are encouraged to access the full report for any articles of interest as only a brief commentary is provided.     

Platelets,thrombosis, coagulation,and atherosclerosis

When I first got the invitation to join a medical delegation going to Moldova, I thought for a moment that our destination was the fictional country in the old Marx Brothers movie Duck Soup. On further checking, it turns out that entertaining place was called Freedonia. I now know that Moldova is indeed a real country, bordered on the west by Romania and on the other three sides by the Ukraine. It is a proud country, rich with traditions, and its people are warm, giving, eager to learn ways to improve their healthcare system, and deeply appreciative of our attempts to help them in the task.     

Spiritual Dimensions of Nursing Practice. edited by V. B. Carson

The Cochrane Library of Systematic Reviewsis published quarterly. Issue one for 2004 of the library was published in February 2004. This issue contains 3,329 reviews and protocols of which 1,921 are fully published reviews. The trials database now stands at over 400,000 records with an additional 4,427 one-page summaries of non-Cochrane reviews in the NHS database of reviews of effectiveness (DARE). This version of the library contains the results of an extensive search for RCTs on EMBASE. The latest library contains 84 new reviews, seven are considered relevant to practitioners in pain and palliative care. References are published in the same format as the citation for Cochrane reviews.     

Advance Care Planning

Predictors of patient wishes and influence of family and clinicians are discussed. Research findings on patient decision-making relating to preferences in end-of-life care are described. Advance directives and durable powers of attorney are defined and differentiated. Most patients have not participated in advance care planning and the need for more effective planning is documented. Appropriate times for discussions of such planning are described. Scenarios discussed include terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. Patient satisfaction is discussed, as is a structured process for discussions about patient preferences. Results of patient responses to hypothetical scenarios are described. Invasiveness of interventions, prognosis and other factors that favor or discourage patient preferences for treatment are discussed. Findings resulting from research funded by the Agency for Healthcare Research and Quality (AHRQ) are discussed. This research can help providers offer end-of-life care based on preferences held by the majority of patients under similar circumstances.     

Évaluation,par l’imagerie ultrasonore,du recrutement musculaire,de la force motrice et de la détente verticale du quadriceps après électromyostimulation (cas de 15 étudiants de l’INJS)

The increase of strength seems to be an element of performance in some sports.     

Single Transseptal Big Cryoballoon Pulmonary Vein Isolation using an Inner Lumen Mapping Catheter

Background: The single big cryoballon technique for pulmonary vein isolation (PVI) has been limited by the need for two transseptal punctures (TP). We therefore investigated feasibility and safety of a simplified approach using a single TP and a novel circumferential mapping catheter (CMC). Methods: Patients underwent 28‐mm cryoballoon PVI using a single TP. The CMC (Achieve^© Medtronic Inc., Minneapolis, MN, USA) served as (1) guidewire and (2) as a PV mapping tool. Primary endpoint was PVI without switching to a regular guidewire. Secondary endpoints included: (1) PV signal quality during freezing, (2) time to PVI, (3) classification of successful ablation technique, (4) complications, and (5) procedural data. Results: A total of 32 patients (126 PVs) were studied (mean age: 62 ± 11 years, 24 males, left atrium: 40 ± 4 mm). The primary endpoint was achieved in 29/32 patients (91%) and 123/126 PVs (98%) with a procedure and fluoroscopy time of 126 ± 26 minutes and 18.9 ± 7.5 minutes, respectively. Real‐time visualization of PVI could be observed in 61/126 (48%) PVs. Time to sustained PVI versus nonsustained PVI was 66 ± 56 seconds versus 129 ± 76 seconds (P < 0.001). One phrenic nerve palsy was observed. After a follow‐up of 250 ± 84 days 23/32 patients (72%) remained in sinus rhythm. Conclusion: The “simplified single big cryoballoon” PVI strategy appears to be safe and feasible. However, real‐time PV recording was achieved in <50% of PVs. Therefore, further catheter refinements are warranted. (PACE 2012; 35:1304–1311)     

Thromboelastogram does not detect pre-injury anticoagulation in acute trauma patients

Purpose

Thromboelastography (TEG) has been recommended to characterize post-traumatic coagulopathy, yet no study has evaluated the impact of pre-injury anticoagulation (AC) on TEG variables. We hypothesized patients on pre-injury AC have a greater incidence of coagulopathy on TEG compared to those without AC.

Évaluation d’un protocole de kinésithérapie ambulatoire pour la prise en charge des coxarthroses et conflits antérieurs fémoro-acétabulaires des sportifs

Introduction

Hip osteoarthritis and femoroacetabular impingement frequently affect sportsmen and are origins of permanent incapacity. The therapic behaviour before surgery step is not yet established. Physiotherapy is often suggested but it is still difficult to prescribe it correctly. The main goal of our study is to show superiority, both in terms of decrease of pain and increase of sportive activity, of the process “PROTOCOX” including both physiotherapy and manual therapy in comparison with a physiotherapy process “CONTROLE”.

Method

Twenty-six sportive patients of the “Institut régional de médecine du sport de Haute Normandie (IRMSHN)” have been included in the study in an 18-month period. Our secondary aims are to show improvement of life quality and range of motion. Several data including HOOS and Lequesne index have been harvested before and after the six sessions and after 3 months.

Results

For patients (n = 11) of the “PROTOCOX” group (P = 0.034), a significant improvement of the HOOS index, mainly on pain (P = 0.04) and allowing an increase of sportive activity (P = 0.007). After 3 months, there was still a transitory improvement allowing an increase of sportive activity for 75% of the patients (n = 8) of the “PROTOCOX” group in comparison of 18.2% for the “CONTROLE” patients.

Conclusion

The “PROTOCOX” process is simple and practicable in liberal sector, and gives benefits in terms of decrease of pain and sportive activity increase with a reduce number of sessions and its transitory efficiency stays at mid term.     

临床路径在社区2型糖尿病和糖尿病高危人群的护理研究

目的开发设计适合我国城市社区2型糖尿病（DM）和糖尿病高危人群诊治的临床路径（Clinical pathway，CP）。方法运用图文式CP对社区DM患者和DM高危人群进行护理干预，并对患者生活质量及各生化指标进行对比分析。结果2型DM和DM高危人群经CP干预后，在生理领域、心理领域、社会领域、环境领域得分均高于干预前，且CP干预后得分高于传统方法干预组（P〈0．05），生活质量有了明显改善。结论图文式CP对于社区2型糖尿病和糖尿病高危人群的具有明显地改善患者生活质量和治疗的作用。     

Minimizing postpartum pain: a review of research pertaining to perineal care in childbearing women

This paper provides a review of literature that relates to perineal pain and care. Articles evaluated include systematic reviews and research papers from the disciplines of midwifery, physiotherapy and obstetrics. The major themes to emerge from the literature and be reviewed are the need for episiotomy, suturing methods and materials, assessment of perineal trauma, treatment of perineum in the postpartum period, and postpartum recovery. Research has highlighted that many practices relating to perineal care remain un-researched and therefore the need for evaluation is urgent. Further postpartum morbidity has been seen to affect many women, but is often unrecognized by practitioners. It is also a topic that requires further evaluation through well-designed and implemented research.     

Ergonomic Pain––Part 2: Differential Diagnosis and Management Considerations

Abstract: Work‐related musculoskeletal disorders (MSDs) can produce ergonomic pain in several different regions of the body, including the shoulder, elbow, wrist and hand, lumbar spine, knee, and ankle/foot. Each family of disorders is distinctive in presentation and requires diagnosis‐specific interventions. Because of the complex nature of these disorders, management approaches may not always eliminate symptoms and or completely restore patient function to a level found prior to symptom onset. As a consequence, ergonomic measures should be implemented to reduce the overload on tissue and contribute to patient recovery. However, functional limits may persist and the clinician must make further decisions regarding a person's functional status in the chronic stages of the patient's care.     

A Call for a Reconsideration of the Use of Fecal Occult Blood Testing in Emergency Medicine

BackgroundFecal occult blood testing (FOBT) was developed to detect microscopic bleeding caused by colorectal neoplasms. The role of FOBT in the emergency department (ED) is typically used for 5 different clinical workups: trauma, anemia, syncope, hypotension, and before the administration of systemic anticoagulants or thrombolytics.ObjectiveWe scrutinized the literature to assess the utility of FOBT for its 5 most common applications in the emergent setting.DiscussionLogic and clinical evidence advocating for FOBT usage in the aforementioned situations are lacking. The test itself requires specific drug and dietary restrictions that are often violated or never met when patients present to the ED with acute pathologies. In addition, the poor sensitivity and specificity of the test in these scenarios dictate that neither a negative nor positive FOBT should change the subsequent clinical workup of patients presenting to the ED.ConclusionClinical decision making should seldom be predicated on the results of a FOBT in the ED setting.     

氧化电位水用于口腔科贮水罐水系统消毒的研究

目的 探讨降低口腔科贮水罐水系统的细菌微生物污染,减少口腔科医源性感染的发生.方法 对照组采用常规方法24 h更换贮水罐与蒸馏水;观察组贮水罐水系统采用每人次氧化电位水进行冲洗消毒.比较两种方法水系统细菌微生物污染数量的变化.结果 对照组60份口腔水系统水样品合格率为63.34％ (40/60),观察组60份水样品合格率为100％,经x2检验P＜0.01.结论 口腔科贮水罐水系统的细菌微生物污染现象较严重,应引起高度重视,加强管理.采用氧化电位水进行贮水罐水系统消毒,可以明显降低微生物数量,是控制口腔科贮水罐水系统细菌微生物污染的有效措施.     

Safety of blind versus guided feeding tube placement: Misplacement and pneumothorax risk

Most intensive care unit patients require a feeding tube, but misplacement risk is high due to the presence of artificial airways and because unconsciousness reduces clinical warnings. Predominantly, tubes are placed 'blindly', where position is not known throughout placement. The result is that 1.6% enter the lung, 0.5% cause pneumothorax and potentially 5% are left in the oesophagus. Guided placement, by identifying tube position in real time, may prevent these problems, but undetected misplacements still occur. We review the safety of guided methods of confirming tube position, including rates of pneumothorax, in the context of current unguided methods.During blind tube placement, tube position can only be tracked intermittently. Excepting X-ray and ultra-sound, most methods of checking position are simple. Conversely, guided tube placement can track tube position from the nose to small intestine (IRIS®), or oesophagus to jejunum (Cortrak™, ENvue®). However, this requires expertise. Overall, guided placement is associated with lower rates of pneumothorax. Unfortunately, for Cortrak, low-use centres have higher rates of undetected misplacement compared with blind placement whereas Cortrak use in high-use centres had lower risk compared with blind placement and low use centres.Because guided placement requires high-level expertise manufacturer training packages have been developed but currently appear insufficient. Specifically, Cortrak’s package is less accurate in determining tube position compared to the 'gastrointestinal flexure' system. Validation of an evidence-based guide for IRIS placement is underway. Recommendations are made regarding the training of new operators, including minimum numbers of placements required to achieve expertise.