Effect of a Mixed Kinesio Taping–Compression Technique on Quality of Life and Clinical and Gait Parameters in Postmenopausal Women With Chronic Venous Insufficiency: Double-Blinded,Randomized Controlled Trial

Objective

To investigate the short-term effect of a mixed Kinesio taping (KT) model on range of ankle motion (ROAM), gait, pain, perimeter of lower limbs, and quality of life in postmenopausal women with chronic venous insufficiency (CVI).

Design

Double-blinded, randomized controlled trial.

Setting

Clinical setting.

Participants

Consecutive postmenopausal women (N=130; mean age ± SD, 65.44±14.7y) with mild CVI. No participant withdrew because of adverse effects.

Intervention

Participants were randomly assigned to either (1) an experimental group to receive a mixed KT-compression treatment following KT recommendations for gastrocnemius muscle enhancement and functional correction of the ankle, and adding 2 tapes to simulate traditional compression bandages (no KT guidelines); or (2) a placebo control group for sham KT. Both interventions were performed 3 times a week during a 4-week period.

Main Outcome Measures

ROAM, gait, pain, perimeter of right and left lower limb, and quality of life were assessed at baseline and 48 hours posttreatment.

Results

Quality of life was better in the intervention group by a mean of 8.76 points (95% confidence interval [CI], 4.96–12.55). The experimental group also showed significant pre-/posttreatment improvements in both lower limbs in gait dorsiflexion ROAM (95% CI, 1.02–2.49), cadence (95% CI, 3.45–1.47), stride length (95% CI, 21.48–10.83), step length (95% CI, 1.68–6.61), stance phase (95% CI, 61–107), and foot (95% CI, .56–.92) and malleolus (95% CI, 1.15–1.63) circumference. None of these variables were significantly modified in the placebo group. Both groups reported a significant reduction in pain.

Conclusions

Ankle dorsiflexion during gait, walking parameters, peripheral edema, venous pain, and quality of life remain improved in patients with CVI at 1 month after mixed KT-compression therapy. KT may have a placebo effect on pain perception.     

Predicting Peripheral Venous Access Difficulty in the Emergency Department Using Body Mass Index and a Clinical Evaluation of Venous Accessibility

Background

Peripheral venous (PV) cannulation, one of the most common technical procedures in Emergency Medicine, may prove challenging, even to experienced Emergency Department (ED) staff. Morbid obesity (body mass index [BMI] ≥ 40) has been reported as a risk factor for PV access failure in the operating room.

Objectives

We investigated PV access difficulty in the ED, across BMI categories, focusing on patient-related predicting factors.

Methods

Prospective, observational study including adult patients requiring PV lines. Operators were skilled nurses and physicians. PV accessibility was clinically evaluated before all cannulation attempts, using vein visibility and palpability. Patient and PV placement characteristics were recorded. Primary outcome was failure at first attempt. Outcome frequency and comparisons between groups were examined. Predictors of difficult cannulation were explored using logistic regression. A p-value <0.05 was considered significant.

Results

PV lines were placed in 563 consecutive patients (53 ± 23 years, BMI: 26 ± 7 kg/m²), with a success rate of 98.6%, and a mean attempt of 1.3 ± 0.7 (range 1–7). Failure at the first attempt was recorded in 21% of patients (95% confidence interval [CI] 17.6–24.4). Independent risk factors were: a BMI ≥ 30 (odds ratio [OR] 1.98, 95% CI 1.09–3.60), a BMI < 18.5 (OR 2.24; 95% CI 1.07–4.66), an unfavorable (OR 1.66, 95% CI 1.02–2.69), and very unfavorable clinical assessment of PV accessibility (OR 2.38, 95% CI 1.15–4.93).

Conclusion

Obesity, underweight, an unfavorable, and a very unfavorable clinical evaluation of PV accessibility are independent risk factors for difficult PV access. Early recognition of patients at risk could help in planning alternative approaches for achieving rapid PV access.     

Derivation of a Clinical Decision Guide in the Diagnosis of Cervical Facet Joint Pain

Objective

To derive a clinical decision guide (CDG) to identify patients best suited for cervical diagnostic facet joint blocks.

Design

Prospective cohort study.

Setting

Pain management center.

Participants

Consecutive patients with neck pain (N=125) referred to an interventional pain management center were approached to participate.

Interventions

Subjects underwent a standardized testing protocol, performed by a physiotherapist, prior to receiving diagnostic facet joint blocks. All subjects received the reference standard diagnostic facet joint block protocol, namely controlled medial branch blocks (MBBs). The physicians performing the MBBs were blinded to the local anesthetic used and findings of the clinical tests.

Main Outcome Measures

Multivariate regression analyses were performed in the derivation of the CDGs. Sensitivity, specificity, positive and negative likelihood ratios, and 95% confidence intervals (CIs) were calculated for the index tests and CDGs.

Results

A CDG involving the findings of the manual spinal examination (MSE), palpation for segmental tenderness (PST), and extension-rotation (ER) test demonstrated a specificity of 84% (95% CI, 77–90) and a positive likelihood ratio of 4.94 (95% CI, 2.8–8.2). Sensitivity of the PST and MSE were 94% (95% CI, 90–98) and 92% (95% CI, 88–97), respectively. Negative findings on the PST were associated with a negative likelihood ratio of .08 (95% CI, .03–.24).

Conclusions

MSE, PST, and ER may be useful tests in identifying patients suitable for diagnostic facet joint blocks. Further research is needed to validate the CDGs prior to their routine use in clinical practice.     

Work Ability Index Predicts Application for Disability Pension After Work-Related Medical Rehabilitation for Chronic Back Pain

Objective

To determine whether the Work Ability Index (WAI), a short 7-item self-report questionnaire addressing issues of perceived disability, impairment, and expectations for resuming work, predicts application for disability pension, recommendations for further treatment, and other adverse work-related criteria in patients with chronic back pain after rehabilitation.

Design

Cohort study with 3-month follow-up.

Setting

Seven inpatient rehabilitation centers.

Participants

Patients (N=294; 168 women; mean age, 49.9y) with chronic back pain.

Intervention

The WAI was completed at the beginning of rehabilitation. All patients were treated according to the German rehabilitation guidelines for chronic back pain and work-related medical rehabilitation.

Main Outcome Measure

Application for disability pension, as assessed by a postal questionnaire 3 months after discharge.

Results

Receiver operating characteristic curve analysis of the association between the WAI at baseline and subsequent application for disability pension revealed an area under the curve of .80 (95% confidence interval [CI], .62–.97). Youden index was highest when the WAI cutoff value was ≤20 points (sensitivity, 72.7%; specificity, 82.2%; total correct classification, 81.7%). After adjusting for age and sex, persons with a baseline WAI score of ≤20 points had 15.6 times (95% CI, 3.6–68.2) higher odds of subsequent application for disability pension, 4.9 times (95% CI, 1.5–16.8) higher odds of unemployment, and 6 times (95% CI, 2.4–15.2) higher odds of long-term sick leave at follow-up.

Conclusions

The WAI could help rehabilitation professionals identify patients with back pain with a high risk of a subsequent application for disability pension.     

Determining the Activation of Gluteus Medius and the Validity of the Single Leg Stance Test in Chronic,Nonspecific Low Back Pain

Objectives

To determine the activation of the gluteus medius in persons with chronic, nonspecific low back pain compared with that in control subjects, and to determine the association of the clinical rating of the single leg stance (SLS) with chronic low back pain (CLBP) and gluteus medius weakness.

Design

Cohort-control comparison.

Setting

Academic research laboratory.

Participants

Convenience sample of people (n=21) with CLBP (>12wk) recruited by local physiotherapists, and age- and sex-matched controls (n=22). Subjects who received specific pain diagnoses were excluded.

Interventions

Not applicable.

Main Outcome Measures

Back pain using the visual analog scale (mm); back-related disability using the Oswestry Back Disability Index (%); strength of gluteus medius measured using a hand dynamometer (N/kg); SLS test; gluteus medius onset and activation using electromyography during unipedal stance on a forceplate.

Results

Individuals in the CLBP group exhibited significant weakness in the gluteus medius compared with controls (right, P=.04; left, P=.002). They also had more pain (CLBP: mean, 20.50mm; 95% confidence interval [CI], 13.11–27.9mm; control subjects: mean, 1.77mm; 95% CI, −.21 to 3.75mm) and back-related disability (CLBP: mean, 18.52%; 95% CI, 14.46%–22.59%; control subjects: mean, .68%; 95% CI, −.41% to 1.77%), and reported being less physically active. Weakness was accompanied by increased gluteus medius activation during unipedal stance (R=.50, P=.001) but by no difference in muscle onset times. Although greater gluteus medius weakness was associated with greater pain and disability, there was no difference in muscle strength between those scoring positive and negative on the SLS test (right: F=.002, P=.96; left: F=.1.75, P=.19).

Conclusions

Individuals with CLBP had weaker gluteus medius muscles than control subjects without back pain. Even though there was no significant difference in onset time of the gluteus medius when moving to unipedal stance between the groups, the CLBP group had greater gluteus medius activation. A key finding was that a positive SLS test did not distinguish the CLBP group from the control group, nor was it a sign of gluteus medius weakness.     

Intravenous Lidocaine for the Emergency Department Treatment of Acute Radicular Low Back Pain,a Randomized Controlled Trial

Background

Acute radicular back pain is a frequent complaint of patients presenting to the Emergency Department.

Study Objective

Determine the efficacy of intravenous lidocaine when compared to ketorolac for the treatment of acute radicular low back pain.

Methods

Randomized double-blind study of 41 patients aged 18–55 years presenting with acute radicular low back pain. Patients were randomized to receive either 100 mg lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60 minutes. Changes in [median] VAS scores were compared over time (within groups) by the signed-rank test and between groups by the rank-sum test. A 5-point Pain Relief Scale (PRS) was administered at the conclusion of the study (60 min) and again at 1 week by telephone follow-up; [median] scores were compared between groups by rank-sum.

Results

Forty-four patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac). Initial VAS scores were not significantly different between the lidocaine and ketorolac groups (83; 95% confidence interval [CI] 74–98 vs. 79; 95% CI 64–94; p = 0.278). Median VAS scores from baseline to 60 min significantly declined in both groups (lidocaine [8; 95% CI 0–23; p = 0.003]; ketorolac [14; 95% CI 0–28; p = 0.007]), with no significant difference in the degree of reduction between groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine, compared to 50% receiving ketorolac. No significant change in PRS between groups was found at the conclusion or at the follow-up.

Conclusion

Intravenous lidocaine failed to clinically alleviate the pain associated with acute radicular low back pain.     

Gabapentinoids Are Effective in Decreasing Neuropathic Pain and Other Secondary Outcomes After Spinal Cord Injury: A Meta-Analysis

Objective

To examine the effectiveness of gabapentin and pregabalin in diminishing neuropathic pain and other secondary conditions in individuals with spinal cord injury (SCI).

Data Sources

A systematic search was conducted using multiple databases for relevant articles published from 1980 to June 2013.

Study Selection

Controlled and uncontrolled trials involving gabapentin and pregabalin for treatment of neuropathic pain, with ≥3 subjects and ≥50% of study population with SCI, were included.

Data Extraction

Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference (SMD), SE, and 95% confidence interval (CI) for primary (pain) and secondary outcomes (anxiety, depression, sleep interference) was conducted.

Data Synthesis

Eight studies met inclusion criteria. There was a significant reduction in the intensity of neuropathic pain at <3 months (SMD=.96±.11; 95% CI, .74–1.19; P<.001) and between 3 and 6 months (SMD=2.80±.18; 95% CI, 2.44–3.16; P<.001). A subanalysis found a significant decrease in pain with gabapentin (SMD=1.20±.16; 95% CI, .88–1.52; P<.001) and with pregabalin (SMD=1.71±.13; 95% CI, 1.458–1.965; P<.001). A significant reduction in other SCI secondary conditions, including sleep interference (SMD=1.46±.12; 95% CI, 1.22–1.71; P<.001), anxiety (SMD=1.05±.12; 95% CI, .81–1.29; P<.001), and depression (SMD=1.22±.13; 95% CI, .967–1.481; P<.001) symptoms, was shown. A significantly higher risk of dizziness (risk ratio [RR]=2.02, P=.02), edema (RR=6.140, P=.04), and somnolence (RR=1.75, P=.01) was observed.

Conclusions

Gabapentin and pregabalin appear useful for treating pain and other secondary conditions after SCI. Effectiveness comparative to other analgesics has not been studied. Patients need to be monitored closely for side effects.     

The Relationship between Patients' Perceptions of Team Effectiveness and their Care Experience in the Emergency Department

Background

Effective teamwork is important in the fast-paced Emergency Department (ED) setting. Most of the teamwork literature addresses the provider's perspective of teamwork rather than the patient's perspective.

Objective

Examine the relationship between patients' perceptions of teamwork and care experience in the ED.

Methods

We conducted a cross-sectional survey study of adult patients seen at the University of Pennsylvania ED during the fall of 2011. Patients rated overall satisfaction, pain management, trust, and confidence in the team and likelihood of treatment compliance (outcomes) and four components of team effectiveness (role clarity, shared goals, relationships, and job satisfaction) on a Likert scale. We examined the relationship between patients' perception of teamwork and the outcomes using multivariate analysis, controlling for sociodemographic factors.

Results

We collected 1010 surveys. Patients rated the individual components of teamwork equally, with about 70% rating teamwork as “Very High.” Most patients who rated teamwork highly also rated their confidence and trust in their providers highly (80–90%) compared to 20% of those who rated teamwork lower. The relative risk ratios between high and low teamwork were 4.1 (95% confidence interval [CI] 2.8–5.9) for overall satisfaction, 3.9 (95% CI 2.7–5.8) for satisfaction with pain treatment, 5.3 (95% CI 3.6–7.8) for confidence in providers, and 1.9 (95% CI 1.5–2.5) for likelihood to follow-up treatment recommendations.

Conclusions

Patient satisfaction and willingness to adhere to treatment recommendations are highly correlated with patients' perceptions of ED teamwork.     

Factors Associated With Home Discharge Among Veterans With Stroke

Objective

To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs.

Design

Retrospective observational study.

Setting

Veterans Affairs facilities nationwide.

Participants

Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (N=12,565).

Intervention

Not applicable.

Main Outcome Measure

Discharge location after hospitalization.

Results

There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]=1.23; 95% confidence interval [CI]=1.11–1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (OR=.04; 95% CI=.03–.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (OR=.61; 95% CI=.50–.74) or other central nervous system hemorrhage (OR=.78; 95% CI=.63–.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (OR=1.36; 95% CI=1.07–1.73) were more likely to return home. Evidence of congestive heart failure (OR=.85; 95% CI=.76–.95), fluid and electrolyte disorders (OR=.86; 95% CI=.77–.96), internal organ procedures and diagnostics (OR=.87; 95% CI=.78–.97), and serious nutritional compromise (OR=.49; 95% CI=.40–.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge.

Conclusions

We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning.     

Early ambulation after diagnostic transfemoral catheterisation: A systematic review and meta-analysis

Background

Femoral arterial puncture is the most common method of vascular access for angiography. Because of possible vascular events, all patients are restricted to strict immobilisation and bed rest for 2–24 h, which is accompanied by back pain and discomfort.

Objective

To assess the effects of the duration of bed rest after transfemoral catheterisation on the prevention of vascular complications and general discomfort, pain, urinary discomfort and patient satisfaction.

Data sources

We searched the Cochrane Library, MEDLINE, SCOPUS, CINAHL, Proquest Dissertations, Open SIGLE, Iranmedex and Irandoc.

Study selection

We included blinded or unblinded randomised controlled trials and quasi-randomised controlled trials that used two different durations of bed rest after angiography before the ambulation was permitted.

Data extraction and analysis

Two reviewers separately assessed the quality of each study and extracted the data. We present dichotomous outcomes as odds ratios with 95% confidence intervals (CI) and continuous outcomes as mean differences with 95% CI.

Data synthesis

Twenty studies involving a total of 4019 participants with a mean age of 59.5 years were included. The studies considered periods of bed rest ranging from 2 to 24 h, which we compared in three main categories. There were no statistically significant differences between categories in the incidence of bleeding, haematoma, bruising, pseudoaneurysm, thrombus or arteriovenous fistula. Back pain intensity was assessed in four studies. Patients had significantly less back pain after 2–4 h bed rest compared to 6 h bed rest at 2 h (mean difference: −0.70, 95% CI: −1.07, −0.32), 4 h (mean difference: −0.60, 95% CI: −0.96, −0.24) and 6 h of follow-up (mean difference: −3.77, 95% CI: −4.48, −2.92). One study that assessed urinary discomfort reported less urinary discomfort when bed rest lasted 4 h compared to 12–24 h (mean difference: −1.48; 95% CI: −2.37, −0.59). In addition, reduced bed rest time may significantly decrease the costs of hospital care.

Conclusions

This systematic review suggests that patients can be ambulated after 2–3 h following transfemoral catheterisation, and that early ambulation had no significant effect on the incidence of vascular complications and may reduce back pain and urinary discomfort.     

Musculoskeletal pain among critical-care nurses by availability and use of patient lifting equipment: An analysis of cross-sectional survey data

Background

Patient handling is a major risk factor for musculoskeletal injuries among nurses. Lifting equipment is a main component of safe patient handling programs that aim to prevent musculoskeletal injury. However, the actual levels of lift availability and usage are far from optimal.

Objective

To examine the effect of patient lifting equipment on musculoskeletal pain by level of lift availability and lift use among critical-care nurses.

Design and participants

A cross-sectional postal survey of a random sample of 361 critical-care nurses in the United States.

Methods

The survey collected data on low-back, neck, and shoulder pain, lift availability, lift use, physical and psychosocial job factors, and sociodemographics. Musculoskeletal pain was assessed by three types of measures: any pain, work-related pain, and major pain. Multivariable logistic regressions were used to examine the associations between musculoskeletal pain and lift variables, controlling for demographic and job factors.

Results

Less than half (46%) of respondents reported that their employer provided lifts. Of 168 nurses who had lifts in their workplace, the level of lift availability was high for 59.5%, medium for 25.0%, and low for 13.7%; the level of lift use was high for 32.1%, medium for 31.5%, and low for 31.5%. Significant associations were found between lift availability and work-related low-back and shoulder pain. Compared to nurses without lifts, nurses reporting high-level lift availability were half as likely to have work-related low-back pain (OR = 0.50, 95% CI 0.26–0.96) and nurses reporting medium-level lift availability were 3.6 times less likely to have work-related shoulder pain (OR = 0.28, 95% CI 0.09–0.91). With respect to lift use, work-related shoulder pain was three times less common among nurses reporting medium-level use (OR = 0.33, 95% CI 0.12–0.93); any neck pain was three times more common among nurses reporting low-level use (OR = 3.13, 95% CI 1.19–8.28).

Conclusions

Greater availability and use of lifts were associated with less musculoskeletal pain among critical-care nurses. These findings suggest that for lift interventions to be effective, lifts must be readily available when needed and barriers against lift use must be removed.     

Risk Factors for Serious Underlying Pathology in Adult Emergency Department Nontraumatic Low Back Pain Patients

Background

Nontraumatic low back pain (LBP) is a common emergency department (ED) complaint and can be caused by serious pathologies that require immediate intervention or that lead to death.

Objective

The primary goal of this study is to identify risk factors associated with serious pathology in adult nontraumatic ED LBP patients.

Methods

We conducted a health records review and included patients aged ≥ 16 years with nontraumatic LBP presenting to an academic ED from November 2009 to January 2010. We excluded those with previously confirmed nephrolithiasis and typical renal colic presentation. We collected 56 predictor variables and outcomes within 30 days. Outcomes were determined by tracking computerized patient records and performance of univariate analysis and recursive partitioning.

Results

There were 329 patients included, with a mean age of 49.3 years; 50.8% were women. A total of 22 (6.7%) patients suffered outcomes, including one death, five compression fractures, four malignancies, four disc prolapses requiring surgery, two retroperitoneal bleeds, two osteomyelitis, and one each of epidural abscess, cauda equina, and leaking abdominal aortic aneurysm graft. Risk factors identified for outcomes were: anticoagulant use (odds ratio [OR] 15.6; 95% confidence interval [CI] 4.2–58.5), decreased sensation on physical examination (OR 6.9; CI 2.2–21.2), pain that is worse at night (OR 4.3; CI 0.9–20.1), and pain that persists despite appropriate treatment (OR 2.2; CI 0.8–5.6). These four predictors identified serious pathology with 91% sensitivity (95% CI 70–98%) and 55% specificity (95% CI 54–56%).

Conclusion

We successfully identified risk factors associated with serious pathology among ED LBP patients. Future prospective studies are required to derive a robust clinical decision rule.     

Short-term changes in median nerve neural tension after a suboccipital muscle inhibition technique in subjects with cervical whiplash: a randomised controlled trial

Objectives

To assess the immediate effect of a suboccipital muscle inhibition (SMI) technique on: (a) neck pain, (b) elbow extension range of motion during the upper limb neurodynamic test of the median nerve (ULNT-1), and (c) grip strength in subjects with cervical whiplash; and determine the relationships between key variables.

Design

Randomised, single-blind, controlled clinical trial.

Setting

Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Spain.

Participants

Forty subjects {mean age 34 years [standard deviation (SD) 3.6]} with Grade I or II cervical whiplash and a positive response to the ULNT-1 were recruited and distributed into two study groups: intervention group (IG) (n = 20) and control group (CG) (n = 20).

Interventions

The IG underwent the SMI technique for 4 minutes and the CG received a sham (placebo) intervention. Measures were collected immediately after the intervention.

Main outcome measures

The primary outcome was elbow range of motion during the ULNT-1, measured with a goniometer. The secondary outcomes were self-perceived neck pain (visual analogue scale) and free-pain grip strength, measured with a digital dynamometer.

Results

The mean baseline elbow range of motion was 116.0° (SD 10.2) for the CG and 130.1° (SD 7.8) for the IG. The within-group comparison found a significant difference in elbow range of motion for the IG [mean difference −15.4°, 95% confidence interval (CI) −20.1 to −10.6; P = 0.01], but not for the CG (mean difference −4.9°, 95% CI −11.8 to 2.0; P = 0.15). In the between-group comparison, the difference in elbow range of motion was significant (mean difference −10.5°, 95% CI −18.6 to −2.3; P = 0.013), but the differences in grip strength (P = 0.06) and neck pain (P = 0.38) were not significant.

Conclusion

The SMI technique has an immediate positive effect on elbow extension in the ULNT-1. No immediate effects on self-perceived cervical pain or grip strength were observed.     

Introduction of Ultrasound into Gross Anatomy Curriculum: Perceptions of Medical Students

Background

The exposure to ultrasound technology during medical school education is highly variable across institutions.

Objectives

The objectives of this study were to assess medical students’ perceptions of ultrasound use to teach Gross Anatomy along with traditional teaching methods, and determine their ability to identify sonographic anatomy after focused didactic sessions.

Methods

Prospective observational study. Phase I of the study included three focused ultrasound didactic sessions integrated into Gross Anatomy curriculum. During Phase II, first-year medical students completed a questionnaire.

Results

One hundred nine subjects participated in this study; 96% (95% confidence interval [CI] 92–99%) agreed that ultrasound-based teaching increased students’ knowledge of anatomy acquired through traditional teaching methods. Ninety-two percent (95% CI 87–97%) indicated that ultrasound-based teaching increases confidence to perform invasive procedures in the future. Ninety-one percent (95% CI 85–96%) believed that it is feasible to integrate ultrasound into the current Anatomy curriculum. Ninety-eight percent (95% CI 95–100%) of medical students accurately identified vascular structures on ultrasound images of normal anatomy of the neck. On a scale of 1 to 10, the average confidence level reported in interpreting the images was 7.4 (95% CI 7.1–7.7). Overall, 94% (95% CI 91–99%) accurately answered questions about ultrasound fundamentals and sonographic anatomy.

Conclusions

The majority of medical students believed that it is feasible and beneficial to use ultrasound in conjunction with traditional teaching methods to teach Gross Anatomy. Medical students were very accurate in identifying sonographic vascular anatomy of the neck after brief didactic sessions.     

Altering Electromyography Studies: Importance of the Electromyographer's Perception of Patient Pain

Objective

To determine the relation between the patient's actual pain, the electromyographer's perception of patient pain, and whether an electromyogram (EMG) is altered.

Design

Patients undergoing electromyography reported expected pain and procedure-related overall pain on a 100-mm visual analog scale (VAS). Blinded electromyographers estimated patient pain levels and indicated if they altered the study in any way because of this perception. Multivariable logistic regression was used to determine predictors of altering the EMG. Paired t tests were used to compare overall pain with expected pain and electromyographer perception of pain.

Setting

Tertiary referral center.

Participants

Referred sample of adult subjects (N=304).

Interventions

Not applicable.

Main Outcome Measures

Patient pain, electromyographer perception of patient pain, and whether an EMG was altered because of the electromyographer's perception of patient pain.

Results

Mean VAS scores ± SD were 48±25mm for patient-expected pain (P<.001), 42±24mm for electromyographer perception of pain (P<.0001), and 36±25mm for actual overall pain. Electromyographers altered their study 31.7% of the time because of concerns about pain. For every 13-mm increase on the VAS (a prespecified clinically meaningful difference), the electromyographer perception of pain increased the odds of altering a study 2.36 times (95% confidence interval [CI], 1.71–3.26), whereas patient overall pain did not have a significant effect (odds ratio=1.12; 95% CI, .86–1.47).

Conclusions

Patients expect EMGs to be more painful than they are. Electromyographers overestimate patient pain and are more likely to alter their studies when they believe patients are experiencing more pain, independently of whether patients actually have more pain. Improving the communication between electromyographers and patients may prevent unnecessary alterations.     

Oblique-axis vs. Short-axis View in Ultrasound-guided Central Venous Catheterization

Background

Ultrasound (US) guidance during central venous catheterization (CVC) reduces complications and improves success rates compared to landmark-guided techniques. A novel “oblique view” (US transducer held at approximately 45° with respect to the target vessel) has been suggested to be superior to the standard short-axis approach usually used during US-guided CVC.

Objectives

The purpose of this study was to compare the rates of posterior vessel wall puncture (PVWP) between the short-axis and oblique-axis approaches to US-guided CVC.

Methods

This was a prospective observational trial of emergency medicine residents and attending physicians, using gelatin models to simulate short-axis and oblique-axis US-guided CVC. Participants were blinded to the primary outcome of PVWP. Data collected included year in training/practice, number of central lines placed, time to successful “flash,” and self-reported confidence of needle tip position using a Likert scale. After CVC simulation, models were deconstructed and inspected for PVWP.

Results

The rate of PVWP was 14.7% using short axis vs. 2.9% using oblique axis, resulting in a difference of 11.8% (95% confidence interval [CI] −4.7–28.3%, p = 0.10) and an odds ratio of 0.2 (95% CI 0.004–1.79). This difference was not statistically significant (p = 0.10). Mean time to flash was 11.9 s using short axis, and 15.4 s using oblique axis (p = 0.14). Confidence in needle tip location was 3.63 using short axis, and 4.58 using oblique axis (p < 0.001).

Conclusions

We found decreased PVWP using the oblique axis approach, though the difference was not statistically significant, and participants felt more confident in their needle tip location using the oblique axis view. Further research into the potential benefits of the oblique axis approach is warranted.     

Does the Emergency Medical Treatment and Labor Act Affect Emergency Department Use?

Background

Emergency departments (EDs) face increasing patient volumes and economic pressures. These problems have been attributed to the Emergency Medical Treatment and Labor Act (EMTALA).

Study objective

To determine whether modifying EMTALA might reduce ED use.

Methods

We surveyed ED patients to assess their knowledge of hospitals’ obligations to treat all patients regardless of insurance and to determine whether knowledge is associated with ED use.

Results

Among 4136 study subjects, 72% reported awareness of the law. Sixty-one percent of subjects were moderate ED users (≥ 1 additional ED visit in 12 months). Moderate users more often knew the law (74% vs. 70%, p = 0.005). Multivariate regression showed that factors associated with moderate use were: awareness of EMTALA (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.24–1.67), adult patient (OR 1.94; 95% CI 1.69–2.22), and government insurance (OR 2.67; 95% CI 2.30–3.08) or uninsured (OR 1.72; 95% CI 1.42–2.08). Only 8% of subjects were high-frequency users (≥5 visits). High-frequency users were more often aware of EMTALA (78% vs. 72%, p = 0.02). Covariates associated with high frequency were EMTALA awareness (OR 1.69; 95% CI 1.28–2.24), adult patient (OR 2.59; 95% CI 2.00–3.36), and government insurance (OR 3.73; 95% CI 2.76–5.06) or uninsured (OR 3.77; 95% CI 2.65–5.35).

Conclusion

Many patients know that the law requires hospitals to provide care. This knowledge is associated with more frequent ED use. EMTALA changes might reduce ED use, but broader policy implications should be considered.     

Injuries occurring in hospital staff attending medical emergency team (MET) calls—A prospective,observational study

Background

Clinical emergency response systems such as medical emergency teams (MET) have been implemented in many hospitals worldwide, but the effect that these systems have on injuries to hospital staff is unknown. The objective of this study was to determine the rate and nature of injuries occurring in hospital staff attending MET calls.

Methods

This study was a prospective, observational study, using a structured interview, of 1265 MET call participants, in a 650 bed urban, teaching hospital. Data was collected on the number and the nature of injuries occurring in hospital staff attending MET calls.

Results

Over 131 days, 248 MET calls were made. An average of 8.1 staff participated in each MET call. The overall injury rate was 13 (95% confidence interval (CI) 7–20) per 1000 MET participant attendances, and 70 (95% CI 38–102) per 1000 MET calls. One injured participant required time off-work, an injury requiring time off-work rate of 1 (95% CI 0–4) per 1000 MET participant attendances, or 4 (95% CI 0–27) per 1000 MET calls. The relative risk of sustaining an injury if the MET participant performed chest compressions, contacted patient body fluids on clothing or protective equipment, without direct contact to skin or mucosa, or lifted the patient or a patient body part was 11.0 (95% CI 4.2–28.6), 8.7 (95% CI 3.4–22.0) and 5.5 (95% CI 2.1–14.2), respectively.

Conclusion

The rate of injuries occurring to hospital staff attending MET calls is relatively low, and many injuries could be considered relatively minor.     

Effectiveness of Aquatic Exercise for Musculoskeletal Conditions: A Meta-Analysis

Objective

To investigate the effectiveness of aquatic exercise in the management of musculoskeletal conditions.

Data Sources

A systematic review was conducted using Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and The Cochrane Central Register of Controlled Trials from earliest record to May 2013.

Study Selection

We searched for randomized controlled trials (RCTs) and quasi-RCTs evaluating aquatic exercise for adults with musculoskeletal conditions compared with no exercise or land-based exercise. Outcomes of interest were pain, physical function, and quality of life. The electronic search identified 1199 potential studies. Of these, 1136 studies were excluded based on title and abstract. A further 36 studies were excluded after full text review, and the remaining 26 studies were included in this review.

Data Extraction

Two reviewers independently extracted demographic data and intervention characteristics from included trials. Outcome data, including mean scores and SDs, were also extracted.

Data Synthesis

The Physiotherapy Evidence Database (PEDro) Scale identified 20 studies with high methodologic quality (PEDro score ≥6). Compared with no exercise, aquatic exercise achieved moderate improvements in pain (standardized mean difference [SMD]=−.37; 95% confidence interval [CI], −.56 to −.18), physical function (SMD=.32; 95% CI, .13–.51), and quality of life (SMD=.39; 95% CI, .06–.73). No significant differences were observed between the effects of aquatic and land-based exercise on pain (SMD=−.11; 95% CI, −.27 to .04), physical function (SMD=−.03; 95% CI, −.19 to .12), or quality of life (SMD=−.10; 95% CI, −.29 to .09).

Conclusions

The evidence suggests that aquatic exercise has moderate beneficial effects on pain, physical function, and quality of life in adults with musculoskeletal conditions. These benefits appear comparable across conditions and with those achieved with land-based exercise. Further research is needed to understand the characteristics of aquatic exercise programs that provide the most benefit.