Diagnostic accuracy of a rapid telemedicine encounter in the Emergency Department

Objectives

Emergency Department crowding is an increasing problem, leading to treatment delays and higher risk of mortality. Our institution recently implemented a telemedicine physician intake (“tele-intake”) process as a mitigating front-end strategy. Previous studies have focused on ED throughput metrics such as door to disposition; our work aimed to specifically assess the tele-intake model for clinical accuracy.

Potentially Modifiable Risk Factors for Long-Term Cognitive Impairment After Critical Illness: A Systematic Review

Long-term cognitive impairment is common in survivors of critical illness. Little is known about the etiology of this serious complication. We sought to summarize current scientific knowledge about potentially modifiable risk factors during intensive care unit (ICU) treatment that may play a substantial role in the development of long-term cognitive impairment. All searches were run on October 1, 2017. The search strategy included Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effect, Scopus, and Web of Science, and included MeSH headings and keywords related to intensive care, critical care, and cognitive disorders. Searches were restricted to adult subjects. Inclusion required follow-up cognitive evaluation at least 2 months after ICU discharge. Studies assessing patients with cardiac arrest, traumatic brain injury, and cardiac surgery history were excluded. The search strategy resulted in 3180 studies. Of these, 28 studies (.88%) met our inclusion criteria and were analyzed. Delirium and duration of delirium were associated with long-term cognitive impairment after ICU admission in 6 of 9 studies in which this factor was analyzed. Weaker and more inconsistent associations have been reported with hypoglycemia, hyperglycemia, fluctuations in serum glucose levels, and in-hospital acute stress symptoms. Instead, most of the studies did not find significant associations between long-term cognitive impairment and mechanical ventilation; use of sedatives, vasopressors, or analgesic medications; enteral feeding; hypoxia; extracorporeal membrane oxygenation; systolic blood pressure; pulse rate; or length of ICU stay. Prolonged delirium may be a risk factor for long-term cognitive impairment after critical illness, though this association has not been entirely consistent across studies. Other potentially preventable factors have not been shown to have strong or consistent associations with long-term cognitive dysfunction in survivors of critical illness.     

Thirty-Day Readmission Rate in Acute Heart Failure Patients Discharged Against Medical Advice in a Matched Cohort Study

Objective

To determine the readmission rate in patients with acute heart failure (AHF) discharged against medical advice (AMA).

Occupational risk factors for low back pain among drivers of three-wheelers in Sri Lanka

Background:

Approximately 5% of all households in Sri Lanka operate a three-wheeler as their primary source of income. However, very little is known about the occupational health risks associated with driving these vehicles.

Objectives:

The aim of this study was to assess occupational risk factors, including the number of hours worked associated with the 4-week prevalence of low back pain (LBP) among drivers of three-wheelers.

Methods:

Questionnaires were administered to 200 full-time drivers of three-wheelers from the Galle District in Sri Lanka. Occupational, psychological, socio-demographic, lifestyle, and anthropometric variables were collected. Univariate and multivariate analysis were used to investigate the correlation between occupational risk factors of the prevalence of LBP.

Results:

15.5% of respondents reported experiencing LBP in the previous 4 months. Univariate analysis revealed that the number of hours worked per week, feeling pressure to compete with other drivers, and perceived stress scale scores were significantly associated with the 4-week prevalence of LBP. Multivariate analysis found that the number of hours worked per week and engine type were significantly associated with LBP.

Conclusions:

LBP is common among drivers of three-wheelers in Sri Lanka. Long work hours and two-stroke engines were significantly associated with LBP. Results from this study point towards a role for educational, behavioral health, and policy interventions to help prevent and reduce LBP among these drivers.     

Electron beam radiotherapy for the management of recurrent extensive ocular surface squamous neoplasia with orbital extension

Recurrent extensive ocular surface squamous neoplasia (OSSN) with orbital invasion can be successfully managed with external radiotherapy using electrons resulting in eye and vision salvage. We report a case of right eye recurrent OSSN in an immunocompetent adult Indian male, with extensive orbital involvement. The patient had two previous surgical excisions with recurrent disease. At this stage, conventionally exenteration is considered the treatment modality. However, he was treated with 5040 cGy radiotherapy (15eV electrons) resulting in complete disease regression. At the end of 3 years follow-up, the patient was disease free, maintained a vision of 20/25, with mild dry eye, well-managed with topical lubricants. Extensive OSSN with orbital invasion does not always need exenteration. External beam electron radiotherapy provides a noninvasive cure with organ and vision salvage and should be considered in extensive OSSN not amenable to simple excision biopsies. Long-term studies to evaluate the effect of radiation on such eyes are suggested.     

Transcutaneous Endoscopic Orbital Surgery: A Less Morbid Alternative to Lateral Orbitotomy

Background: Retrobulbar lesions of the orbit situated lateral to the optic nerve are difficult to access. In this article, the authors would like to present a new perspective to approach these lesions where the goals of surgery are met with minimal complications.

Methods: A retrospective analysis of patients’ charts was performed.

Results: For approaching retrobulbar lesions an endoscopic technique was developed. Four patients (2 male and 2 female patients) presenting with retrobulbar lesions lateral to the optic nerve have been included in this study. Two patients underwent endoscopic drainage for orbital abscess and two patients were successfully biopsied endoscopically. No intra-operative complications were noted. Open procedures such as lateral orbitotomy were avoided in all the cases.

Conclusion: Transcutaneous orbital endoscopy is a safe and a versatile technique to approach retrobulbar lesions lateral to the optic nerve. It can be used as an effective alternative to lateral orbitotomy for well selected cases. One can obtain adequate material for histopathological examination and also drain deep-seated orbital abscess using this technique. It would be possible with increasing experience to use this technique for extended applications.     

Magnetic resonance venography and genetics of a female patient with pelvic venous thrombosis

A femoral vein thrombosis, originally diagnosed with conventional ultrasound, was fully elucidated and monitored utilizing serial high-resolution magnetic resonance venography in a 19-year-old female with a family history of venous thromboembolism. Genetic testing revealed she was heterozygous for a F5 gene mutation, an abnormality that predisposes carriers to factor V Leiden thrombophilia. An additional risk factor included use of oral contraceptive pills. Subsequent testing of her family uncovered other carriers of the mutation, allowing for the implementation of preventive measures for the entire family. Although magnetic resonance venography has not yet proven to be a cost-effective method for monitoring clot resolution, the case presented here encourages further research on the clinical utility and cost-benefit of utilizing this technology for monitoring venous thrombosis and for clinical management purposes.     

Fibrin glue mitigates the learning curve of microneurosurgical repair

Microneurosurgical technique has a steep learning curve. An alternative to microepineurial suture repair of peripheral nerves that circumvents this learning curve would be ideal. We investigated the effect of surgeon experience on suture versus fibrin glue coaptations in a mouse sciatic nerve graft model. Sixty‐four mice received sciatic nerve grafts with either suture or fibrin glue repair by either a naïve surgeon (medical student) or a surgeon with extensive microsurgical experience. Grafts underwent quantitative histomorphometry at 3 weeks postoperatively. Suture repairs performed by the naïve surgeon demonstrated significantly poorer distal regeneration than all other repairs. Histomorphometric parameters of suture and glue repairs performed by the experienced surgeon were not significantly different from the glue coaptation by the naïve surgeon. Fibrin glue may be considered as an alternative to microepineurial suture repair, particularly in the setting of relative surgeon inexperience with microsurgical technique. © 2010 Wiley‐Liss, Inc. Microsurgery 2010.