Failure to Validate a Predictive Model for Refusal of Care to Emergency-department Patients

Objective: To determine whether previously developed triage criteria for refusal of care to patients presenting to an emergency department (ED) with nonurgent problems could be validated for an independent patient population.
Methods: A convenience sample of 534 adults presenting to a municipal hospital ED between July 1, 1992, and October 15, 1992, who met preestablished criteria for refusal of care were entered into a prospective, observational, cohort study. The single target outcome variable was hospitalization. In order to optimize the criteria's performance, both the triage nurse and the physician caring for the patient had to agree that all criteria for "refusal of care" were specifically met. No patient was refused care, nor was a patient's management or disposition interfered with in any way by the investigators. All patients were followed until hospital admission or release from the ED.
Results: Six (1.1%) of 534 patients (95% CI 0.4–2.4) who met the criteria for refusal of care were hospitalized. This represents a greater than 50-fold difference in incidence of hospitalization when compared with that found by other investigators, who reported that only 0.02% (95% CI 0.0004–0.04) of those patients who were refused care subsequently required hospitalization (p < 10–7).
Conclusion: The authors were unable to validate a previously developed predictive model for refusal of care to patients presenting to an ED. Refusal of care to selected ED patients based on current guidelines is not a viable solution to overcrowding. Alternative strategies must be sought.     

Incidence and risk factors of pneumonia acquired in intensive care units

Objective To estimate the incidence of pneumonia acquired in the intensive care unit (ICU), and to define risk factors for developing such an event.Design European prospective survey, in which all patients admitted to the participating ICU from January, 17 to 23, 1990, were followed until ICU discharge.Setting 107 general ICUs from 18 countries.Patients Of 1078 admitted to the ICUs, 996 patients without pneumonia at admission were studied.Measurements Pneumonia was diagnosed by the staff physician on the basis of clinical, radiological and microbiological criteria, secondly validated by an expert committee who reviewed all the forms and even recontacted ICU physicians. Crude incidence and time to occurrence of pneumonia were estimated, then both used as endpoints for prognosis analysis.Results 89 pneumoniae were observed: crude incidence was estimated at 8.9%, 7-day and 14-day pneumonia rates at 15.8% and 23.4%, respectively. The risk of developing pneumonia increased when either coma, trauma, respiratory support, Apache II >16 and/or impaired airway reflexes were present at ICU admission. To predict time to occurrence of pneumonia, only two variables remained significant: the presence of impaired airway reflexes at admission and the use of mechanical ventilation during ICU course.Conclusion The role of the injury to the respiratory system — with the subsequent need for respiratory support-appears central in determining the risk to acquire pneumonia in ICU. In the future, the predictive value of severity scores during ICU course should be otherwise assessed.     

Migraine Triggered by Rubbing the Eyes

A patient with recurrent exertional headaches was able, on multiple occasions, to trigger his typical headaches within 30 minutes of rubbing his eyes gently and inducing bilateral photopsias. No intracranial or orbital lesions were identified. His EEG, obtained while rubbing his eyes and inducing photopsias, did not show epileptic discharges or background changes. His ophthalmologic examination, including visual field testing, was normal. Ocular pressure and massage of the carotid sinuses failed to cause bradycardia to imply vagal mediation of his physically induced headaches. It is hypothesized that in this patient mechanical displacement of the eyes precipitated retinal auras leading to migraines.     

Sonographic Differentiation of Thyroid Nodules With Eggshell Calcifications

Objective. The purpose of this study was to assess the role of known suspicious sonographic findings and to find other additional sonographic findings to differentiate benign and malignant thyroid nodules with “eggshell” calcifications. Methods. Our Institutional Review Board approved this retrospective study, and informed consent was not required. We reviewed sonographic findings of thyroid nodules in 795 patients who underwent thyroid surgery in our institution between August 2006 and February 2007. Ninety‐three thyroid nodules with eggshell calcifications in 92 patients were included in this study. Each lesion was evaluated for known suspicious sonographic criteria, including marked hypoechogenicity, irregular or microlobulated margins, and a taller‐than‐wide shape, as well as 2 additional sonographic findings: a hypoechoic halo and disruption of eggshell calcifications (halo and disrupted calcification rim). The sensitivity and specificity based on the sonographic criteria were calculated and compared among the 2 types of criteria. Results. Among the 93 thyroid nodules, 59 were malignant and 34 were benign. The halo and disrupted calcification rim showed higher sensitivity (62.7% and 76.3%, respectively) than any of the known suspicious sonographic criteria (40.7%, 35.6%, and 55.9%). The combination of both the halo and the disrupted calcification rim showed significantly higher sensitivity (93.2%) than the combination of the known suspicious sonographic criteria (78%; P < .05), although both had the same specificity (64.7%). Conclusions. In thyroid nodules with eggshell calcifications but no other calcifications, the findings of a peripheral halo and disruption of the eggshell calcifications may be more useful sonographic predictors of malignancy than hypoechogenicity, microlobulated margins, and a taller‐than‐wide shape.     

Technical Performance and Reflection Capacity of the Anaesthetic Conserving Device—A Bench Study with Isoflurane and Sevoflurane

Objective

The anaesthetic conserving device (AnaConDa^®, Sedana Medical, Sundbyberg, Sweden) facilitates administration of isoflurane or sevoflurane by liquid infusion. An anaesthetic reflector inside the device conserves exhaled anaesthetic and re-supplies it during inspiration. In this bench study, we examined the influence of infusion rates and ventilatory settings on the resulting anaesthetic concentrations on patient (C_pat) and ventilator side of the reflector (C_loss) to describe its technical performance.

Methods

A Puritan Bennett 840 ICU ventilator (Pleasanton, US), AnaConDa^®, and a test lung (3 l-chloroprene-bag) were assembled. Infusion rates (IR, 0.2-50 ml h^-), respiratory rates (RR, 5-40 breaths min^-1), and tidal volumes (V_T, 0.3, 0.5, and 1.0 l) were varied. C_pat was measured via a thin catheter in the middle of the 3 l-bag in steady state (online data storage and averaging over >10 min). C_loss was calculated from IR (to yield the volume of vapour per unit of time), and expired minute volume (in which the vapour is diluted) on the assumption that, in the steady state, input by liquid infusion equals output through the reflector.

Results

At lower concentrations (C _pat< 1 vol%) the ratio C_loss/C_pat was constant (R _C = 0.096?±±0.012) for all combinations of IR, RR and V_T, both for isoflurane and sevoflurane. The device could efficiently reflect up to 10 ml vapour per breath (e.g. 2 vol% in 0.5 l). When exceeding this capacity, surplus vapour “spilled over” and R_C markedly increased indicating decreased performance.

Conclusions

The triple product minute volume times R_C times C_pat describes anaesthetic losses through the reflector. It can easily be calculated as long as the 10 ml reflection capacity is not exceeded and thus R_C is constant. Increased minute ventilation necessitates increasing the IR to keep C_pat constant. When using large V_T and high C_pat “spill over” occurs. This effect offers some protection against an inadvertent overdose.     

The Web-based worksheet: an opportunity for prompt,consistent, and expert feedback in a community-based hospice experience

We faced a challenge in providing a consistent high-quality learning experience in hospice care, especially because our community-based medical school has students rotating in hospices in six separated communities and the number of faculty with expertise in palliative care is limited. To address these concerns, a Web-based worksheet with interaction with a central campus faculty member was designed for use in a hospice module in a family practice clerkship.     

Modern management of cancer-related intestinal obstruction

Malignant-associated bowel obstruction remains a common and perplexing problem for patients with advanced gynecologic and gastrointestinal malignancies. The ability to locate and define its cause preoperatively has improved with the advent of computed tomography. Initial clinical experience with half-Fourier acquisition single-shot turbo spin-echo magnetic resonance imaging (HASTE MRI) and virtual colonoscopy is exciting. The surgical approach for primary obstructing colon cancer has become more aggressive, with experienced surgical groups doing one-stage procedures. Yet to be defined are guidelines for surgical management of obstructions occurring in the face of recurrent disease. Stent placement for upper and lower bowel obstructions is an option in nonoperable patients. Pharmacologic symptom management for intestinal obstructions consists of an opioid, an anticholinergic, and an antiemetic. Octreotide, either alone or added to the original regimen, will palliate symptoms that are resistant to the three-drug combination.     

Music Does Not Reduce Alfentanil Requirement During Patient-Controlled Analgesia (PCA) Use in Extracorporeal Shock Wave Lithotripsy for Renal Stones

To evaluate the impact of music on opioid requirements and pain levels during renal lithotripsy using alfentanil patient-controlled analgesia (PCA), we conducted a prospective, blinded, randomized controlled trial. Patients undergoing lithotripsy were instructed in PCA use and asked to rate their anxiety and select their preferred type of music. They were then premedicated with morphine and ketorolac and randomly allocated into two groups. Group 1 (n = 97) had music started 10 min before the procedure and maintained until 10 min after its conclusion. Group 2 (n = 96) had music begun at the conclusion of lithotripsy and continued for 10 min. Pain intensity, alfentanil requirement, side effects, quality of analgesia, patient satisfaction, and acceptance of the technique were evaluated. Demographics, alfentanil requirement, pain levels, side effects, quality of analgesia, and patient satisfaction were similar in both groups. The addition of music did not provide any benefit. This result raises the possibility that some nonpharmacologic therapies have minimal impact in settings where the painful stimulus is moderate to severe and adequate pharmacotherapy is available.