Patients with bipolar illness admitted to a general medical service

BACKGROUND: This study was done to assess the size and characteristics of the patient population with bipolar illness treated on the general medical service of two divisions of the Charleston Area Medical Center, the largest hospital complex in West Virginia. METHODS: A total of 779 admitting and/or discharge summaries were reviewed. RESULTS: The average age of the manic patients (50.5 years) was lower than that of schizophrenic patients (56.1 years) or the general population (58.9 years). The most common reasons for admission in the manic group were chest pain (5 patients) and drug overdose (4 patients). Alcohol abuse was more common in the bipolar group (20%) than in the schizophrenic group (11%) or the general population (12%). CONCLUSIONS: Additional studies of the prevalence of bipolar disorder in West Virginia are warranted.     

Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service

Objective

Overcrowding in the emergency department (ED) has been associated with patient harm, yet little is known about the association between ED boarding and adverse hospitalization outcomes. We sought to examine the association between ED boarding and three common adverse hospitalization outcomes: rapid response team activation (RRT), escalation in care, and mortality.

Drug misuse among patients admitted to a general hospital

Aims In this paper we report the prevalence of prescribed drugs of misuse and illicit drugs used by patients admitted to a general hospital and the level of detection of drug problems by general medical staff.

Design This is a prospective questionnaire survey, interview and case note review.

Setting This study is a snapshot of one week's admission to a general hospital.

Findings Of the 408 people approached, 285 (70%) participated in the study. One hundred and sixty‐six people (62%) reported misuse of drugs at some time in their lives. Of these, 46 (17%) reported use of illegal drugs at some time in their lives, 22 (8%) in the past year, and 7 (2.6%) in the previous month. The most frequently reported drug type used ever, in the past year, and in the previous month, was over‐the‐counter medication and sedatives. All nine dependent patients identified by the interview were polydrug users and were significantly younger. Two of these patients were assessed for substance misuse by the medical staff.

Conclusion This study suggests that younger patients should be asked about their drug use, especially their use of more readily available drugs. At present, few questions are being asked by health professionals, leaving drug misuse to continue to drain both healthcare and society's resources.     

Clinical emergencies and outcomes in patients admitted to a surgical versus medical service

Background

The merit of rapid response systems (RRSs) remains controversial. A tailored approach to specific groups may increase the efficacy of these teams. The purpose of this study was to compare differences in triggers for RRS activation, interventions, and outcomes in patients on medical and surgical services.

Methods

A retrospective review RRS events was performed. The incidence of out of ICU cardiac arrests and hospital mortality were compared 2 years prior to and following RRS implementation. Call trigger, interventions, and disposition between medical and surgical patients were compared over a 15 month period.

Results

Out of ICU cardiac arrest was significantly more prevalent in the medical group both before and after implementation of RRS. The out of ICU cardiac arrest rate decreased 32% in the surgical group (p = 0.05) but hospital mortality did not change. Out of ICU cardiac arrest decreased 40% in the medical group (p < 0.001) and hospital mortality decreased 25% (p < 0.001) following RRS implementation. There were 1082 RRS activations, 286 surgical and 796 medical. Surgical patients were more likely to have received sedation within 24 h of evaluation (14% vs. 4%, p < 0.001). The majority of patients in both cohorts were discharged alive.

Conclusion

Implementation of a RRS had greater impact on reduction of out of ICU cardiac arrest and mortality in medical inpatients. Triggers for activation and interventions were similar between groups; however, surgical patients demonstrated substantial risk for decompensation within the first 24 h following operation. More research is needed to evaluate the disproportionate benefit observed between cohorts.     

Factors associated with refractory pain in emergency patients admitted to emergency general surgery

BACKGROUND: Oligoanalgesia in emergency departments (EDs) is multifactorial. A previousstudy reported that emergency providers did not adequately manage patients with severe paindespite objective findings for surgical pathologies. Our study aims to investigate clinical andlaboratory factors, in addition to providers’ interventions, that might have been associated witholigoanalgesia in a group of ED patients with moderate and severe pains due to surgical pathologies.METHODS: We conducted a retrospective study of adult patients who were transferred directlyfrom referring EDs to the emergency general surgery (EGS) service at a quaternary academic centerbetween January 2014 and December 2016. Patients who were intubated, did not have adequaterecords, or had mild pain were excluded. The primary outcome was refractory pain, which wasdefi ned as pain reduction <2 units on the 0–10 pain scale between triage and ED departure.RESULTS: We analyzed 200 patients, and 58 (29%) had refractory pain. Patients with refractory painhad signifi cantly higher disease severity, serum lactate (3.4±2.0 mg/dL vs. 1.4±0.9 mg/dL, P=0.001), and lessfrequent pain medication administration (median [interquartile range], 3 [3–5] vs. 4 [3–7], P=0.001), whencompared to patients with no refractory pain. Multivariable logistic regression showed that the number of painmedication administration (odds ratio [OR] 0.80, 95% confi dence interval [95% CI] 0.68–0.98) and ED serumlactate levels (OR 3.80, 95% CI 2.10–6.80) were signifi cantly associated with the likelihood of refractory pain.CONCLUSIONS: In ED patients transferring to EGS service, elevated serum lactate levelswere associated with a higher likelihood of refractory pain.     

The general medicine consult service in a university teaching hospital

A general internal medicine consult service that provides continuity of care, availability, and preoperative out-patient consultation was instituted at UCDMC in September 1977. The volume and source of consultations increased dramatically with little impact on the medical specialty consult services. We believe the organization of our consult service has helped to provide optimal training in an often neglected area of Internal Medicine.     

'Catching the spike and tracking the flow': Holter-temperature monitoring in patients admitted in a general internal medicine ward

Objective: To study if a 24‐h continuous monitoring of temperature reveals information not accessible through conventional care. This included omitted fever peaks and circadian and complexity characteristics that may correlate with specific aetiologies. Design: Ours was a prospective, observational study. A total of 62 patients, admitted to a general internal medicine ward, in whom a temperature > 38 °C had been observed the day before inclusion underwent a 24‐h long continuous monitoring of both central and peripheral temperatures. The time series were recorded in a file, while they otherwise followed conventional care. Time series were analysed for standard statistics, chronobiological analysis (amplitude, mesor, acrophase, intra‐daily variability) and complexity analysis (Approximate Entropy of both central and peripheral temperature, cross‐ApEn). A month after discharge, the clinical reports were reviewed and a definitive diagnosis of the febrile syndrome was established. Results: A total of 62 patients were initially included. In six cases, no time series could be obtained because of technical problems, leaving 56 patients accessible for analysis. In 10 cases, no definitive diagnosis was established. Continuous monitoring detected a mean of 0.7 (CI = 0.27–1.33) peaks of fever (central temperature > 38.0 °C) unobserved by conventional care per patient. A proportion of 16% (CI = 6–26) of patients considered afebrile by conventional care had at least one fever peak detected by continuous monitoring. Circadian rhythm persisted or was exacerbated in febrile patients. Circadian amplitude was increased in patients with tuberculosis. Complexity analysis did not differ among different diagnostic groups, although in subgroup analysis, viral infections had a higher complexity than other infectious diseases. Conclusions: Temperature Holter monitoring reveals fever peaks that pass otherwise unobserved. Furthermore, chronobiological and complexity analysis of the temperature profile may provide quick and easy ‘hidden information’, not available to conventional care.     

Residual urine volumes in patients with spinal cord injury: measurement with a portable ultrasound instrument

Spinal cord injured (SCI) patients are often placed on an intermittent catheterization (IC) program during their initial rehabilitation in an effort to establish a catheter-free state. A noninvasive method to quantitatively determine residual urine volumes would decrease unnecessary catheterizations and be useful in the management of an IC program. This study was undertaken to determine if bladder volumes could be accurately determined in a group of SCI patients using a portable ultrasound scanner. Fifteen SCI patients underwent a total of 224 ultrasonic bladder volume determinations and 57 urethral catheterizations. Immediately prior to catheterization, two investigators alternately performed a total of four ultrasound readings on each patient using a hand-held portable instrument, the BVI 2000. The first ultrasound volume determination was comparable to the average ultrasound volume (r2 = 0.956). For catheterized volumes versus the initial ultrasound volume determination, r2 = 0.80. The average error was 18% for catheterized volumes within the range 50-700ml. Our results compare favorably with both real-time scanning using standard equipment and other portable instruments. The noninvasive nature, negligible risks, and reasonable estimates of volume warrant consideration of portable ultrasound scanning for the determination of bladder volumes in SCI patients.     

Prevalence of neuropathic pain in terminally ill patients with cancer admitted to a general ward: a prospective observational study

ObjectivesTo determine the prevalence of neuropathic pain among terminally ill patients with cancer admitted to a general ward, using the International Association for the Study of Pain algorithm.MethodsThis prospective observational study was conducted at a tertiary care center. We enrolled terminally ill patients with cancer admitted to the general ward between September 2018 and September 2019. On the day of consultation with our palliative care team, pain management clinicians examined and diagnosed neuropathic pain using the International Association for the Study of Pain diagnostic criteria.ResultsA total of 108 patients were enrolled during the study period. The median age was 69 years (interquartile range [IQR] 58.3–76.8 years), 72 patients (66.7%) were men, and the median survival time was 33 days (IQR 14.3–62 days). Of the 108 patients, 33 (30.6%) had neuropathic pain. Patients with neuropathic pain had more severe pain than those without neuropathic pain.ConclusionsThe prevalence of neuropathic pain in terminally ill patients with cancer admitted to a Japanese general ward was 30.6%. Further studies are warranted to elucidate whether the accurate diagnosis of neuropathic pain can improve pain control and/or patient conditions.     

Longitudinal study of inpatients admitted to a general activation service: variables that predict discharge to a patient's discharge goal location

OBJECTIVE: To determine which sociodemographic and clinical characteristics of patients admitted to a general activation service (GAS) are predictive of discharge to patients' discharge goal locations (DGLs). DESIGN: Prospective cohort study. SETTING: Rehabilitation and complex continuing care hospital in southern Ontario, Canada. PARTICIPANTS: Patients admitted from January 2000 to December 2002 (N=154). INTERVENTION: The GAS. MAIN OUTCOME MEASURE: Patients indicated on their service applications where they wanted to be discharged. This is termed the DGL. RESULTS: Fifty-three percent of the sample were discharged to their DGLs. Ninety-eight percent of these patients were discharged by 9 months. Eighty-seven percent who were discharged to their DGLs were discharged to their own home. Predictors of being discharged to the DGL were better activities of daily living scores, good vision, and having sufficient help at home. Expert clinician opinion of the likelihood of each patient being discharged to his/her DGL, based on initial assessment, was also predictive of each patient's eventual discharge to his/her DGL. CONCLUSIONS: The GAS has a 53% success rate in discharging patients to their DGLs. Variables have been identified that should be useful in predicting whether patients will be discharged to their DGLs. Our findings are meaningful and informative in determining future admission criteria for the service.     

Integrating a complementary medicine service within a general surgery department: from contemplation to practice

This article describes experience in developing a complementary and alternative medicine (CAM) service within a general surgery department in a public academic hospital in Israel. A framework is suggested for integrating CAM services within a hospital, based on the authors' experience, along three themes: the organizational structure of such a service, communication with the conventional team, and self-appraisal using a research-based documentation and assessment process. With the anticipated increase in CAM utilization within medical institutions, it is hoped this article will provide foundations for successful integration of other such services.     

Measurement of care time in patients with acute myocardial infarction admitted to a general ICU: evaluation and improvement

Acute myocardial infarction (AMI) requires early and safe nursing care, particularly with respect to initiating and following up thrombolytic treatment, the most effective therapy according to the literature. Time is decisive. Recommended door-to-needle time should not exceed 35 minutes (from patient's arrival to injection of the thrombolytic agent in the ICU). This quality of care study centered on the measurement of four partial times and their sum. These times corresponded to different phases a patient with AMI undergoes from arrival at the hospital emergency room center to thrombolysis in the ICU. The intrahospital delay in patient care was examined. Times were recorded on a specific register of all patients with priority I AMI (clear criteria for fibrinolysis) who were seen at our center. Total time to fibrinolysis in the ICU was 60 minutes (excessive intrahospital delay). A corrective intervention plan was designed and implemented, which reduced the delay to an acceptable 30 minutes. This improved the quality of care of AMI patients at our center.     

Prenatal ultrasound findings in a fetus with congenital contractural arachnodactyly.

Congenital contractural arachnodactyly (CCA) or Beals-Hecht syndrome is an autosomal dominant disorder caused by mutations in the fibrillin-2 (FBN2) gene. The principal features of CCA are a marfanoid habitus, multiple congenital contractures, camptodactyly, arachnodactyly, kyphoscoliosis, muscular hypoplasia, and external ear malformations. Our case is the first that shows typical sonographic signs in a fetus at 25 weeks' gestation with molecular genetically verified CCA in a large family with many members affected over four generations. This demonstrates that CCA can be detected prenatally by non-invasive ultrasonography. The importance of confirmation of CCA by means of DNA sequence analysis of the FBN2 gene is stressed.     

Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18?yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US.Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5–72.1), CRP >0.5?mg/dL (OR 2.64, 95% CI 1.0–6.8), or WBC?>?10 (OR 4.36, 95% CI 1.66–11.58). Duration of abdominal pain >3?days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003–0.395). Combined, the absence inflammatory changes, CRP?<?0.5?mg/dL, WBC?<?10, and pain, ≤3?days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3?days.     

Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event

Objective

The objective of this study is to review the mortality after discharge in clinically stable infants admitted with a first apparent life-threatening event.

Methods: design

Retrospective chart review of all infants 0 to 6 months presenting with a first apparent life-threatening event (ALTE) over a 5-year period using explicit criteria. Patients with an emergency department (ED) diagnosis of ALTE, seizure, choking spell, or cyanosis were reviewed by 2 of 3 physicians. Level of agreement between reviewers was monitored. Mortalities were identified by a review of the county death record database and hospital records.

Results

Three hundred sixty-six charts were reviewed; 176 cases met inclusion criteria. All apparent life-threatening event (ALTE) cases were admitted; 1 signed out against medical advice. Blood cultures were obtained in 111 patients (63%)—no pathogens were identified. Cerebrospinal fluid analysis and culture was performed in 65 patients (37%)—no pathogens were identified. One patient had pleocytosis. Chest radiographs were obtained in 115 patients (65%); 12 patients had infiltrates. Respiratory syncytial virus nasal washings were obtained in 32% of patients and were positive in 9 patients. The average length of follow-up was 34 months; 2 patients (1.1%) had died at the time of follow-up. Both deaths occurred after hospital discharge and within 2 weeks of the ED visit. Neither of the fatalities had a positive diagnostic evaluation in the ED. The cause of death by coroner report was pneumonia in both instances.

Conclusions

The risk of subsequent mortality in infants admitted from our pediatric ED with an ALTE is substantial. Emergency physicians should consider routine admission for patients with ALTE.     

Pathway for patients admitted with gastroenteritis to a military hospital

As part of the Clinical Effectiveness Programme, a care pathway was developed for use within the isolation facility in a military hospital in Iraq. The development of the care pathway was necessary to provide direction and to standardize the care provided. A care pathway using a structured and planned approach was developed, critically appraised and amended to ensure evidence-based and patient-focused care. This article provides an amended methodology for the development of further pathways suitable for use within military nursing based on the standard pathway produced by De Lue (2002). The production of the pathway and supporting guideline will ensure standardized care for patients admitted with gastroenteritis.