Preventive Care in the Emergency Department A Systematic Literature Review on Emergency Department-based Interventions that Address Smoke Detectors in the Home

OBJECTIVES: To assess the effectiveness of an emergency department (ED)-based strategy to identify and counsel selected patients about the importance of an operational smoke detector in the home and to offer a graded recommendation regarding such a strategy. METHODS: A systematic review was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. Two Medline combined searches were performed using the following terms: emergency medical services and counseling, protective devices and smoke detectors, accidents, home, burns, fires, and residential fires. A free-text search of indexed and nonindexed citations in Emergency Medical Abstracts from 1977 to 1999 and a search of the Cochrane Library were also performed. In addition, reviewers performed independent Medline searches and suggested four additional studies. Studies selected for inclusion in this systematic review were required to meet the following criteria: 1) report ED-based research and 2) address the topic of fire and burn prevention with some pertinent discussion of ED-based interventions. The initial inclusion criteria had restricted studies to those that reported the results of counseling strategies for smoke detectors. The authors later decided to consider, as indirectly relevant, studies that did not investigate counseling strategies. Data from the selected studies were extracted using the template form, and the validity and applicability of the results to emergency practice were assessed. Recommendations were derived following criteria developed by a systematic review of preventive interventions in the ED. RESULTS: Six articles were closely reviewed. Four of the six studies met the inclusion criteria. One other study that did not meet the inclusion criteria was also considered. No study focused specifically on the counseling of ED patients about smoke detectors. CONCLUSIONS: Following the criteria of the graded recommendations used for the parent project. a recommendation cannot be made either for or against an ED-based strategy to counsel patients on the importance of smoke detectors. No studies located in our review directly assessed the effectiveness of such a strategy. Based on the retrospective case series study of the potential opportunity for a home fire safety intervention during an emergency medical services visit and the Safe Block Project study, it may be worthwhile to consider further research on the effectiveness of systems-level/structural interventions, with a targeted focus on strategies that attempt to overcome barriers associated with active interventions.     

Visual parameters in patients with pituitary adenoma before and after transsphenoidal surgery

Eighty-two patients with pituitary adenoma who underwent transsphenoidal surgery were examined before and after surgery. Nineteen patients had a normal preoperative neuro-ophthalmological examination. All of these patients maintained normal visual parameters postoperatively. The remaining 63 patients had tumour-related loss of visual acuity, visual field, or both. These patients ranged in age from 18 to 78 years. Duration of symptoms ranged from one day to ten years, with a median of six months. Preoperative visual acuity was 6/12 or better in 72% of eyes, with 90% of patients having 6/12 or better in their better eye. Only 7% of eyes had a normal preoperative visual field. Both visual acuity and visual field improved postoperatively in the majority of eyes. In eyes that were examined within one week after surgery and subsequently, substantial improvement occurred within the first postoperative week, but further improvement continued over weeks to months postoperatively, with visual field taking longer to stabilise than visual acuity. Visual acuity at last examination was 6/12 or better in 87% of eyes, and visual field at last examination was normal in 50% of eyes. A total of 92% of patients had visual acuity of 6/12 or better in their better eye, and 62% of patients had a normal visual field in their better eye. Visual acuity at last examination was correlated with both age and preoperative visual acuity. Last visual field also was correlated with both age and preoperative visual field. Patients with preoperative optic atrophy had a poorer visual prognosis than did patients with normal fundi.     

Inside “Pandora’s box”

OBJECTIVE: To explore the attitudes and experiences of abused women to identify characteristics that helped or hindered abuse disclosure to clinicians and to determine how women viewed potential interventions to improve detection and treatment in a medical setting. DESIGN: Focus group data conducted and analyzed with qualitative methodology. SETTING: Three community-based mental health centers and one women’s shelter. PARTICIPANTS: Twenty-one women in group therapy for domestic violence. MAIN RESULTS: Eighteen (86%) of the 21 women had seen their “regular doctor” in the prior year; only 1 in 3 had discussed the abuse with the clinician. The major discussion themes were medical problems that were exacerbated with abuse, lack of ability to access medical care due to abuser interference, emotional attitudes about abuse that acted as barriers to disclosure, clinician characteristics that helped or hindered disclosure, and treatment experiences and preferences. Women described how their medical problems began or worsened during the abusive period. one in three women described how abusers blocked them from receiving medical care. Women reported intense shame about the abuse and described their self-denial of abuse. Women stated they were inclined to discuss abuse if they felt the clinician was perceived to be caring, was easy to talk to, had a protective manner, or if the clinician offered a follow-up visit. There was no consistent clinician gender preference among the women. One in four women had received psychotropic medication for problems associated with abuse. Many feared addiction, or a loss of alertness, increasing their risk for more abuse. CONCLUSIONS: Many abused women experience worsening health and seek medical care; most do not volunteer a history of violence even to their regular clinicians. Many of the barriers to disclosure of abuse could be overcome by a physician’s knowledge of the link between abuse and medical illness, an understanding of the women’s emotions about abuse, and her treatment preferences. Presented at the Society of General Internal Medicine national meeting, Washington, DC, May 1997.