Gender-based differential management of acute low back pain in the emergency department: A survey based on a clinical vignette

BACKGROUND

Women may receive suboptimal pain management compared with men, and this disparity might be related to gender stereotypes.

OBJECTIVES

To assess the influence of patient gender on the management of acute low back pain.

DESIGN

We assessed pain management by 231 physicians using an online clinical vignette describing a consultation for acute low back pain in a female or male patient. The vignette was followed by a questionnaire that assessed physicians' management decisions and their gender stereotypes.

METHODS

We created an online clinical vignette presenting a patient with acute low back pain and assessed the influence of a patient's gender on pain management. We investigated gender-related stereotyping regarding pain care by emergency physicians using the Gender Role Expectation of Pain questionnaire.

RESULTS

Both male and female physicians tended to consider that a typical man was more sensitive to pain, had less pain endurance, and was more willing to report pain than a typical woman. These stereotypes did not translate into significant differences in pain management between men and women. However, women tended to be referred less often for imaging examinations than men and were also prescribed lower doses of ibuprofen and opioids. The physician's gender had a modest influence on management decisions, female physicians being more likely to prescribe ancillary examinations.

CONCLUSION

We observed gender stereotypes among physicians. Our findings support the hypothesis that social characteristics attributed to men and women influence pain management. Prospective clinical studies are needed to provide a deeper understanding of gender stereotypes and their impact on clinical management.

Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol

Background

The clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting.

Methods/design

A pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game.

Discussion

Study results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.

False negative computed tomography scan due to pelvic binder in a patient with pelvic disruption: a case report and review of the literature

Background

Pelvic binders are routinely used in the prehospital setting for stabilization of pelvic injuries in patients with trauma. Emergency department trauma management relies on primary and secondary survey assessment and imaging, most often computed tomography, in hemodynamically stable patients. Maintaining the pelvic binder in situ allows stabilization of pelvic injuries during imaging but may hinder the visualization of some pelvic lesions. We report a very rare case of severe pelvic disruption with an absolutely normal computed tomography scan due to the effective placement of a pelvic binder.

Case presentation

We report the case of a 49-year-old Caucasian man referred to our Emergency Department after a high velocity motorcycle accident. Primary assessment revealed a left wrist deformation and pelvic pain, and a pelvic binder was applied by paramedics. A total body computed tomography scan was performed after arrival in our Emergency Department and did not reveal any pelvic injury. The pelvic binder was removed and because of persisting symphyseal pain, pelvic plain radiography was performed revealing a pelvic disruption with an opening of the pubic symphysis and of the left sacroiliac joint (“open book” type pelvic injury) requiring surgical stabilization.

Conclusions

Pelvic binders may mask pelvic disruption in patients with trauma. Pelvic plain radiography should be repeated after pelvic binder removal in patients with high velocity trauma and pelvic symptoms or neurological alterations limiting the reliability of clinical examination.

Electronic supplementary material

The online version of this article (10.1186/s13256-018-1808-7) contains supplementary material, which is available to authorized users.

The Digital Pen and Paper

Objectives: To evaluate the efficiency and acceptance of digital pen and paper technology for real-time clinical data acquisition.

Methods: A prospective interventional unblinded study involving consecutive patients in two clinical settings during a defined time-frame was proposed. The first trial was designed as a stress test to evaluate acceptance in a workload-intensive environment. Acceptance was assessed using observations and a satisfaction questionnaire. The second trial was intended to determine the reliability of data acquisition in a controlled environment. Reliability was assessed by comparing the performance of the digital pen against scanner analysis and a double human blinded acquisition.

Results: Overall, users were satisfied with the use of the digital pen (median 3 on a Likert-scale (–5, 5)). Without any specific user training, successful data acquisition was greater than 80%. Use of this technology required less adaptation than standard computer devices, and was easy to learn and use. Ergonomic problems shaded the perception of the technology by inducing an increased cognitive load. Digitalized data was missing either because of a bug or due to lack of data validation. The reliability obtained with the digital pen was significantly lower to that obtained with the scanner.

Conclusions: Natural technology such as the digital pen proved to be a good tool in stressful clinical environments without interfering with the normal workload or increasing the time for data acquisition. However, in order to improve quality of data acquisition, designing acquisition forms specifically for the use of digital pens is of paramount importance.

Risk factors for community-acquired acute kidney injury in patients with and without chronic kidney injury and impact of its initial management on prognosis: a prospective observational study

Background

We aimed to describe clinical characteristics of patients with community-acquired acute kidney injury (CA-AKI), the effectiveness of initial management of CA-AKI, its prognosis and the impact of medication on its occurrence in patients with previous chronic kidney injury (CKI).

Methods

We undertook a prospective observational study within the Emergency Department (ED) of a University Hospital, screening for any patient >16 years admitted with an eGFR <60 ml/mn/1.73 m² and a rise in serum creatinine as compared to previous values. Patients’ medical files were reviewed by a panel of nephrologists in the subsequent days and at one and three-years follow-up.

Results

From May 1st to June 21st 2013, there were 8464 admissions in the ED, of which 653 had an eGFR <60 ml/mn/1.73 m². Of these, 352 had previous CKI, 341 had CA-AKI, and 104 had CA-ACKI (community-acquired acute on chronic kidney injury). Occurrence of superimposed CA-AKI in CKI patients was associated with male gender and with use of diuretics, but not with use of ARBs or ACEIs.

Adequate management of CA-AKI defined as identification, diagnostic procedures and therapeutic intervention within 24 h, was recorded in 45% of the cases and was not associated with improved outcomes.

Three-year mortality was 21 and 48% in CKI and CA-ACKI patients respectively, and 40% in patients with only CA-AKI (p < 0.001). Mortality was significantly associated with age, hypertension, ischemic heart disease and CA-AKI.

Progression of renal insufficiency was associated with male gender and age.

Conclusions

CA-AKI is more frequently encountered in male patients and those treated with diuretics and is an independent risk factor for long-term mortality. Its initial adequate management failed to improve outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12882-017-0792-2) contains supplementary material, which is available to authorized users.

[Management of suspected meningitis in the emergency department]

Febrile meningeal syndrome is a medical emergency. Lumbar puncture keeps its gold-standard status as clinical findings are neither sensitive nor specific enough. Antibiotics and steroids are ideally administered within the first 30 minutes after admission when bacterial meningitis is suspected. A cerebral CT-scan before lumbar puncture is mandatory for selected patients only. PCR for viruses in the cerebrospinal fluid can inform diagnosis and treatment. Meningitis caused by enterovirus can usually be managed at home.

Predictors and Implications of Early Clinical Stability in Patients Hospitalized for Moderately Severe Community-Acquired Pneumonia

Background

Assessment of early response to treatment is crucial for the management of community-acquired pneumonia (CAP).

Objective

To describe the predictors and the outcomes of early clinical stability

Methods

We did a secondary analysis of a multicentre randomized controlled trial on CAP treatment in which 580 patients hospitalized for moderately severe CAP were included. The association between demographic, clinical and biological variables available at inclusion and early clinical stability (stabilization of vital signs within 72 hours with predetermined cut-offs) was assessed by multivariate logistic regression. The association between early clinical stability and mortality, severe adverse events, and length of stay was also tested.

Results

Younger age (OR 0.98, 95% CI 0.96–0.99), lower platelet count (OR per 10 G/L increment 0.96, 95% CI 0.94–0.98), lower respiratory rate (OR 0.94, 95% CI 0.90–0.97), absence of hypoxemia (OR 0.58, 95% CI 0.40–0.85), lower numbers of co-morbid conditions (OR 0.82, 95% CI 0.69–0.98) and signs or symptoms (OR 0.78, 95% CI 0.68–0.90) were significantly associated with early clinical stability. Patients with early clinical stability had lower 90-days mortality (3.4% vs. 11.9%, p<0.001), fewer admissions to the intensive care unit (2.7% vs. 8.0%, p = 0.005) and a shorter length of stay (6.0 days, IQR 4.0–10.0 vs. 10.0 days, IQR 7.0–15.0, p<0.001).

Conclusions

Patients with younger age, less co-morbidity, fewer signs or symptoms, less respiratory compromise, and a lower platelet count are more likely to reach early clinical stability. Patients without early clinical stability have a worse prognosis and warrant close scrutiny.

[Emergency medicine: updates 2015]

The year 2015 was marked by several publications questioning the practice of emergency medicine. The systematic administration of oxygen in STEMI patients offers no benefit. Similarly, medical expulsive therapy in patients with ureteric stones was questioned. Administration of steroids for acute radiculopathy showed only short-term, but no mid-term pain improvement. Several studies have demonstrated the benefit combining intraarterial and intravenous thrombolytic therapy for ischemic stroke. However, studies assessing optimal management strategy for patients hospitalized with community acquired pneumonia, showed conflicting results. Finally, these developments occur in the context of an aging population and increase of pre-hospital management for the elderly, raising the question of how to reduce hospital admissions in this population.

Adjunctive Corticotherapy for Community Acquired Pneumonia: A Systematic Review and Meta-Analysis

BACKGROUND

Community-acquired pneumonia (CAP) induces lung and systemic inflammation, leading to high morbidity and mortality. We systematically reviewed the risks and benefits of adjunctive corticotherapy in the management of patients with CAP.

METHODS

We systematically searched Pubmed, Embase and the Cochrane Library for randomized controlled trials comparing adjunctive corticotherapy and antimicrobial therapy with antimicrobial therapy alone in patients with CAP. The primary outcome was 30-day mortality. Secondary outcomes were length of hospital stay, time to clinical stability and severe complications.

RESULTS

14 trials (2077 patients) were included. The reported 30-day mortality was 7.9% (80/1018) among patients treated with adjunctive corticotherapy versus 8.3% (85/1028) among patients treated with antimicrobial therapy alone (RR 0.84; 95%CI 0.55 to1.29). Adjunctive corticotherapy was associated with a reduction of severe complications (RR 0.36; 95%CI 0.23 to 0.56), a shorter length of stay (9.0 days; 95%CI 7.6 to 10.7 vs 10.6 days; 95%CI 7.4 to 15.3) and a shorter time to clinical stability (3.3 days; 95% CI 2.8 to 4.1 vs 4.3 days; 95%CI 3.6 to 5.1). The risk of hyperglycemia was higher among patients treated with adjunctive corticotherapy (RR 1.59; 95%CI 1.06 to 2.38), whereas the risk of gastro-intestinal bleeding was similar (RR 0.83; 95%CI 0.35 to 1.93). In the subgroup analysis based on CAP severity, a survival benefit was found among patients with severe CAP (RR 0.47; 95%CI 0.23 to 0.96).

CONCLUSION

Adjunctive corticotherapy is associated with a reduction of length of stay, time to clinical stability, and severe complications among patients with CAP, but the effect on mortality remains uncertain.

[Emergency medicine: updates 2014]

The year 2014 was marked by new therapeutic acquisitions in emergency medicine. Nephrolithiasis likelihood estimation should avoid imaging in patients at high risk. Therapeutic hypothermia post cardio-respiratory arrest has no benefit compared to a strategy of controlled normothermia. Treatment of acute bronchitis with no signs of severity by coamoxicillin or NSAIDs is useless. Adding colchicine to standard treatment of acute pericarditis reduces the rate of recurrence. The D-dimerthreshold adjustment by age reduces the number of imaging in case of low or intermediate risk of pulmonary embolism. Finally, the speed of the initial management of septic shock is crucial to the outcome of patients, but an early invasive monitoring provides no benefit.

β-Lactam monotherapy vs β-lactam-macrolide combination treatment in moderately severe community-acquired pneumonia: a randomized noninferiority trial

IMPORTANCE

The clinical benefit of adding a macrolide to a β-lactam for empirical treatment of moderately severe community-acquired pneumonia remains controversial.

OBJECTIVE

To test noninferiority of a β-lactam alone compared with a β-lactam and macrolide combination in moderately severe community-acquired pneumonia.

DESIGN, SETTING, AND PARTICIPANTS

Open-label, multicenter, noninferiority, randomized trial conducted from January 13, 2009, through January 31, 2013, in 580 immunocompetent adult patients hospitalized in 6 acute care hospitals in Switzerland for moderately severe community-acquired pneumonia. Follow-up extended to 90 days. Outcome assessors were masked to treatment allocation.

INTERVENTIONS

Patients were treated with a β-lactam and a macrolide (combination arm) or with a β-lactam alone (monotherapy arm). Legionella pneumophila infection was systematically searched and treated by addition of a macrolide to the monotherapy arm.

MAIN OUTCOMES AND MEASURES

Proportion of patients not reaching clinical stability (heart rate <100/min, systolic blood pressure >90 mm Hg, temperature <38.0°C, respiratory rate <24/min, and oxygen saturation >90% on room air) at day 7.

RESULTS

After 7 days of treatment, 120 of 291 patients (41.2%) in the monotherapy arm vs 97 of 289 (33.6%) in the combination arm had not reached clinical stability (7.6% difference, P = .07). The upper limit of the 1-sided 90% CI was 13.0%, exceeding the predefined noninferiority boundary of 8%. Patients infected with atypical pathogens (hazard ratio [HR], 0.33; 95% CI, 0.13-0.85) or with Pneumonia Severity Index (PSI) category IV pneumonia (HR, 0.81; 95% CI, 0.59-1.10) were less likely to reach clinical stability with monotherapy, whereas patients not infected with atypical pathogens (HR, 0.99; 95% CI, 0.80-1.22) or with PSI category I to III pneumonia (HR, 1.06; 95% CI, 0.82-1.36) had equivalent outcomes in the 2 arms. There were more 30-day readmissions in the monotherapy arm (7.9% vs 3.1%, P = .01). Mortality, intensive care unit admission, complications, length of stay, and recurrence of pneumonia within 90 days did not differ between the 2 arms.

CONCLUSIONS AND RELEVANCE

We did not find noninferiority of β-lactam monotherapy in patients hospitalized for moderately severe community-acquired pneumonia. Patients infected with atypical pathogens or with PSI category IV pneumonia had delayed clinical stability with monotherapy.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00818610.

[Emergency medicine: updates 2013]

New evidences published this year are susceptible to change the management of several medical emergencies. Combined antiplatelet therapy might be beneficial for the management of TIA or minor stroke and rapid blood pressure lowering might improve the outcome in patients with intracerebral hemorrhage. A restrictive red cell transfusion strategy is indicated in case of upper digestive bleeding and coagulation factors concentrates are superior to fresh frozen plasma for urgent warfarin reversal. Prolonged systemic steroid therapy is not warranted in case of acute exacerbation of BPCO, and iterative physiotherapy is not beneficial after acute whiplash. Finally, family presence during cardiopulmonary resuscitation may reduce post-traumatic stress disorder among relatives.

[Emergency medicine: updates 2012]

We review some of the most influential papers from 2012 in the different aspects of emergency medicine, such as prehospital medicine, resuscitation, early diagnosis and timely ED discharge and treatment. In particular, intramuscular benzodiazepines have been shown to be efficient in prehospital status epilepticus, epinephrines usefulness in cardiopulmonary resuscitation has been challenged, colloids have been shown to be deleterious in the treatment of severe sepsis and septic shock, the time window for thrombolysis in acute stroke will probably be extended, acute pyelonephritis treatment duration can be decreased, new D-dimers thresholds for older patients may prevent further diagnosis tests, and hs-Troponin may allow earlier discharge of low coronary risk patients.

[Emergency medicine: updates 2011]

Emergency medicine physicians aim to stabilize or restore vital functions, establish diagnosis, initiate specific treatments and adequately orientate patients. This year, new evidences have improved our knowledge about diagnostic strategy for patients with acute non traumatic headache, treatment of acute atrial fibrillation and outpatient management of acute pulmonary embolism. Reducing injection pain of local anesthetics, reducing irradiation by using alternative diagnostic tools in appendicitis suspicion, and identification of trauma patients who benefit from tranexamic acid administration are other illustrations of the efforts to improve efficacy, safety and comfort in the management of emergency patients.

[Management of acute asthma in the emergency room]

Acute asthma is a frequent occurrence in the emergency room. Early care includes gradation of severity and rapid administration of systemic corticosteroid and bronchodilators. After initial treatment, if the patient has no longer criteria for severe asthma, and no poor outcome risk factor, continuation of treatment at home is a possible option. It requires to schedule a close appointment for medical follow-up, establishment of an asthma treatment plan, prescription of a short course of oral corticosteroids together with a combination of inhaled corticosteroid and long acting beta-2-agonist for longer duration of treatment.

[Viral infection in acute exacerbation of COPD]

According to international recommendations, severe COPD exacerbations should be treated with antibiotics. However, these recommendations are based on limited evidence, including old studies with small group of patients. Systematic virological testing by RT-PCR suggests that viruses are responsible for more than half of these exacerbations, although the causal link is not yet clearly established. To date, neither clinical nor biological markers can help distinguish an exacerbation caused by a virus from those due to other causes.

Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT

OBJECTIVES

To evaluate an algorithm integrating ultrasound and low-dose unenhanced CT with oral contrast medium (LDCT) in the assessment of acute appendicitis, to reduce the need of conventional CT.

METHODS

Ultrasound was performed upon admission in 183 consecutive adult patients (111 women, 72 men, mean age 32) with suspicion of acute appendicitis and a BMI between 18.5 and 30 (step 1). No further examination was recommended when ultrasound was positive for appendicitis, negative with low clinical suspicion, or demonstrated an alternative diagnosis. All other patients underwent LDCT (30 mAs) (step 2). Standard intravenously enhanced CT (180 mAs) was performed after indeterminate LDCT (step 3).

RESULTS

No further imaging was recommended after ultrasound in 84 (46%) patients; LDCT was obtained in 99 (54%). LDCT was positive or negative for appendicitis in 81 (82%) of these 99 patients, indeterminate in 18 (18%) who underwent standard CT. Eighty-six (47%) of the 183 patients had a surgically proven appendicitis. The sensitivity and specificity of the algorithm were 98.8% and 96.9%.

CONCLUSIONS

The proposed algorithm achieved high sensitivity and specificity for detection of acute appendicitis, while reducing the need for standard CT and thus limiting exposition to radiation and to intravenous contrast media.

[Critical pathway for community-acquired pneumonia]

A clinical pathway is a methodological tool for standardizing medical practice, improving the quality and efficiency of care delivery, and enhancing the diffusion of evidence-based medicine. Despite the fact that a majority of trials have shown that the use of clinical pathways improves certain specific outcomes such as length of stay or complications, the overall impact of these pathways in the clinical setting has yet to be documented. In the setting of community-acquired pneumonia, a few observational and one large randomized trial have shown positive effects on various outcomes. We describe in this article the clinical pathway for community-acquired pneumonia developed at our institution.

[Emergency medicine: update 2010]

Several scores with predictive value for morbidity or mortality have been published this year. Their current purpose is to improve the direction of admissions and lengths of stay in hospital. Their use permits more directed care, especially for the elderly, and therefore could improve the proper orientation and admission of patients. Also this year, certain procedures are undergoing evaluation, namely: new assays for troponin, and non-contrast CT in the diagnosis of acute appendicitis. Furthermore in the therapeutic realm: the importance of cardiac massage and the advantages of therapeutic hypothermia in cardiac arrest, and the efficacy of oxygen therapy in cluster headache.

[When should a patient with headaches be referred to the emergency ward?]

Secondary headaches are rare though potentially severe. A systematic search of red flags helps to suspect headaches of secondary origin that require further urgent investigation. Main red flags are: sudden onset, exceptionally severe headache, new headache in patient over 50, vomiting or syncope, focal neurological sign or neck stiffness, recent trauma, uncommon headache during pregnancy or anticoagulant therapy, suspicion of glaucoma.

[Emergency medicine: update 2009]

Emergency medicine is a cross-discipline characterized by its ability to identify critical threats, as well as its ability to prioritize investigations and identify appropriate treatments. Recent publications have been published on upper gastrointestinal haemorrhage, elbow fracture or brain haemorrhage, to optimize and standardize the investigations. In parallel, conditions such as cardiopulmonary arrest, spontaneous pneumothorax or stroke, benefit from recent therapeutic advances. However, emergency physicians and primary care physicians must remain critical of the numerous medical publications, as evidenced by the contradictory results concerning the interaction between proton pump inhibitors and clopidogrel.

[Indications for low-dose CT in the emergency setting]

CT delivers a large dose of radiation, especially in abdominal imaging. Recently, a low-dose abdominal CT protocol (low-dose CT) has been set-up in our institution. "Low-dose CT" is almost equivalent to a single standard abdominal radiograph in term of dose of radiation (about one sixth of those delivered by a standard CT). "Low-dose CT" is now used routinely in our emergency service in two main indications: patients with a suspicion of renal colic and those with right lower quadrant pain. It is obtained without intravenous contrast media. Oral contrast is given to patients with suspicion of appendicitis. "Low-dose CT" is used in the frame of well defined clinical algorithms, and does only replace standard CT when it can reach a comparable diagnostic quality.

[Emergency medicine: update 2008]

The emergency medicine appears more and more as a transversal discipline, leaning on specific competences regularly updated with evidence-based medicine concepts. This selection of recent articles presents an update on frequent conditions, including the place of neuroimaging for patients with seizures or minor head injuries, the management of acute cocaine intoxications, the diagnosis of aortic dissections, or the management of cardiopulmonary arrest. The primary care physician will find elements of diagnostic or therapeutic strategies. This selection reflects the dynamism of emergency medicine.

[Role of long-acting beta-agonists in the treatment of asthma]

Long acting beta2-agonists (LABA) are one of the most widely prescribed anti-asthmatic therapies. Nevertheless, their chronic utilization has been associated in large clinical studies with severe asthma exacerbations and asthma-related deaths raising concern about their safety. Awaiting further evidence to definitely identify susceptible subgroups, LABA should be used with caution. Inhaled corticosteroids (ICS) is the preferred asthma controller option and LABA should be used only in association with ICS in patients insufficiently controlled under ICS therapy.

Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial

BACKGROUND

Multislice CT (MSCT) combined with D-dimer measurement can safely exclude pulmonary embolism in patients with a low or intermediate clinical probability of this disease. We compared this combination with a strategy in which both a negative venous ultrasonography of the leg and MSCT were needed to exclude pulmonary embolism.

METHODS

We included 1819 consecutive outpatients with clinically suspected pulmonary embolism in a multicentre non-inferiority randomised controlled trial comparing two strategies: clinical probability assessment and either D-dimer measurement and MSCT (DD-CT strategy [n=903]) or D-dimer measurement, venous compression ultrasonography of the leg, and MSCT (DD-US-CT strategy [n=916]). Randomisation was by computer-generated blocks with stratification according to centre. Patients with a high clinical probability according to the revised Geneva score and a negative work-up for pulmonary embolism were further investigated in both groups. The primary outcome was the 3-month thromboembolic risk in patients who were left untreated on the basis of the exclusion of pulmonary embolism by diagnostic strategy. Clinicians assessing outcome were blinded to group assignment. Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00117169.

FINDINGS

The prevalence of pulmonary embolism was 20.6% in both groups (189 cases in DD-US-CT group and 186 in DD-CT group). We analysed 855 patients in the DD-US-CT group and 838 in the DD-CT group per protocol. The 3-month thromboembolic risk was 0.3% (95% CI 0.1-1.1) in the DD-US-CT group and 0.3% (0.1-1.2) in the DD-CT group (difference 0.0% [-0.9 to 0.8]). In the DD-US-CT group, ultrasonography showed a deep-venous thrombosis in 53 (9% [7-12]) of 574 patients, and thus MSCT was not undertaken.

INTERPRETATION

The strategy combining D-dimer and MSCT is as safe as the strategy using D-dimer followed by venous compression ultrasonography of the leg and MSCT for exclusion of pulmonary embolism. An ultrasound could be of use in patients with a contraindication to CT.

[How urgent is it to decrease high blood pressure?]

Severe hypertension represents a frequent problem for the general practitioner. One has to decide if the blood pressure needs to be decreased immediately (hypertensive emergency), or if the blood pressure maybe progressively decreased in a few hours and normalized in a few days (hypertensive crisis). Thus it is crucial to identify on the basis of the clinical history and a careful physical examination, the patients for whom the arterial blood pressure elevation represents an acute danger for organ damage or a vital threat in the absence of immediate blood pressure control. In the case of hypertensive crisis, oral medication is usually sufficient (slow release or GITS nifedipine, nitroglycerin, labetalol, captopril). The hypertensive emergency sometimes requires an oral medication before the admission to the emergency room, then followed by intravenous drug administration (sodium nitroprussiate, nitroglycerin, labetalol).

[Vertigo: it all revolves around the physical exam]

Dizziness is a common complaint in an emergency department. True vertigo, characterized by subjective sensation of rotation of the subject or of objects around the subject, may be peripheral (85%) or central (15%). Patient's history and physical exam identify the etiology of vertigo in more than 70% of patients. Hallpike test is easily performed and crucial for the diagnosis of benign paroxysmal peripheral vertigo. Central vertigo should be suspected and brain imaging performed in the presence of neurological symptoms, in older patients, or when several risk factors for cerebrovascular disease are present.

[Headache: physical exam or CT?]

The life time prevalence of headache is more than 90% in the general population. The majority of patients presenting to physicians suffer from migraine. A simple clinical predictive score based on five questions will allow clinicians to confirm this diagnosis and will prevent further investigations. In all other circumstances, evidence is not sufficient to develop prediction rules to exclude secondary headache. However, neuroimaging should be performed in patients with a unexplained abnormal finding on the neurological examination.

Acceptance and cognitive load in a clinical setting of a novel device allowing natural real-time data acquisition

INTRODUCTION

This paper reports the findings of an evaluation study in the field of human-computer interaction about the use of a new data acquisition device, the digital pen. It focuses on specific aspects of the interaction between the users and the technology: the cognitive burden induced by the design of the tool in real conditions of use and its impact on user acceptance.

METHODOLOGY

Human cognition is embedded in a complex sociocultural world. Therefore, we opted for ethnographically informed investigations reinforced by a satisfaction survey. The work context chosen for these investigations was the emergency room triage process.

RESULTS

The technology meets a high acceptance (median 3 on a [-5,5] scale) shaded by unexpected additional cognitive burdens. These burdens originate in several technological and ergonomic flaws that have been discovered during the observations. These results have been used to improve the technology.

CONCLUSION

We demonstrate the importance of this kind of field study to uncover unexpected possible sources of failure of acceptance of a new technology. Such kind of study should be held prior to the introduction of a new technology to lower the common failure rate encountered in the field of medical informatics.

[Impact of urinary incontinence in community-dwelling women]

Urinary incontinence (UI) is a frequent problem in an aging population and prevalence of urinary incontinence for elderly women may be up to 50% and imposes a huge burden on the health care system comparable to osteoporosis or osteoarthritis. The impact of UI shows clear associations between UI and depression and decline of quality of life comparable to congestive heart failure, major respiratory condition or gastrointestinal tract conditions. Some limited data suggest that UI is also a risk factor for institutionalization and hospitalization. Despite effective treatments, UI is significantly underdiagnosed by clinicians, and underreported by patients. This results in unmet needs for incontinence treatment, in particular for older individuals.

[Lake Geneva Region guidelines on management of adult asthma]

Asthma is a major cause of chronic morbidity throughout the world. In Switzerland, 6.9% of the adult population is suffering from asthma. The standards of treatment are unfortunately not met in most western countries, as well as in Switzerland. We put forward a complete guideline on management of adult asthma, inspired from GINA and BTS guidelines, and adapted to the specific needs of general practitioners working in french part of Switzerland. This guideline reflects a consensus between allergy, lung and emergency specialists, working in the 2 university hospitals of the Lake Geneva Region (HUG and CHUV).

Paroxysmal atrial fibrillation after recreational marijuana smoking: another "holiday heart"?

Paroxysmal atrial fibrillation (AF) is a common arrhythmia that may occur after various triggers. With the exception of the well recognized "holiday heart" associated with acute alcohol consumption, the cause of AF is rarely identified in young adults. We report a case of paroxysmal AF after marijuana smoking in a 22 year old female with no other identifiable triggers and normal echocardiography. Marijuana smoking should be included in the list of possible triggers in young adults presenting with paroxysmal AF, once cardiac disease and other common causes of AF have been excluded.

Factors associated with failure of noninvasive positive pressure ventilation in the emergency department

OBJECTIVES

To determine the factors associated with failure of noninvasive positive pressure ventilation (NPPV) in patients presenting with acute respiratory failure to the emergency department (ED).

METHODS

The authors retrospectively analyzed patients admitted to the ED for acute respiratory failure (defined as a PaCO2 level >45 mm Hg, and pH < or = 7.35 or a PaO2/FiO2 ratio < 250 mm Hg) and who were treated with NPPV. NPPV was delivered routinely according to an institutional protocol. Failure of NPPV was defined as the requirement of endotracheal intubation at any time.

RESULTS

A total of 104 patients were included. NPPV failed in 31% (32/104), and the mortality was significantly higher in this group (12/32 [44%]) compared with patients who were not intubated (2/72 [3%]) (p < 0.0001). Factors associated with failure of NPPV were Glasgow Coma Scale score < 13 at ED admission (odds ratio [OR], 3.67; 95% confidence interval [CI] = 1.33 to 10.07), pH < or = 7.35 (OR, 3.23; 95% CI = 1.25 to 8.31), and respiratory rate (RR) > or =20 min(-1) (OR, 3.86; 95% CI = 1.33 to 11.17) after one hour of NPPV. The negative predictive value for NPPV failure was 86% (95% CI = 70% to 95%) for RR > or =20 min(-1). In the multivariate analysis, pH < or = 7.35 and RR > or =20 min(-1) after one hour of NPPV were independently associated with NPPV failure (adjusted ORs, 3.51; 95% CI = 1.29 to 9.62 and 3.55; 95% CI = 1.13 to 11.20, respectively).

CONCLUSIONS

Patients with pH < or = 7.35 and an RR > or =20 min(-1) after one hour of NPPV had an increased risk of subsequent endotracheal intubation.

[Should disease management be feared? (2): outpatient care]

Outpatient disease management is a multidisciplinary team intervention for managing complex processes of chronic diseases, in order to improve healthcare quality and decrease process variations. Interventions are based on: (1) evidence-based guidelines; (2) educational programs; (3) close patient follow-up. This can be achieved by telephone follow-up, by outpatient clinic programs, or by homecare visits performed by case managers. For the management of patients with chronic heart failure, disease management programs have resulted in a 25% decrease in hospitalization and in reduced costs. In our Swiss health care system, however, a majority of patients are taken care of by private practitioners; thus, the involvement of these physicians in the development and in the realization of disease management programs will be key to their success.

[Should disease management be feared? (1): hospital care]

The goals of disease management are: (1) an integrated health care delivery system; (2) knowledge-based care; (3) elaborate information systems; (4) continuous quality improvement. In-hospital disease management and, more specifically, critical pathways, establish standardized care plans, set goals and time actions to reach these goals. They can reduce variations in practice patterns and resource utilization without compromising quality of care. Such strategies participate to quality improvement programs in hospitals when they involve and empower all actors of a given process of care, are not imposed from outside, and use sound and rigorous development and evaluation methods.

Die Folgen einer ungenügenden Herdimmunität bei «pädiatrischen» Infektionskrankheiten – Beispiel einer Masernepidemie

Von Januar bis Mitte Februar 2005 wurden dem Kantonsarzt von Genf 15 Fälle von bestätigten Masern gemeldet; verglichen zu einem einzelnen Fall im 2004. Ungewöhnlich an dieser Epidemie war das Alter der betroffenen Personen von 17 bis 44 Jahren. Vier unter ihnen waren Mitarbeiter eines öffentlichen Spitals, die sich nach Kontakt zu einem einzigen, 44-jährigen Patienten ansteckten und die Infektion zum Teil weiter übertrugen. Die Annahme, dass Masern eine pädiatrische Infektion sind, erschwerte die Diagnose. Keiner der betroffenen Erwachsenen war immun nach dem heutigen Stand der Empfehlungen. Trotz vorhandenem Impfplan, behördlichen Empfehlungen, Kostenübernahme durch die Krankenkassen und den guten Impfergebnissen mit den heute zur Verfügung stehenden Vakzinen, ist die freiwillige Durchimpfungsrate in der Schweiz unter Kindern und Erwachsenen zu gering um den Ausbruch von Epidemien zu verhindern. Im Gegensatz zu den Zielen des Bundesamt für Gesundheit (BAG) und der Weltgesundheitsorganisation (WHO) sind wir in der Schweiz aus verschiedenen Gründen noch nicht so weit eine genügend hohe Herdimmunität aufzubauen, um gesundheitliche und volkswirtschaftliche Schäden durch aufflackernde Epidemien zu verhindern.

[Management of asthma attacks in primary care practice]

Most fatal asthma attacks are explained by an underestimation of the severity of the episode and by an underutilization of adequate treatments. The primary care physician should: 1) identify predictors of poor outcome requiring immediate hospital admission, 2) evaluate the severity of the attack, using clinical criteria and peak-flow measurements, and 3) initiate a treatment combining inhaled beta2-agonists and oral steroids. Life threatening asthma attacks warrant immediate hospitalisation as well as severe attacks persisting after initial treatment. Moderate attacks don't usually require referral. Other factors, such as social factors, compliance to treatment, or co-morbid conditions, may warrant hospitalisation.

Paroxysmal atrial fibrillation after recreational marijuana smoking: another "holiday heart"?

Paroxysmal atrial fibrillation (AF) is a common arrhythmia that may occur after various triggers. With the exception of the well recognized "holiday heart" associated with acute alcohol consumption, the cause of AF is rarely identified in young adults. We report a case of paroxysmal AF after marijuana smoking in a 22 year old female with no other identifiable triggers and normal echocardiography. Marijuana smoking should be included in the list of possible triggers in young adults presenting with paroxysmal AF, once cardiac disease and other common causes of AF have been excluded.

The digital pen and paper. Evaluation and acceptance of a new data acquisition device in clinical settings

OBJECTIVES

To evaluate the efficiency and acceptance of digital pen and paper technology for real-time clinical data acquisition.

METHODS

A prospective interventional unblinded study involving consecutive patients in two clinical settings during a defined time-frame was proposed. The first trial was designed as a stress test to evaluate acceptance in a workload-intensive environment. Acceptance was assessed using observations and a satisfaction questionnaire. The second trial was intended to determine the reliability of data acquisition in a controlled environment. Reliability was assessed by comparing the performance of the digital pen against scanner analysis and a double human blinded acquisition.

RESULTS

Overall, users were satisfied with the use of the digital pen (median 3 on a Likert-scale (-5, 5)). Without any specific user training, successful data acquisition was greater than 80%. Use of this technology required less adaptation than standard computer devices, and was easy to learn and use. Ergonomic problems shaded the perception of the technology by inducing an increased cognitive load. Digitalized data was missing either because of a bug or due to lack of data validation. The reliability obtained with the digital pen was significantly lower to that obtained with the scanner.

CONCLUSIONS

Natural technology such as the digital pen proved to be a good tool in stressful clinical environments without interfering with the normal workload or increasing the time for data acquisition. However, in order to improve quality of data acquisition, designing acquisition forms specifically for the use of digital pens is of paramount importance.

Acute left colonic diverticulitis: can CT findings be used to predict recurrence?

OBJECTIVE

We explored CT and demographic predictors for unfavorable outcome of nonoperative treatment in patients with a first event of left colonic diverticulitis.

MATERIALS AND METHODS

We retrospectively analyzed the medical files and CT scans of 312 consecutive patients who were diagnosed as having diverticulitis on an admission CT report or who had a final diagnosis of left colonic diverticulitis. Patients who did not undergo nonoperative treatment or were lost to follow-up (n = 144) were excluded from the study. Admission CT scans of 168 consecutive patients with a diagnosis of left colonic diverticulitis who underwent nonoperative treatment and had an 18-month follow-up were reassessed by three radiologists unaware of the clinical findings. Nonoperative treatment was defined as an attempt to treat the patient with only antibiotics without scheduling them for elective (delayed) surgery. Unfavorable outcome was defined as a failure of nonoperative treatment 18 months after admission that required either surgery or rehospitalization for antibiotic treatment. The risk of unfavorable outcome was modeled using logistic regression as a function of sex, age, and CT criteria including the maximum number of diverticula per 10 cm of colon; the presence of intraabdominal abscess or extraintestinal gas bubbles (< 5 mm diameter) or gas pockets (>or=5 mm); the length and location of the abnormal colonic segment; the maximum thickness of the colonic wall; the presence of associated free intraperitoneal fluid; and the extent of fatty infiltration.

RESULTS

Among these 168 patients, 115 (68%) had an uneventful outcome, but nonoperative treatment failed in 53 (32%). The presence of an abscess (n = 19) or extraintestinal gas pocket (n = 14) were the only CT findings significantly associated with failure of nonoperative treatment. Adjusted odds ratios (95% confidence interval) for failure were 6.18 (1.76-21.68) when an abscess was diagnosed and 4.26 (1.04-17.57) when pockets of free air were observed. Sex and age were not significantly associated with unfavorable outcome of nonoperative treatment.

CONCLUSION

Abscess and pockets of extraintestinal gas 5 mm in diameter or larger correlated with unfavorable outcome of nonoperative treatment. None of the other criteria evaluated were predictive of failure of nonoperative treatment, including bubbles of extraintestinal gas smaller than 5 mm in diameter.