Missed diagnoses in an Accident & Emergency Department

The diagnoses which were missed at patients' first attendance at an A & E Department over a 6-month period were noted and investigated. The most common cause of missed diagnosis was failure to interpret X-ray findings correctly; this and other causes are discussed. Recommendations as to how this can be improved are made.     

Analysis of wax burn cases presenting to an Emergency Department in Hong Kong during the Chinese Mid-Autumn festival

Records of patients presenting to the Emergency Department (ED) of the Prince of Wales Hospital with wax burns during Mid-Autumn festival from 1998 to 2001 were retrieved and analyzed. There were 26 patients in total (21 males, 5 females). Annual attendances from 1998 to 2001 were 11, 7, 4 and 4, respectively. Age ranged from 1 to 33 years (median age: 11.5). Most patients were injured by molten wax (n=23, 88.5%), the rest were burnt by flame (n=3, 11.5%). Partial thickness burn (superficial and deep) was the most common (n=23, 88.4%). Superficial burn accounted for the rest (n=3, 11.5%). No patient had full thickness burn. All patients had <5% of body surface area (BSA) burnt, with the majority only involving <1% BSA (n=16, 61.5%). The commonest sites of injury were the lower limbs (n=15, 57.7%), the upper limbs (n=8, 30.8%) and face (n=7, 26.9%). Three patients (11.5%) had multiple sites burnt. Only eight patients (30.8%) required burns surgeon's consultation, out of which seven (26.9%) required in-patient treatment. Most burns caused by or related to boiling wax were minor. The declining incidence is the combined result of legislation, product modification, education and publicity.     

Breath alcohol analysis in the Accident and Emergency Department

Breath alcohol analysis was undertaken in 1044 consecutive patients aged over 15 years attending the Accident and Emergency (A and E) Department of a rural district general hospital during a 50-day period. 16.5 per cent of all patients had the smell of alcohol on their breath, with 10.2 per cent of the patients recording a breath alcohol level equivalent to a blood level of 80 mg/100 ml or more.One-third of all patients attending between 9 pm and midnight, and almost two-thirds of patients attending between midnight and 3 am had positive breath tests.Positive breath tests were most likely in males, patients with head injuries, with overdoses, in victims of assault and in patients with a depressed conscious level, irrespective of cause.Clinical estimation of intoxication by alcohol may be accurate in the co-operative patient, but in the patient with a head injury or with a depressed conscious level from another cause, this is more difficult. Breath alcohol analysis is rapid, not-invasive, accurate and of clinical value in these and other high-risk patients attending hospital as emergencies.     

Management of Knee Injuries in the Accident and Emergency Department

Abstract Background and Purpose: Knee injuries are frequently seen in the accident and emergency (A&E) department. A prospective study was carried out to investigate the reliability of the initial diagnosis of knee injuries made in the A&E department. Patients and Methods: All patients (n = 425) who presented at the A&E Department of the Red Cross Hospital in the Hague, the Netherlands, in 1996 with a knee injury were clinically examined and an X-ray was obtained. The patients were reviewed in the outpatient clinic after 4 days and then at 6 weeks. At these times, patients were referred to the orthopedic outpatient clinic for further investigation and treatment as indicated. After 5 years, a final evaluation was undertaken. Results: After 6 weeks, the subsequent diagnosis was found to differ from the initial one in 6% of cases. This finding had no further consequences with regard to prognosis. After 5 years, all patients were approached by telephone. In total, 94% of the patients were contacted and of these, three patients (1%) had been re-referred to the orthopedic outpatient clinic. The final diagnosis of these three patients was different to the initial diagnosis. Of these patients, one needed an arthroscopy, the other two received conservative treatment. Conclusion: The study found that 1% of knee injuries were misdiagnosed at the A&E department. It is therefore beneficial to review patients with knee injuries in the outpatient clinic after 4 days.     

Head scanning during admission through the Accident and Emergency Department

In order to illustrate our current pattern of use, 50 patients were reviewed who were examined by computerized tomography (CT) of the head during admission through the Accident and Emergency (A & E) Department.Fourteen (28 per cent) had no history of head injury but exhibited diminished conscious level, epilepsy, headache, or hemiplegia. The 36 cases of head injury were analysed in order to see whether they met certain criteria proposed by other authors, and to suggest the advantage to be gained when CT was available in a district general hospital (with teaching status).     

The selective reporting of X-ray films from the Accident and Emergency Department

This study of one thousand casualty patients referred for radiological examination is intended to ascertain whether selective formal reporting is good enough. The conclusion is made that selective reporting of the films that a casualty officer requests produces a significant reduction in radiological workload, but also produces a parallel increase in missed abnormalities.     

Emergency Sleeve Gastrectomy as Rescue Treatment for Acute Gastric Necrosis Due to Type II Paraesophageal Hernia in an Obese Woman with Gastric Banding

A morbidly obese 42-year-old woman presented with a 1-week history of left chest pain. She had undergone laparoscopic adjustable gastric banding 16 months earlier with a body mass index (BMI) of 49.2 kg/m². Diagnostic workup revealed a large left pleural empyema and ruled out band slippage. At left thoracotomy, a misdiagnosed type II paraesophageal strangulated hernia with gastric necrosis and large perforation of the fundus was evident. At laparotomy, the band was removed, the stomach was reduced into the abdomen, and a sleeve gastrectomy was performed. Her postoperative course was uneventful, and 6 months after surgery, her BMI is 31 kg/m². Emergency sleeve gastrectomy could represent a good option to treat, at the same time and in a safe way, both gastric necrosis and paraesophageal hernia, improving the good results in terms of weight loss after gastric restriction from gastric banding.     

A 1 year study of burn injuries in a British Emergency Department

OBJECTIVES: To determine the number of patients attending an Emergency Department with burns and to establish the epidemiology, management and outcome of these cases. METHOD: A retrospective study of all patients attending an Emergency Department with a diagnosis of "burn" during 2004. RESULTS: Seven hundred and eighty-five patients presented with a diagnosis of burns, accounting for 1% of all attendances. Fifty-three percent of patients were male and most were young adults of working age. Scalds and flame injuries were the most common causes of injury. Only 30% of patients performed adequate first aid. The majority of burns were small and did not require admission to hospital. Assessment and documentation by the Emergency Department staff was found to be generally poor and this may reflect a lack of experience in managing burns. CONCLUSION: Burns remain a relatively uncommon presenting complaint in the Emergency Department, even in a hospital accepting tertiary referrals. Most injuries are minor and are managed within the department. This study suggests that there is a role for better education of less experienced staff in the management of burns. There remains a need for public education in the prevention and first aid of burns.     

Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction

Background: Small bowel obstruction (SBO) is a leading cause of admission to surgical emergency units. Strangulation is associated with a 10-fold increase in mortality. The aim of the present study was to identify the most frequent causes of strangulation in patients presenting with small bowel obstruction. Methods: A prospective study was conducted of all patients presenting with SBO in one teaching hospital between 2003 and 2004. Results: One hundred and sixty-one patients with symptoms and signs of small bowel obstruction were admitted. Eighty-three were confirmed with contrast studies. The male:female ratio was 1:1.6. The aetiology of obstruction was adhesions in 97 patients (60.2%), hernia in 29 (18%), malignancy in 17 (10.6%) and miscellaneous causes in 18 (11.2%). Operative procedures were performed on 74 patients (46%), 31 of them (42%) with adhesions, 25 (34%) with hernias and 18 (24%) due to other causes. Strangulated bowel occurred in 15 patients (9.3%); 12 had hernias whilst three had adhesions (P < 0.0001). Of the strangulated hernias, ten were femoral, one was inguinal and one was paraumbilical. There were seven deaths; three occurred in patients declared unfit for surgery, while four occurred post-operatively—two had strangulated bowel, the other two had advanced cancer. Conclusion: Whilst adhesions are the most common cause of small bowel obstruction, hernias remain the most frequent cause of strangulation in patients presenting with this condition.     

责任护师制在急诊科的实施

目的使急救护理工作能够与诊疗技术水平同步提高,为患者提供最快、最新、最佳的护理技术服务。方法在急诊科实施责任护师制,聘用4名责任护师,负责24 h业务技术管理并协助护士长的行政管理工作,实行12 h对班制,并制定奖惩措施。结果实施责任护师制1年多来,医护抢救配合满意率、院前急救患者处置满意率、院前急救药品器械到位率分别提高17%、8%、4%,急救器械返修率下降15%,护理纠纷下降至0。结论责任护师制的实施使急救护理技术提高,质量改善,护士素质全面提高。     

责任护师制在急诊科的实施

目的使急救护理工作能够与诊疗技术水平同步提高，为患者提供最快、最新、最佳的护理技术服务。方法在急诊科实施责任护师制，聘用4名责任护师，负责24h业务技术管理并协助护士长的行政管理工作，实行12h对班制，并制定奖惩措施。结果实施责任护师制1年多来．医护抢救配合满意率、院前急救患者处置满意率、院前急救药品器械到位率分别提高17％、8％、4％，急救器械返修率下降15％。护理纠纷下降至0。结论责任护师制的实施使急救护理技术提高，质量改善，护士素质全面提高。     

Prevalence and incidence rates of pressure ulcers in an Emergency Department

Older patients represent an increasing population in emergency department (ED) with underlying diseases and longer ED length of stay, which are potential risk factors of pressure ulcers (PUs). The aim of the study was to determine the prevalence and incidence rates of PUs in an Emergency Department and to analyse variables related to PUs occurrence. The study was carried out in the Emergency Department of Bordeaux (France), and included 602 patients from 1 to 15 June 2010. All the potential body sites of pressure were examined at admission and discharge for all the patients by trained nurses. Comorbidity score, list of treatment, length of stay (hours), PUs (including stage I) and C‐reactive protein (CRP) level were systematically recorded. A total of 47 (7·8%) patients had prevalent PUs at admission and 74 (12·3%) at discharge. The cumulative incidence was 4·9% and the incidence density was 5·4 per 1000 patients per hour. In multivariate analysis, higher comorbidities (OR 1·3; P = 0·014) and CRP levels (OR 1·005; P = 0·017) were both independent risk factors for developing PU. In conclusion, these data show that even a very short stay to the ED is sufficient to induce PUs especially stage I.     

Thymic carcinoma. A clinicopathologic study of 13 cases.

Thymic carcinoma (TCA) is a thymic epithelial neoplasm with obvious cytologic atypia. We studied 13 cases of TCA by light microscopy, immunohistochemistry, and electron microscopy and correlated the findings with clinical features. The patients' mean age was 54.2 years (range 30-74); the male/female ratio was 7/6. Twelve of the 13 patients presented with signs and symptoms caused by compression of mediastinal organs; the other patient was asymptomatic. Paraneoplastic syndromes were never seen. At thoracotomy, 11 tumors invaded or adhered to surrounding structures; the other two were encapsulated. The histologic types include squamous carcinoma including the lymphoepithelioma-like subtype (seven cases), small cell carcinoma (four cases), clear cell carcinoma (one case), and adenosquamous carcinoma (one case). Positive immunoperoxidase studies were as follows: keratin (13 cases), epithelial membrane antigen (EMA) (13 cases), leukocyte common antigen (none), carcinoembryonic antigen (CEA) (five cases), B72.3 (seven cases), Leu 7 (two cases), human placental alkaline phosphatase (none), vimentin (none), and chromogranin (one case). This profile is similar to those of normal thymus and thymoma except for the absence of CEA, B72.3, EMA in normal thymus, and the absence of CEA and B72.3 in thymoma. Electron-microscopic studies performed on eight cases showed glandular and squamous differentiation in one adenosquamous carcinoma, squamous differentiation in five squamous carcinomas, and neuroendocrine differentiation in one small-cell carcinoma. Nine patients died (three due to postoperative complications and six due to recurrences or metastasis at 3-36 months). Four patients (all with squamous carcinoma) were alive without disease at 2-60 months. The clinical and pathologic features were comparable with those of approximately 62 other cases of TCA previously reported. There are a number of well-defined histologic types of TCA that allow the pathologist to make a differential diagnosis of TCA from tumors extending or metastatic to thymus or other primary mediastinal tumors. Although neither asymptomatic presentation nor encapsulation improves the poor prognosis of TCA, the squamous carcinoma subtype is associated with a better outcome than the other subtypes. Based on the electronmicroscopic and immunohistochemical findings, the presence of normal thymic tissue at the periphery of several tumors, and the observation that several TCA arose from preexisting thymomas or thymic cysts, we conclude that TCA is derived from thymic epithelium.     

Cavitary lesions close to heart valve rings. A necropsy study of 13 cases

Necropsy reports of 13 patients with 15 cavitary lesions situated close aortic or mitral valve rings were studied in patients who ranged in age from 1 month to 57 (mean 24.9) years; 10 patients were male. Infective endocarditis occurred in 7 patients, rheumatic heart disease in 4, congenital heart diseases in 4, previous valve replacement in 4, and syphilis in 1 patient. Diameters of the cavitary lesions ranged between 1.2 and 10.5 cm; the aortic valve ring was involved in 11 patients; cavitary thrombosis occurred in 2 cases; the orifice communicating the cardiac chamber with the cavitary lesions was situated above the aortic leaflet in 5 lesions, below the aortic leaflet in 4 lesions, and above and below the aortic leaflets in 3 lesions. The mitral valve ring was involved in 3 lesions. Thus, different etiologies may be involved in the pathogenesis of these lesions; positions of the lesion may vary in relation to the valve ring, and the lesions may be a morphological expression of the fragility of the fibrous skeleton of the heart.     

Malignant lymphoma. A study of 75 cases presenting in soft tissue

We report 75 cases of malignant lymphoma presenting in soft tissue taken from the files of the Armed Forces Institute of Pathology. All histologic subtypes with the exception of lymphoblastic lymphoma were represented. Our findings indicate that virtually any soft tissue site may be involved; there is no sex predilection; and size is not helpful in predicting survival. Among the 55 patients for which race was known, there were no black patients. Thirty-three patients with extensive evaluations at the time of diagnosis had no evidence of disseminated disease, but eight of these exhibited widespread disease within 3 months of diagnosis, and seven of the eight died of disease (median survival, 4 months). The remaining 25 patients had much better outcomes; 18 of 19 with intermediate and high-grade lymphomas were alive and well at a median of 74 months after diagnosis. Some tumors exhibited a propensity for involvement of remote soft tissue sites.     

Penile strangulation and necrosis due to condom catheter

Condom catheters are often used in the management of male urinary incontinence, and are considered to be safe. As condom catheters are placed on the male genitalia, sometimes adequate care is not taken after placement owing to poor medical care of debilitated patients and feelings of embarrassment and shame. Similarly, sometimes the correct size of penile sheath is not used. Strangulation of penis due to condom catheter is a rare condition; only few such cases have been reported in the literature. Proper application and routine care of condom catheters are important in preventing this devastating complication especially in a neurologically debilitated population. We present a case of penile necrosis due to condom catheter. We will also discuss proper catheter care and treatment of possible complications.     

Intramedullary spinal cord metastasis. A clinicopathological study of 13 cases

A retrospective autopsy study of 627 patients with systemic cancer disclosed 153 patients with metastasis to the central nervous system (CNS) and 13 patients with intramedullary spinal cord metastasis (ISM). Thus, the frequency of ISM was 8.5% of cases of metastasis to the CNS and 2.1% of all cases of cancer. Bronchogenic carcinoma accounted for 11 cases of ISM, and breast carcinoma and melanoma for the other two. There were two distinct patterns of spinal cord involvement, indicating spread of tumor to the cord by two different routes. In nine of the 13 ISM patients a metastasis was found deep within the spinal cord, unassociated with leptomeningeal carcinomatosis; this most likely resulted from hematogenous spread of tumor from a pulmonary source. In the other four patients there was focal or multifocal direct extension of leptomeningeal metastatic tumor across the pia into the parenchyma of the cord. Only four of the 13 patients had a clinical myelopathy; in three of these four this was the presenting feature of an occult lung cancer.     

Emergency Department Visits in the Year Prior to Total Shoulder Arthroplasty as a Risk Factor for Postoperative Emergency Department Visits

Background: Recent research has found a high rate of emergency department (ED) use after lower extremity arthroplasty; one study found a risk factor for ED presentation after lower extremity arthroplasty was presentation to the ED in the year prior to surgery. It is not known whether a similar association exists for total shoulder arthroplasty (TSA). Questions/Purposes: The goal of this study was to investigate the relationship between preoperative ED visits and postoperative ED visits after anatomic TSA. Methods: The 100% Medicare database was queried for patients who underwent anatomic TSA from 2005 to 2014. Emergency department visits within the year prior to the date of TSA were identified. Patients were additionally stratified by the number and timing of preoperative ED visits. The primary outcome measure was one or more postoperative ED visits within 90 days. A multivariate logistic regression analysis was used to control for patient demographics and comorbidities. Results: Of the 144,338 patients identified, 32,948 (22.8%) had an ED visit in the year prior to surgery. Patients with at least 1 ED visit in the year before surgery presented to the ED at a significantly higher rate than patients without preoperative ED visits (16% versus 6%). An ED visit in the year prior to TSA was the most significant risk factor for postoperative ED visits (in the multivariate analysis). The number of preoperative ED visits in the year prior to surgery demonstrated a significant dose-response relationship with increasing risk of postoperative ED visits. Conclusions: Postoperative ED visits occurred in nearly 10% of Medicare patients who underwent TSA in the period studied. More frequent presentation to the ED in the year prior to anatomic TSA was associated with increasing risk of postoperative ED visits. Future studies are needed to investigate the reasons for preoperative ED visits and if any modifiable risk factors are present to improve the ability to risk stratify and optimize patients for elective TSA.     

Subtypes of chromophobe cell renal carcinoma: an ultrastructural and histochemical study of 13 cases.

The Mainz classification of renal epithelial neoplasms has become accepted as a reproducible morphologic and cytogenetic classification of epithelial tumors of the kidney. Chromophobe cell renal carcinoma (CCRC) is a distinct type of renal epithelial neoplasm, first described by Thoenes et al. in 1985. Both a typical type of CCRC, composed of cells with pale reticular cytoplasm, and an eosinophilic variant (EVCCRC) have been identified. Both variants have been reported to show cytoplasmic staining with the Hale's colloidal iron method. Cytogenetic analysis has tended to confirm the Mainz classification. CCRC has been shown to have consistent chromosomal abnormalities that are not shared by other renal tumors. Ultrastructurally, CCRC is typically characterized by a cytoplasm containing scant numbers of mitochondria, which have tubulovesicular christae, and by the presence of innumerable 150-300-microm microvesicles scattered between the mitochondria. Erlandson et al. recently described two subtypes of EVCCRC. One subtype has sparse microvesicles and abundant mitochondria that have tubulovesicular christae, whereas the second type (described as an oncocytic EVCCRC) has no microvesicles and abundant mitochondria containing pseudovesicular or lamellar christae. This was believed to be more akin to the ultrastructural appearances of a renal oncocytoma. The authors believe that the phenotype of the EVCCRC shows a range of appearances at both the light microscopic and the ultrastructural levels, from features similar to the typical type CCRC through to a neoplasm that is phenotypically similar to renal oncocytoma. A series of 13 cases of CCRC from the files of the Massachusetts General Hospital for which ultrastructural examination was available is described. These cases include six cases of typical type CCRC and seven cases of EVCCRC. The authors confirm the findings of Erlandson et al. of two subtypes of EVCCRC and designate them as type 1 EVCCRC (with some microvesicles and mitochondria with tubulovesicular christae) and type 2 EVCCRC (with no identifiable microvesicles and mitochondria with pseudovesicular or lamellar christae).