When Should Abdominal Computed Tomography Be Considered in Patients with Lower Rib Fractures?

Background

Lower rib fractures are considered as a marker of intra-abdominal organ injury. Abdominal computed tomography (CT) is the “gold standard” examination for patients with lower rib fractures. However, the reported incidence of concomitant intra-abdominal injuries (IAI) is 20%–40%.

Automated Computed Tomography–Ultrasound Cross-Modality 3-D Contouring Algorithm for Prostate

A novel fully automated algorithm is introduced for 3-D cross-modality image segmentation of the prostate, based on the simultaneous use of co-registered computed tomography (CT) and 3-D ultrasound (US) images. By use of a Gabor feature detector, the algorithm can outline in three dimensions and in cross-modality the prostate, and it can be trained and optimized on specific patient populations. We applied it to 16 prostate cancer patients and evaluated the conformity between the automatically segmented prostate contours and the contours manually outlined by an experienced physician, on the CT–US fusion, using the mean distance to conformity (MDC) index. When only the CT scans were used, the average MDC value was 4.5 ± 1.7 mm (maximum value = 9.0 mm). When the US scans also were considered, the mean ± standard deviation was reduced to 3.9 ± 0.7 mm (maximum value = 5.5 mm). The cross-modality approach acted on all the largest distance values, reducing them to acceptable discrepancies.     

Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

Objectives: The primary goal of evaluation for acute‐onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute‐onset headache. Methods: This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. Results: SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). Conclusions: CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute‐onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%. ACADEMIC EMERGENCY MEDICINE 2010; 17:444–451 © 2010 by the Society for Academic Emergency Medicine     

Is there a place for epidemiology in nursing?

BACKGROUND: Epidemiological research is seen by many to have immense value in helping to determine the health of populations and in helping to plan and determine health service policy. Despite this it seems to be poorly understood and greatly underused by the nursing profession. CONCLUSION: Epidemiological studies can potentially offer considerable benefits to the way nurses incorporate health-related practices into their professional role. Research also offers a valuable opportunity for the nursing profession to become more active in helping to determine health policy issues. This article explores the nature of the dilemmas surrounding nursing and epidemiology and argues that nursing might be better served by a more proactive role in this valuable research discipline.     

What Interventions Improve Outcomes for the Patient Who Is Depressed and in Pain?

Specific Clinical IssueThe purpose of this clinical consultation is to offer nurses evidence-based strategies to provide holistic care to their patients with comorbid depression and pain. The combination of depression and pain is common and, if not managed effectively, has negative outcomes. Treatment-resistance is one negative outcome. The worst-case scenario for unrelieved depression and/or pain is suicide.Major Practice Recommendations Based on Best EvidenceAntidepressants, particularly duloxetine, have had efficacy for pain and depression. Cognitive behavioral therapy, an evidence-based treatment for depression, has been found to decrease pain. Examples of additional interventions include exercise, relaxation techniques, mindfulness, and music. Providing holistic nursing care and working with other disciplines optimizes more effective management of these co-occurring conditions.     

Investigating the Impact of Positron Emission Tomography–Computed Tomography Versus Computed Tomography Alone for High-risk Volume Selection in Head and Neck and Lung Patients Undergoing Radiotherapy: Interim Findings

IntroductionThe aim of this study was to quantify the impact of positron emission tomography–computed tomography (PET-CT) on clinical target volume (CTV) selection in non–small cell lung cancer (NSCLC) and head and neck squamous cell cancer (HNSCC) cancer patients.MethodsEight radiation oncologists with expertise in either NSCLC or HNSCC prospectively contoured target volumes with and without PET-CT findings. All volumes were contoured manually, and computed tomography (CT)-alone contours were identified as gross tumour volume CT and clinical target volume (CTV) CT, whereas those contoured with the aid of PET-CT were GTV PET and CTV PET. PET-CT contours were used for actual treatment delivery. Test treatment plans were generated based on the CT-alone volumes and applied to the final PET-CT contours. PET-CT had an impact if the test plans failed department quality assurance guidelines. For each patient, the dose to critical structures and any changes in the treatment plan were recorded.ResultsEighty patients (49 HNSCC and 31 NSCLC) were analyzed. PET-CT impacted 42.9% of HNSCC cases and 45.2% of NSCLC cases. On average, PET-CT volumes were significantly larger than CT-alone volumes for HNSCC cases (P < .01) but not for NSCLC cases (P = .29). For organs at risk, no statistically significant differences were noted, with the exception of mean parotid dose for the right and left parotids (P = .0137and P = .0330, respectively).ConclusionsInterim analysis of data found that the use of PET-CT in the radiation therapy planning process impacted CTV selection, resulting in a major change in radiation therapy plans in 43.7% (HNSCC 42.9% and NSCLC 45.2%) of patients.     

Is there a place for e-learning in infection prevention?

BackgroundIn the last few decades, e-learning, a method which integrates information technology and the learning process by using materials delivered through the internet, has become widely used in educational initiatives for healthcare professionals.PurposeTo evaluate whether there is a place for e-learning in the field of infection prevention.MethodsNon-comprehensive review of the literature.FindingsE-learning courses in the field of infection prevention and control are still scarce, often restricted to local initiatives and not specifically directed toward critical care providers. Although methodological flaws and potential biases hamper the generalizability of results from some currently available studies, findings related to both learners’ satisfaction and effectiveness suggest that e-learning might prove an effective educational tool for the (continuing) education of healthcare providers. Further investigations, including research pertaining to the cost-effectiveness of e-learning, are required to provide a better insight in these issues.ConclusionFurther research is required to determine the (cost)effectiveness of e-learning in general, and in the field of infection prevention and control in particular. Current insights suggest that e-learning should be based Web 2.0 technologies to address a wide range of learning styles and to optimize interactivity. As a gap in the literature was detected with respect to e-learning modules on infection prevention and control which are specifically oriented toward critical care providers, it can be recommended to promote the development and subsequent assessment of such tools that meet high-quality standards.     

Is There a Role for Statins in Atrial Fibrillation?

3-Hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (statins) are some of the most commonly prescribed drugs in the world. While lipid modification remains the primary function of statins, there has been increasing interest in its potential pleiotropic effects, particularly as an anti-inflammatory agent in its role as an antiarrhythmic. Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and carries with it a significant burden in both morbidity and mortality. Treatment for AF currently involves either rate or rhythm control where both have demonstrable associated risks. Rate control necessitates anticoagulation, which can cause life-threatening bleeding, while rhythm control has a poor side-effect profile that may lead to greater mortality and may not completely eliminate the need for anticoagulation. Considering this pressing need for novel therapeutic interventions in AF, this long overdue systematic review explores the potential role of statins in the treatment and prevention of AF. Physicians, especially cardiologists, need to be aware of the host of currently available literature and, more importantly, need to be stimulated to generate discussion and formulate studies that will help debate the issues under the most erudite standards .     

Abdominal Migraine in Children: Is It All in Their Heads?

Abdominal migraine in children is a migraine variant, described as isolated, paroxysmal attacks of severe periumbilical abdominal pain associated with nausea, vomiting, pallor, anorexia, headache, and photophobia, with intervening periods of normality. Abdominal migraine is a diagnosis of exclusion, as presenting symptomatology can also be characteristic of other disease processes. An extensive history and physical examination are necessary to differentiate between abdominal migraine and acute abdominal pain. Limited studies have been conducted on the management of children with an acute abdominal migraine attack. Treatment and prophylaxis of acute attacks is essential to reduce recurrence, severity, and extent of pain.     

Is there a role for melatonin in the ICU?

Summary In the last decade, there have been significant developments in the understanding of the hormone melatonin in terms of its physiology, regulatory role and potential utility in various domains of clinical medicine. Melatonin’s purported properties include, among others, regulation of mitochondrial function, anti-inflammatory, anti-oxidative and neuro-protective effects, sleep promotion and immune enhancement. As such, its role has been explored specifically in the critical care setting in terms of many of these properties. This review addresses the physiological basis for considering melatonin in the critical care setting as well as the current evidence pertaining to its potential utility Contributions of the study This review examines and discusses the role of melatonin in the intensive care unit in terms of sleep, delirium and sepsis, both the physiology and as a therapy.     

Nonspecific Interstitial Pneumonia and Usual Interstitial Pneumonia: Is Differentiation Possible by High-Resolution Computed Tomography?

Nonspecific interstitial pneumonia (NSIP) is a form of idiopathic interstitial pneumonia characterized histologically by varying degrees of interstitial inflammation and fibrosis that are temporally and morphologically homogeneous in comparison with usual interstitial pneumonia (UIP). Differentiation from UIP is very important because treatment and prognosis are different between NSIP and UIP. Although there are limitations for the differentiation between NSIP and UIP on computed tomography, some computed tomography findings contribute to it. Relatively peribronchovascular distribution, wide extent of areas with ground-glass attenuation, and subpleural sparing are more highly seen in patients with NSIP, whereas wide extent of honeycombing and subpleural distribution are more common characteristics in patients with UIP.     

Is there a case for paternalism in forensic nursing?

Forensic nurses often face a competing duty to patients and society. This article explores possible solutions to the ethical conflict.