Photodiagnostic services in the UK and Republic of Ireland: a British Photodermatology Group Workshop Report

BACKGROUND

Photodiagnostic investigations are essential for the accurate diagnosis of abnormal cutaneous photosensitivity and provide important information for the management of patients with photodermatoses (cutaneous photosensitivity disorders). Although photodiagnosis has been undertaken since the early 1970s, specialist services in the United Kingdom (UK) and Republic of Ireland are limited and there is no formal guidance on diagnostic approach. Indeed, there is a limited literature in this area of methodology and diagnostic practice.

OBJECTIVES

The primary objective was to undertake a British Photodermatology Group Workshop to review the role and activities of specialist centres in the UK and Republic of Ireland in order to ascertain whether there were consensus practices. Secondary objectives were to identify key priorities for service, training and research.

METHODS

An initial detailed survey review of current activities was undertaken prior to the Workshop and data from this survey were used to inform discussion at the Workshop, which was attended by key photodermatology experts from the UK and Republic of Ireland.

RESULTS/CONCLUSIONS

We have undertaken a detailed review of current Photodiagnostic Services in the UK and Republic of Ireland and report on our findings from the 12 centres and we have identified key areas of consensus practice. This is an important step in the process of standardising and optimising procedures and protocols and defining minimum clinical standards for photodiagnostic investigations, which are of such diagnostic importance in Dermatology.

Unpredicted late-, new-onset thrombocytopenia and hypofibrinogenemia in Fab antivenom-treated rattlesnake envenomation

The use of Fab antivenom (Crotalidae Polyvalent Immune Fab (Ovine) (CroFab); Boston Scientific) against North American Crotalidae envenomation is associated with the development of late- (≥4 days post-envenomation), new-onset of hematological abnormalities. Although attempts have been made to identify predictive indicators during the acute phase of an envenomation, of patients who are not at-risk of late-, new-onset of hematological abnormalities, there has been at least one prior report of a patient who developed thrombocytopenia that was unpredicted by current indicators. We add three cases of unpredicted, late-, new-onset of hematological abnormalities in patients with Fab-treated rattlesnake bite.

Improving palliative treatment of patients with non-operable cancer of the oesophagus: training doctors and nurses in the use of self-expanding metal stents (SEMS) in Malawi

Cancer of the oesophagus is the 6th most common cancer in Malawi. Nationwide only three hospitals are able to perform oesophagectomies, and there is no radiotherapy or chemotherapy available. Owing to late presentation of the patients (sometimes in combination with co-morbidities such as HIV/AIDS or tuberculosis) the vast majority of patients are not suitable for surgery. Self-expanding metal stents (SEMS) of the oesophagus provide a suitable palliative option to improve the quality of life for patients. This project took a nationwide approach, raising funds for both technical equipment and training of endoscopists and nursing staff throughout Malawi.

Clinical and economic impact of contaminated blood cultures within the hospital setting

Blood cultures have an important role in the diagnosis of serious infections, although contamination of blood cultures (i.e. false-positive blood cultures) is a common problem within the hospital setting. The objective of the present investigation was to determine the impact of the false-positive blood culture results on the following outcomes: length of stay, hotel costs, antimicrobial costs, and costs of laboratory and radiological investigation. A retrospective case-control study design was used in which 142 false-positive blood culture cases were matched with suitable controls (patients for whom cultures were reported as true negatives). The matching criteria included age, comorbidity score and month of admission to the hospital. The research covered a 13-month period (July 2007 to July 2008). The findings indicated that differences in means, between cases and controls, for the length of hospital stay and the total costs were 5.4 days [95% CI (confidence interval): 2.8-8.1 days; P<0.001] and £5,001.5 [$7,502.2; 95% CI: £3,283.9 ($4,925.8) to £6,719.1 ($10,078.6); P<0.001], respectively. Consequently, and considering that 254 false-positive blood cultures had occurred in the study site hospital over a one-year period, patients with false-positive blood cultures added 1372 extra hospital days and incurred detrimental additional hospital costs of £1,270,381 ($1,905,572) per year. The findings therefore demonstrate that false-positive blood cultures have a significant impact on increasing hospital length of stay, laboratory and pharmacy costs. These findings highlight the need to intervene to raise the standard of blood-culture-taking technique, thus improving both the quality of patient care and resource use.

Endometrial Stromal Neoplasms Are Immunoreactive with WT-1 Antibody

WT-1 positivity has previously been noted in nonneoplastic endometrial stroma. In this study we examined WT-1 expression in endometrial stromal neoplasms to ascertain whether these tumors are immunoreactive and whether this antibody might be of value in the diagnosis of these lesions. We also stained cases of cellular and highly cellular leiomyomas to investigate whether WT-1 might be of value in distinguishing these from an endometrial stromal neoplasm. We compared WT-1 staining with CD10, desmin, alpha smooth muscle actin, h-caldesmon, and AE1/3, many of these antibodies being commonly used to distinguish between an endometrial stromal and a smooth muscle phenotype. Cases of ESN (n = 5), low grade ESS (n = 14), and cellular or highly cellular leiomyoma (n = 14) were stained with the aforementioned antibodies. Cases were scored on a scale of 0 to 4+, with 4+ cases exhibiting positivity of >50% of cells. Sixteen of 19 endometrial stromal neoplasms were positive with WT-1, most (14 of 16) with 4+ positivity. Staining was nuclear (5 cases), cytoplasmic (5 cases), or combined nuclear and cytoplasmic (6 cases). All endometrial stromal neoplasms exhibited 4+ staining with CD10. Staining for alpha smooth muscle actin was present in most cases (14 of 19) and desmin and h-caldesmon were positive in a smaller number of cases (8 and 2 respectively). There was 4+ positivity with desmin in only 1 case. The 2 cases that were h-caldesmon positive both exhibited 1+ staining (<5% cells positive). Six cases were positive with AE1/3, 1 with 4+ staining. Leiomyomatous neoplasms always exhibited 4+ staining with desmin and alpha smooth muscle actin and in most cases (12 of 14) with h-caldesmon. The other 2 cases exhibited 2+ positivity. Most cases (12 of 14) were positive with WT-1 (7 of 14 with 4+ staining) and CD10 (5 of 14 with 4+ positivity). One case was positive with AE1/3. We conclude that diffuse WT-1 positivity is characteristic of endometrial stromal neoplasms and that this may be of value in diagnosis. However, WT-1 is of limited use in the distinction between an endometrial stromal and a cellular leiomyomatous neoplasm because many of the latter are also positive. This study confirms the value of h-caldesmon in the distinction between an endometrial stromal neoplasm (almost always h-caldesmon negative) and a cellular leiomyomatous neoplasm (h-caldesmon positive). Although CD10 is positive in endometrial stromal neoplasms, the commonly observed immunoreactivity of cellular and highly cellular leiomyomas with this antibody limits its diagnostic usefulness. Desmin is useful as all leiomyomatous neoplasms exhibited diffuse positivity, whereas only a small number of endometrial stromal neoplasms were focally positive and only 1 case exhibited 4+ positivity. Smooth muscle actin is of limited value since most neoplasms studied were positive. The overlapping immunophenotype of endometrial stromal and leiomyomatous neoplasms may reflect the origin of both cell types from a common progenitor within the uterus.

Repeat ambulance use by pediatric patients

OBJECTIVE

To compare pediatric patients transported by ambulance on more than one occasion (repeat) with those transported only once.

METHODS

The authors analyzed pediatric (patient < 21 years old) transports for 1992-1995 by the ambulance service that provides 99% of transports for a non-innercity metropolitan area. Repeat transports were compared with single transports with regard to patient age, gender, chief complaint, and payment source.

RESULTS

There were 17,448 transports involving 15,168 patients. Nearly half (49.0%) of the repeat transports involved patients in the oldest age category, 17 to 20.9 years, contrasted with 38.0% of single transports (p < 0.00001). Females comprised 51.4% of the repeat transports and 48.5% of the single transports (p = 0.0008). Traumatic complaints accounted for one-third (33.0%) of the repeat transports and half (51.1%) of the single transports (p < 0.0001). Chief complaints of the patients with repeat transports were more likely to be seizure, assault, abdominal pain, and respiratory problems, and less likely to be falls and motor vehicle-related complaints, than chief complaints of the patients with single transports (p < 0.0001). More than one-third (39.0%) of the repeat transports were funded by Medicaid, in contrast with 19.8% of the single transports (p < 0.0001).

CONCLUSIONS

Compared with single transports, repeat transports were more likely to involve patients more than 16 years of age, female, and with a chief complaint of seizure, assault, abdominal pain, or respiratory distress, and more likely to be funded by public insurance (Medicaid). Repeat pediatric transports warrant further investigation. This information may be useful in designing interventions targeted at reducing emergencies and hence ambulance use.

Guns, alcohol, and intimate partner violence: the epidemiology of female suicide in New Mexico

Suicide is among the leading causes of death in the United States, and in women the second leading cause of injury death overall. Previous studies have suggested links between intimate partner violence and suicide in women. We examined female suicide deaths to identify and describe associated risk factors. We reviewed all reports from the New Mexico Office of the Medical Investigator for female suicide deaths occurring in New Mexico from 1990 to 1994. Information abstracted included demographics, mechanism of death, presence of alcohol/drugs, clinical depression, intimate partner violence, health problems, and other variables. Annual rates were calculated based on the 1990 census. The New Mexico female suicide death rate was 8.2/100,000 persons per year (n = 313), nearly twice the U.S. rate of 4.5/100,000. Non-Hispanic whites were overrepresented compared to Hispanics and American Indians. Decedents ranged in age from 14 to 93 years (median = 43 years). Firearms accounted for 45.7% of the suicide deaths, followed by ingested poisons (29.1%), hanging (10.5%), other (7.7%), and inhaled poisons (7.0%). Intimate partner violence was documented in 5.1% of female suicide deaths; in an additional 22.1% of cases, a male intimate partner fought with or separated from the decedent immediately preceding the suicide. Nearly two-thirds (65.5%) of the decedents had alcohol or drugs present in their blood at autopsy. Among decedents who had alcohol present (34.5%), blood alcohol levels were far higher among American Indians compared to Hispanics and non-Hispanic Whites (p = .01). Interpersonal conflict was documented in over 25% of cases, indicating that studies of the mortality of intimate partner violence should include victims of both suicide and homicide deaths to fully characterize the mortality patterns of intimate partner violence.

Disturbing trends: the epidemiology of pediatric emergency medical services use

OBJECTIVE

To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints.

METHODS

An out-of-hospital database for the primary transporting service in an urban area was analyzed for patients 0-20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed.

RESULTS

There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0-11-year-olds (4.2%); 11-16-year-olds (17.5%); and 17-20-year-olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p < 0.0001) compared with the overall group.

CONCLUSIONS

A substantial proportion of pediatric emergency medical services transports are for high-risk conditions. This patient population differs from the overall group by age distribution and reimbursement source.

One-week survey of pain intensity on admission to and discharge from the emergency department: a pilot study

The purpose of this pilot study was to determine the incidence and severity of pain intensity in patients 4 years of age and older presenting to the noncritical ward of the emergency department (ED). All patients presenting to the ED of two university hospitals (one general, one pediatric) who were triaged to the noncritical ward during 12 h/day for 1 week were asked to report their pain intensity on admission and again asked just prior to discharge home. The chromatic analogue scale with a range of 0-10 was used as the measure of pain intensity. Pain reports were obtained from half of all patients (58% of adults, 47% of children) admitted during the study week. Approximately one-third (29% of adults and 31% of children) reported no pain on admission, but half of both age groups (52% of adults, 48% of children) reported pain 4/10 or higher. On discharge, one-third of both groups reported pain 4/10 or higher. Eleven percent of both adults and children reported pain 1.5/10 or higher on discharge than on admission. Adult patients with musculoskeletal complaints had the highest pain intensities (mean score admission-discharge, 5.6-4.7/10; other categories, <5). For children, neurological complaints, exclusively headaches, were highest (mean score admission-discharge, 4.8-5.2/10; other categories, <5). Children accompanied by their mothers alone had poorer pain improvement (no change) than children accompanied by their fathers alone or both parents (score improvement of 1). It thus appears that pain is a problem for the majority of patients presenting to the ED. An important percentage of patients leave the ED with more pain than when they arrived. Further investigation is warranted to determine factors predicting poor pain resolution during an ED visit.

Relationships between ambulance transports for alcohol intoxication and assault

OBJECTIVE

To evaluate the association between ambulance transports for assault and those for alcohol intoxication.

METHODS

A retrospective analysis of emergency medical services (EMS) calls was performed. The authors used logistic regression models to compare patients transported for alcohol intoxication with a control group of patients transported for respiratory distress (asthma or shortness of breath) with respect to whether they had been transported on a separate occasion for a chief complaint of assault.

RESULTS

Patients transported for alcohol intoxication had 9 times the risk of transport for assault as compared with the control group (OR = 9.3; 95% CI = 6.4, 13.6). The odds of transport for assault among the alcohol patients increased 17.1% with each alcohol transport (OR = 1.17; 95% CI = 1.14, 1.20) but decreased for the control group (OR = 0.34; 95% CI = 0.26, 0.44). Repeat transports for assault were more common among the alcohol patients than among the control group (OR = 3.3; 95% CI = 1.1, 11.3). The mean number of assault transports was higher among the alcohol patients than among the patients never transported for alcohol intoxication (p < 0.0001).

CONCLUSIONS

Patients transported on multiple occasions for acute alcohol intoxication are at relatively high risk for assault. This risk group should be targeted for focused assault prevention interventions that include components designed to reduce incidents of repeat alcohol intoxication.

Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness

Three chronic conditions were examined--acute alcohol intoxication, seizure disorder, and respiratory illness--to quantify the extent of repetitive emergency medical services (EMS) use in a defined population. Urban EMS system ambulance data from 1992 to 1994 were analyzed for the three designated conditions with respect to transports by condition and individual patient. Analysis by chi2 was used for comparing proportions. Analysis of variance after square root transformation was used to evaluate differences among means. The total number of transports analyzed was 15,541: 7,488 for acute alcohol intoxication, 4,670 for respiratory illness, and 3,383 for seizure disorder. These transports involved 8,692 patients who were transported at least once for one of the three designated conditions. The mean number of transports for alcohol was 1.96 (95% confidence intervals [CI]: 1.92, 2.01), seizure 1.32 (95% CI: 1.27, 1.36), and respiratory 1.18 (95% CI: 1.15, 1.21). Of 369 patients transported five or more times during the study period, 260 (70.5%) were for alcohol, 56 (15.2%) for seizure, and 53 (14.4%) for respiratory complaints. This group comprised only 4.3% of patients, but 28.4% of all transports. Acute alcohol intoxication resulted in more repetitive ambulance transports than either seizure disorder or respiratory illness. A small number of patients were responsible for a large number of transports. Focused intervention for patients with high ambulance transport deserves further study.

Guns and knives in New Mexico: patterns of penetrating trauma, 1978-1993

OBJECTIVE

To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.

METHODS

The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978-1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.

RESULTS

Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.

CONCLUSIONS

Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.

Farm-related injury mortality in New Mexico, 1980-91

To compare the epidemiology of farm with non-farm occupational injury deaths, we reviewed state medical examiner data for all occupational injury deaths in New Mexico from 1980 to 1991. We identified 53 farm-related injury deaths for a rate of 21.3 per 100,000 worker-years. Farm workers were four times more likely than non-farm workers to die from occupational injury. American Indians had the highest farm injury death rate. Farm decedents were older than non-farm decedents (t498 = 6.29, p < 0.0001). Half of the farm decedents were 50 years of age or older; one-third were 60 years of age or older. Crush injuries accounted for half of all farm injury deaths including 18 of 23 motor vehicle deaths, half of these involving a tractor rollover. One in six farm injury deaths were from electrocution: one in five involved alcohol. Our study indicates that New Mexico has high farm-related injury mortality related to tractor use, alcohol intoxication, farm animals, and exposure to electricity. American Indians and older males are especially susceptible to these factors.

Increasing emergency physician recognition of domestic violence

STUDY OBJECTIVE

To determine whether recognition of domestic violence in the emergency department is affected by restructuring of the ED chart to include a specific question about domestic violence, to evaluate whether training concerning domestic violence further increases its recognition, and to develop a profile of women who present to the ED as a result of domestic violence.

METHODS

We collected prospective data on all females aged 15 to 70 years who presented to an urban Level I trauma center during a 3-month period. Two keywords were used to define domestic violence: (1) mechanism (eg, kicked, hit, pushed) and (2) perpetrator (eg, current/former boyfriend, spouse). We used the first month to define the baseline number of domestic violence cases. We modified charts in the second and third months (intervention months) to include, "Is the patient a victim of domestic violence?" In addition, the third month included a 1-hour educational lecture on the identification of domestic violence in the ED.

RESULTS

We identified 123 cases of domestic violence from a survey population of 4,073: 25 (2.0%) in the baseline month, 49 (3.4%) in the chart-modification month, and 49 (3.6%) in the education month. The proportion of cases identified during the intervention months was 1.8 times higher than during the control month (relative risk [RR], 1.78; 95% confidence interval [CI], 1.15 to 2.75), but did not differ between each other (RR, 1.06; 95% CI, .72 to 1.57). Women identified as domestic violence cases ranged in age from 15 to 61 years (median, 28.5 years). Most of the identified domestic violence patients presented with a triage classification of assault (54.5%), trauma (8.1%), or abdominal complaints (7.3%). Triage complaint differed for domestic violence and non-domestic violence cases (chi 2 = 830; P < .0001). Nearly one third of domestic violence patients (31.7%) presented between 11 PM and 6:59 AM, compared with 19.0% of non-domestic violence patients (chi 2 = 12.4; P = .005).

CONCLUSION

Modification of the chart significantly increased the recognition rate of domestic violence. An education intervention did not significantly improve this rate. The profile of a woman presenting to the ED differs from those of other women with respect to chief complaint and time of presentation.

Occupational injury mortality in New Mexico

STUDY OBJECTIVE

To examine specific risks for occupational injury deaths in New Mexico.

DESIGN

Retrospective review of state medical investigator reports from 1980 through 1991 with regard to industry, agent of death, gender, ethnicity, location, and alcohol and other drug involvement.

PARTICIPANTS

New Mexico residents who were fatally injured while on the job.

RESULTS

We identified 613 deaths: 87.1% unintentional, 10.6% homicides, and 2.3% suicides. Industries with the most fatalities were construction (11.8%), oil/gas (10.6%), and farming (8.6%). The primary agents of death were motor vehicles (41.7%), firearms (10.1%), and falling objects (10.0%). Almost all (95.6%) of the decedents were male. However, females were overrepresented among homicide deaths (P < .0001). Most unintentional injuries occurred in rural areas (69.1%), whereas most homicides (73.4%) and suicides (71.4%) occurred in urban areas. Drug or alcohol use was evident in 19.4% of cases.

CONCLUSION

New Mexico has a high rate of occupational injury death, which appears to be associated with rural location and use of motor vehicles and alcohol.