Identification of patients with low-risk pulmonary embolism suitable for outpatient treatment using the pulmonary embolism severity index (PESI)

BACKGROUND

There is increasing evidence that outpatient treatment of patients with low-risk stable pulmonary embolism (PE) is safe, effective and potentially reduces costs. It is not clear how many patients presenting to an Irish Emergency Department (ED) are potentially suitable for outpatient management.

AIMS

To identify how many patients presenting to our ED over a 1-year period who were diagnosed with acute PE are potentially suitable for outpatient treatment.

METHODS

A retrospective observational study was conducted over a 1-year period. Clinical notes for patients who had a positive computed tomographic pulmonary angiogram (CTPA) within 24 h of presentation to the ED were examined to risk stratify the patients according to the pulmonary embolism severity index (PESI).

RESULTS

Forty-seven patients who presented to our ED were diagnosed with a PE. Clinical notes were missing for 3 cases, and 44 cases were analysed further. The mean age was 64.3 (±16.8 SD) years and 24 (54.5 %, 95 % CI 40-68.3 %) were males. Six patients (13.6 %, 95 % CI 6.4-26.7 %) had a background of cancer. Fifteen cases (34.1 %, 95 % CI 21.9-48.7 %) were deemed to be low risk as they were categorised as PESI risk class I or II. Our study found that 61/420 (14.5 %, 95 % CI 11.5-18.2) of CTPAs done were positive for PE.

CONCLUSION

This study suggests that a significant percentage of patients diagnosed with acute PE are low risk as per PESI and therefore potentially suitable for outpatient management.

Atrial laceration caused by removal of a transjugular intrahepatic portosystemic shunt necessitates emergent cardiopulmonary bypass during liver transplant: a case report

In situ transjugular intrahepatic portosystemic shunting (TIPS) can complicate liver transplantation. We present a case where an intraoperative attempt to remove a malpositioned TIPS resulted in atrial laceration. Massive transfusion and emergent institution of cardiopulmonary bypass allowed patient resuscitation and completion of surgery. We describe our surgical and anesthesiologic management, and discuss the absence of criteria to predict when TIPS may become adherent to the inferior vena cava or the right atrium and difficult to remove.

Criteria for compulsory admission in some European countries

Compulsory admission to mental health facilities is a controversial topic, as it impinges on personal liberty and the right to choose, and it carries the risk of abuse for political, social and other reasons (Gostin, 2000). However, involuntary admission can prevent harm to self and others, and assist people in attaining their right to health, which, due to their mental disorder, they are unable to manage voluntarily. Since the 1950s and 1960s, the delivery of mental health has shifted from a paternalistic emphasis on the need to treat those who are not able to look after themselves, to the rights of patients who have a mental illness. The Principles for the Protection of Persons with Mental Illness ('the MI Principles') adopted by the United Nations in 1991 play an important role in raising awareness about the human rights of people with mental health problems. They provide guidance on areas such as the procedures for involuntary admission to mental health facilities and standards of care (Knapp et al, 2007). Legal frameworks for involuntary placement of those who are mentally ill have been reformed in many European countries. Most regulate compulsory admission and treatment by special mental health laws. Only Greece, Spain, Italy and those member states of the European Union (EU) that joined in 2004 and 2007 have no separate laws (Dressing & Salize, 2004).

Criteria for compulsory admission in some European countries

Compulsory admission to mental health facilities is a controversial topic, as it impinges on personal liberty and the right to choose, and it carries the risk of abuse for political, social and other reasons (Gostin, 2000). However, involuntary admission can prevent harm to self and others, and assist people in attaining their right to health, which, due to their mental disorder, they are unable to manage voluntarily. Since the 1950s and 1960s, the delivery of mental health has shifted from a paternalistic emphasis on the need to treat those who are not able to look after themselves, to the rights of patients who have a mental illness. The Principles for the Protection of Persons with Mental Illness (‘the MI Principles’) adopted by the United Nations in 1991 play an important role in raising awareness about the human rights of people with mental health problems. They provide guidance on areas such as the procedures for involuntary admission to mental health facilities and standards of care (Knapp et al, 2007). Legal frameworks for involuntary placement of those who are mentally ill have been reformed in many European countries. Most regulate compulsory admission and treatment by special mental health laws. Only Greece, Spain, Italy and those member states of the European Union (EU) that joined in 2004 and 2007 have no separate laws (Dressing & Salize, 2004).

Metabolic syndrome and cerebral vasomotor reactivity

BACKGROUND AND PURPOSE

Metabolic syndrome has been proposed as a risk factor for stroke and transient ischaemic attack. One pathophysiological mechanism could be impairment of endothelial function. Thus, we hypothesized that cerebral vasomotor reactivity would be decreased in patients with metabolic syndrome, compared to patients without metabolic syndrome.

METHODS

In this retrospective analysis, 83 consecutive patients (aged 59.19 ± 15.98; 33 women) underwent Doppler examination for carotid artery disease including bi-hemispherical vasomotor reactivity assessment using transcranial Doppler monitoring. Vasomotor reactivity data were analyzed from the hemisphere with no or low-grade carotid stenosis (<40%). Cerebral vasomotor reactivity was calculated as percent increase in mean flow velocity per mmHg pCO(2) during 2 min of 5% CO(2) inhalation delivered by anesthesia mask (normal if ≥ 2%/mmHg). Univariate and multivariable linear regression models were used to determine factors, including metabolic syndrome, that were independently associated with pathologic vasomotor reactivity.

RESULTS

After adjusting for the presence of contralateral carotid stenosis and ipsilateral stroke in the multivariable model, metabolic syndrome was independently associated with lower vasomotor reactivity values (2.27 ± 1.24% vs. 2.68 ± 1.37; ß = -0.258, P = 0.033). In this model, there was no association of cerebral vasomotor reactivity with age, gender, race, cardiac disease, current statin therapy, or small vessel disease.

CONCLUSIONS

Our findings suggest that impaired cerebral vasomotor reactivity may be a mediator of stroke in patients with metabolic syndrome, a syndrome affecting a significant and growing proportion of the population. A prospective longitudinal study is warranted to study the cerebral haemodynamic effect of metabolic syndrome.

An evaluation of the outcomes of psychosocial intervention training for qualified and unqualified nursing staff working in a low-secure mental health unit

Psychosocial intervention (PSI) training results in enhanced knowledge, more positive attitudes, increased confidence and lower levels of clinical burnout for qualified mental health professionals and better outcomes for service users who they work with. This paper describes an evaluation of a PSI training course for qualified and unqualified nurses working in a low-secure unit. Forty-two staff (21 qualified) were randomly allocated to an experimental training group or a waiting list control group. Knowledge, attitudes and burnout were assessed before and after the training. In addition, a random sample of 44 care plans written by the qualified nurses were audited before and after to examine evidence of implementation of PSI in practice. Qualified and unqualified nurses in the experimental group showed significant improvements in knowledge and attitudes compared with the control group. Care plans showed a significant increase in the implementation of PSI. The only significant change in burnout was a reduction in depersonalization for qualified nurses in the experimental group. The PSI training may result in improvements in knowledge, attitude and practice in qualified and unqualified nurses working with severely mentally ill patients in low-secure settings, but in this study the training did not incur protection against burnout.

The role of liver transplantation for hepatic adenomatosis in the pediatric population: case report and review of the literature

Hepatic adenomas are benign lesions often found in young women during childbearing age. These tumors are often solitary but can also be multiple in which case this is referred to as hepatic adenomatosis (HA). HA is defined as having greater than or equal to ten adenomas within an otherwise normal liver. We present a case of a teenager with HA who underwent an orthotopic liver transplant for complications of her HA. To date there are only four reports of teenagers, without an underlying glycogen storage disease, who have undergone a liver transplant for HA. Liver transplantation within the pediatric population is an acceptable treatment for HA that are deemed unresectable.

Fertility after abdominal myomectomy

This study aimed to evaluate the morbidity and pregnancy outcome of myomectomy in infertile women with uterine fibroids. This was a cross-sectional study. Records were reviewed for 100 consecutive women in the Rotunda Hospital who underwent myomectomy in the years 1995-1996. A questionnaire regarding subsequent fertility was sent. The study was carried out in the infertility unit at the Rotunda Hospital, Dublin, Ireland. Seventy-five women responded. Multiple myomectomy was performed in 52 (70%). Mean fibroid size was 6.8 cm (range 2-14.5 cm). Nine women (12%) developed complications; five had menstrual problems, two had wound discomfort and two had abdominal discomfort. Twenty-five women (33%) became pregnant. Seven (28%) were IVF pregnancies. Overall six (24%) miscarried. In 19 of 25, pregnancy occurred where fibroids were the only identifiable cause of infertility. We conclude that abdominal myomectomy is associated with a favourable outcome in infertile women particularly if no other confounding variable is present.

Activated protein C resistance, factor V Leiden and assessment of thrombotic risk

Venous thromboembolism comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). Acute venous thromboembolism (VTE) is a serious and potentially fatal disorder which often complicates the course of hospitalized patients, but also affects ambulatory and otherwise healthy people. The annual incidence of venous thromboembolism is 1 to 2 cases per 1000 person and the risk of the disorder rises exponentially with age, from an annual rate of less than 5 per 100,000 children to greater than 400 per 100,000 adults older than 80 years.