Virchow: Gargantuan Appetite for Knowledge,Battles, Causes

Chemonucleolysis is the last step in “conservative” care of a patient with disk herniation. In experienced hands, the technique is less traumatic than spinal surgery.     

家庭医疗服务管理对慢性心衰患者预后生存质量的影响

目的 探讨家庭医疗服务对慢性心衰患者预后生存质量的影响。方法 选取90例慢性心力衰竭患者作为研究对象,干预组采用家庭医疗服务模式。采用Lee氏心衰积分对患者干预后心衰疗效进行评估。应用心肺运动实验和6分钟步行测试（6MWT）评估患者的心功能状态。评估营养状况、生活质量和再入院率。结果 经干预后干预组患者的pVO2、% pVO2和VO2无氧阈值显著高于对照组（P<0.05）。干预组患者的MNA评分、Hb和ALB水平显著高于对照组。干预组患者的心衰再入院率显著低于对照组。结论 家庭医疗服务模式应用于慢性心衰患者的管理,能显著改善患者的营养状况,改善患者心衰症状和心肺运动功能。     

基于德尔菲法的农村定向临床医学生培养效果评价指标体系的建立

目的:通过建立用人单位对新疆订单定向临床医学生培养效果评价指标体系,为培养效果评价奠定基础。方法:在问卷调查和访谈用人单位培养要求的基础上,运用德尔菲法确定指标体系及权重。结果:用人单位对自治区定向免费医学生能力的培养要求依次为可以胜任工作、知识和实践能力、较好的道德素质。免费定向医学生应具备的个人素养是良好的人际交往...     

Temporal arteritis

Abstract

Objective: To assess rates of diagnosis and antihyperglycemic dose adjustment in patients with moderate to end-stage renal impairment (RI) and type 2 diabetes mellitus (T2DM). Methods: Retrospective database analysis using GE Centricity Outpatient Electronic Medical Records. Patients aged ≥ 18 years with evidence of T2DM (International Classification of Diseases, Ninth Edition, Clinical Modification codes 250.x0 and 250.x2) between January 1, 2000 and June 30, 2009, and ≥ 12 months of data after identification were selected. Moderate to end-stage RI was evaluated using a formula-derived estimated glomerular filtration rate (eGFR) based on serum creatinine (SCr). Patients were classified as moderate (eGFR, 30–59 mL/min/1.73 m²), severe (eGFR, 15–29 mL/min/1.73 m²), or end-stage (eGFR, < 15 mL/min/1.73 m²), per the National Kidney Foundation guidelines, based on the first-observed SCr test. Among patients with a physician diagnosis, the time to diagnosis was reported. Dose adjustment was reported for patients receiving metformin and sitagliptin. Predictors of progression to end-stage RI based on logistic regressions were examined. Results: 35.2% of patients with T2DM had evidence of moderate to end-stage RI. Of these patients, 20% had a chart-documented physician diagnosis (range, 16% [moderate RI] to 66% [end-stage RI]). Patients with moderate or severe RI had a physician diagnosis mean of 253.4 (standard deviation [SD], 584.5) and 86.9 (SD, 417.4) days, respectively, after the eGFR calculation indicating RI. Patients with end-stage RI had a physician diagnosis mean of 83.6 (SD, 399.2) days before the eGFR calculation. After the eGFR calculation, 15.1% and 0.1% of patients with orders for sitagliptin and metformin, respectively, received doses of the drug appropriate for their degree of RI. Among patients with moderate or severe RI, appropriate diagnosis of RI was associated with significantly lower odds of progressing to end-stage RI (odds ratio, 0.200; 95% confidence interval, 0.188–0.213). Conclusions: Renal impairment is common but often undetected in patients with T2DM. Patients with a documented RI diagnosis have lower odds of progression to end-stage RI. Metformin and sitagliptin are frequently used at inappropriate doses in patients with RI. Further analyses to understand the clinical and economic consequences of these findings are needed.     

Etiology and Treatment of Pernicious Anemia

Pernicious anemia is defined in accordance with the most recent views concerning its cause and clinical characteristics. The relationship of folic acid and vitamin B¹² to the etiology and treatment of the condition is discussed. Cases are presented which illustrate the principal diagnostic criteria of the disease and the proper treatment of pernicious anemia and other macrocytic anemias.     

P REHOSPITAL U SE OF A NALGESIA FOR S USPECTED E XTREMITY F RACTURES

Introduction. Pain and its control have been studied extensively in the emergency department. Numerous studies indicate that inadequate treatment of pain is common, despite the availability of myriad analgesics. It has been suggested that oligoanesthesia is also a common practice in the prehospital setting. Objective. To assess the use of prehospital analgesia in patients with suspected extremity fracture. Methods. Emergency medical services (EMS) call reports were reviewed for all patients with suspected extremity fractures treated from June 1997 to July 1998 in a midwestern community with a population base of 223,000. Data collected included demographic information, mechanism of injury, medications given, and field treatment. Standing orders for administration of analgesia were available and permitted paramedics to give either morphine sulfate or nitrous oxide per protocol. Results. The EMS call reports were analyzed for 1,073 patients with suspected extremity fractures. The mean patient age was 47 years. Accidental injuries comprised 86.5% of those reviewed. Suspected leg fractures were most common (20%), followed by hips (18%), arms (11%), knees (10%), ankles (9%), shoulders (7.2%), hands (5.5%), and wrists (5.3%). Multiple trauma and assorted broken digits accounted for the remaining 14%. The most common mechanisms of injury were: fall (43%), motor vehicle collision (21%), and human assault (10%). Intravenous lines were placed in 9.4% of patients; 17% received ice packs; 16% received bandage/dressings; 25% received air splints; and 19% were fully immobilized. Analgesia was administered to 18 patients (1.8%): 16 patients received nitrous oxide and two received morphine. Conclusion. Administration of analgesics to prehospital patients with suspected fractures was rare. Prehospital identification and treatment of pain for patients with musculoskeletal trauma could be improved.     

Establishing biennial paramedic experience benchmarks

Objective. Since stroke symptoms are often vague, and acute therapies for stroke are more recently available, it has been hypothesized that stroke patients may not be treated with the same urgency as myocardial infarction (MI) patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county-based EMS system for transportation to a single hospital during 1999. Methods. Patients were first identified by their hospital discharge diagnosis as stroke (ICD-9 430–436, n = 50) or MI (ICD-9 410, n = 55). Trip sheets with corresponding transport times were retrospectively obtained from the 911 center. A separate analysis was performed on patients identified by dispatchers with a chief complaint of stroke (n = 85) or MI (n = 372). Results. Comparing stroke and MI patients identified by ICD-9 codes, mean EMS transport times in minutes did not meaningfully differ with respect to dispatch to scene arrival time (8.3 vs 8.9, p = 0.61), scene time (19.5 vs 21.4, p = 0.23), and transport time (13.7 vs 16.2, p = 0.10). Mean total call times in minutes from dispatch to hospital arrival were similar between stroke and MI patients (41.5 vs 46.4, p = 0.22). Results were similar when comparing patients identified by dispatchers with a chief complaint indicative of stroke or MI. Conclusion. In this single county, EMS response times were not different between stroke and MI patients. Replication in other EMS settings is needed to confirm these findings.     

Pilot Study to Determine the Feasibility of Training Army National Guard Medics to Perform Focused Cardiac Ultrasonography

Abstract

Objective. To assess the ability of Army National Guard combat medics to perform a limited bedside echocardiography (BE) to determine cardiac activity after a brief training module. Methods. Twelve Army National Guard health care specialists trained to the level of emergency medical technician–basic (EMT-B) underwent an educational session consisting of a 5-minute lecture on BE followed by hands-on practical training. After the training session, each medic performed BEs, in either the subxiphoid (SX) or parasternal (PS) location at his or her discretion, on four healthy volunteers. The time required to complete the BE and the anatomic location of the examination (SX vs. PS) was documented. A 3-second video clip representing the best image was recorded for each BE. These clips were subsequently reviewed independently by two of the investigators with experience performing and interpreting BE; each BE was graded on a six-point scale designed for the study, the Cardiac Ultrasound Structural Assessment Scale (CUSAS). A score of 3 or greater was considered to be adequate to assess for the presence of cardiac activity. Where there was disagreement on the CUSAS score, the reviewers viewed the clip together and agreed on a consensus CUSAS score. We calculated the median time to completion and interquartile range (IQR) for each BE, the median CUSAS scores and IQR for examinations performed in the SX and PS locations, and kappa for agreement between the two reviewers on the CUSAS. Results. A total of 48 BEs were recorded and reviewed. Thirty-seven of 48 (77%) were obtained in the SX location, and 11 of 48 (23%) were obtained in the PS location. Forty-four of 48 (92%) were scored as a 3 or higher on the CUSAS. Median time to completion of a BE was 5.5 seconds (IQR: 3.7–10.9 seconds). The median CUSAS score in the SX location was 4 (IQR: 4–5), and the median CUSAS score in the PS location was 4 (IQR: 4–4). Weighted kappa for the CUSAS was 0.6. Conclusion. With minimal training, the vast majority of the medics in our study were able to rapidly perform a focused BE on live models that was adequate to assess for the presence of cardiac activity.     

A MBULANCE,F IRE,AND P OLICE D ISPATCH T IMES C OMPARED WITH THE A TOMIC C LOCK

Objectives. To quantify any differences between the times used by public safety answering points (PSAPs) in a multijurisdictional county compared with the atomic clock and to determine whether there was consistency in any time differences. Methods. All 25 ambulance, fire, and police PSAPs were contacted by telephone. The current time in hours, minutes, and seconds on the dispatch center's timepiece was -requested. The atomic clock time was simultaneously recorded. Time differences between the reported and atomic clock times were calculated and the absolute values were used to calculate the mean difference. The procedure was repeated one week later. Consistency in time deviation was evaluated by subtracting the time differences between weeks 1 and 2 for each center. Results. All 25 centers were contacted and three declined to participate. Time differences ranged from ?551 to 117 seconds (mean difference: 61.2 ± 120.3) for week 1 and ?103 to 79 seconds (mean difference: 36.9 ± 33.4) for week 2. Time deviations between weeks 1 and 2 were: 0 seconds for one center, 1 to 30 seconds for 12 centers, 31 to 60 seconds for four centers, and more than 60 seconds for five centers. Conclusions. The maximum time difference between dispatch center and atomic clock times was 551 seconds. This difference may be clinically significant for time-dependent research, quality improvement tasks, or medical legal reviews when multiple PSAPs are involved. Lack of consistency in time deviation over one week suggests systematic adjustment for these differences may not be possible.     

R EDUCTION OF THE C ALL -R ESPONSE I NTERVAL WITH A MBULANCE B ASE P AGING

Objective. To determine whether the call-response interval for an emergency medical services (EMS) system would be decreased through the introduction of ambulance base paging. Methods. The study community included a mixture of urban and rural areas with a total population of approximately 400,000. The EMS system is composed of two ambulance services and one central ambulance communication center with computer-aided dispatching capabilities. Approximately 30,000 calls are responded to yearly by the combined ambulance services. A before-and-after study design was used. In a retrospective review of one ambulance service, there were 224 calls collected in the period before base paging and 200 calls collected in the period after base paging was introduced. In the other ambulance service, there were 571 calls captured in the period before base paging and 515 calls captured in the period after base paging. Results. The call-receipt-to-crew-notified interval was reduced from the before period to the after period in both ambulance services: Cambridge—61.8 to 49.8 seconds (p < 0.0001); Kitchener—66.6 to 46.2 seconds (p < 0.0001). The crew-notified-to-vehicle-mobile interval was reduced from the before period to the after period in both ambulance services: Cambridge—91.8 to 73.2 seconds (p < 0.0001); Kitchener—80.4 to 66.0 seconds (p < 0.0001). Conclusions. The introduction of ambulance base paging reduced components of the call-response interval in this EMS system. Overall, the reduction in time was approximately 30 seconds, which was found to be statistically significant.