Showing papers by "David W. Wright published in 2011"

Standardizing data collection in traumatic brain injury.

Abstract: Collaboration among investigators, centers, countries, and disciplines is essential to advancing the care for traumatic brain injury (TBI). It is thus important that we “speak the same language.” Great variability, however, exists in data collection and coding of variables in TBI studies, confounding comparisons between and analysis across different studies. Randomized controlled trials can never address the many uncertainties concerning treatment approaches in TBI. Pooling data from different clinical studies and high-quality observational studies combined with comparative effectiveness research may provide excellent alternatives in a cost-efficient way. Standardization of data collection and coding is essential to this end. Common data elements (CDEs) are presented for demographics and clinical variables applicable across the broad spectrum of TBI. Most recommendations represent a consensus derived from clinical practice. Some recommendations concern novel approaches, for example assessment of ...

Nonmydriatic ocular fundus photography in the emergency department.

Abstract: To the Editor: Examination of the ocular fundus is imperative in the diagnosis and treatment of many acute medical and neurologic conditions, but direct ophthalmoscopy is underused and difficult to perform without pharmacologic pupillary dilation.1,2 We believe that nonmydriatic ocular fundus photography (i.e., performed without pupillary dilation) represents a promising alternative to direct ophthalmoscopy, particularly in the emergency department, where limited training in ophthalmoscopy, increased demands on physicians' time, and underappreciation of the prognostic value of ocular fundus examination can place patients at risk for poor outcomes and expose their caregivers to medicolegal liability.1,3 The FOTO-ED (Fundus Photography . . .

Feasibility of nonmydriatic ocular fundus photography in the emergency department: Phase I of the FOTO-ED study.

Abstract: ACADEMIC EMERGENCY MEDICINE 2011; 18:928–933 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Examination of the ocular fundus is imperative in many acute medical and neurologic conditions, but direct ophthalmoscopy by nonophthalmologists is underutilized, poorly performed, and difficult without pharmacologic pupillary dilation The objective was to examine the feasibility of nonmydriatic fundus photography as a clinical alternative to direct ophthalmoscopy by emergency physicians (EPs) Methods: Adult patients presenting to the emergency department (ED) with headache, acute focal neurologic deficit, diastolic blood pressure ≥ 120 mm Hg, or acute visual change had ocular fundus photographs taken by nurse practitioners using a nonmydriatic fundus camera Photographs were reviewed by a neuroophthalmologist within 24 hours for findings relevant to acute ED patient care Nurse practitioners and patients rated ease, comfort, and speed of nonmydriatic fundus photography on a 10-point Likert scale (10 best) Timing of visit and photography were recorded by automated electronic systems Results: A total of 350 patients were enrolled There were 1,734 photographs taken during 230 nurse practitioner shifts Eighty-three percent of the 350 patients had at least one eye with a high-quality photograph, while only 3% of patients had no photographs of diagnostic value Mean ratings were ≥ 87 (standard deviation [SD] ≤ 19) for all measures The median photography session lasted 19 minutes (interquartile range [IQR] = 13 to 29 minutes), typically accounting for less that 05% of the patient’s total ED visit Conclusions: Nonmydriatic fundus photography taken by nurse practitioners is a feasible alternative to direct ophthalmoscopy in the ED It is performed well by nonphysician staff, is well-received by staff and patients, and requires a trivial amount of time to perform

The role of progesterone in traumatic brain injury.

Abstract: ITHIN the last 20 years, a significant body ofliterature has advanced our understanding ofthe pathophysiologic mechanisms that result from trau-matic brain injury (TBI). Most importantly, we now rec-ognize that brain injuries cause both central and sys-temic effects. For example, a number of studies havedemonstrated increased release of proinflammatory cy-tokines and augmented oxidative stress reactions in pe-ripheral tissues after isolated head injury.

A novel technology to screen for cognitive impairment in the elderly.

Abstract: BACKGROUND Traditional evaluation of mild cognitive impairment (MCI) can be costly, time consuming, and impractical for widespread screening. DETECT is a portable device developed to rapidly perform cognitive testing in diverse settings. This study compares DETECT with formal clinical assessment. METHODS A prospective cross-sectional comparison of the DETECT device versus an expert neuropsychologist's assessment (NPA). A total of 405 participants ≥65 years old, recruited from geriatric clinics and retirement facilities, completed both DETECT and NPA. Multivariable logistic regression methods were used to evaluate the degree of correlation between DETECT testing and the NPA diagnosis. RESULTS Predictive modeling demonstrated very good ability to discriminate between normal, MCI, and dementia per the NPA reference standard using DETECT subtests (c = 0.85 for any impairment; c = 0.99 for dementia). CONCLUSION DETECT scores closely correlate with NPA. DETECT can identify and discriminate between normal, MCI, and dementia and could be incorporated as a screener for MCI.

Evidence-based community consultation for traumatic brain injury.

Abstract: Objectives: The objective was to determine if geospatial techniques can be used to inform targeted community consultation (CC) and public disclosure (PD) for a clinical trial requiring emergency exception from informed consent (EFIC). Methods: Data from January 2007 to December 2009 were extracted from a Level I trauma center's trauma database using the National Trauma Registry of the American College of Surgeon (NTRACS). Injury details, demographics, geographic codes, and clinical data necessary to match core elements of the clinical trial inclusion criteria (Glasgow Coma Scale [GCS] 3-12 and blunt head injury) were collected on all patients. Patients' home zip codes were geocoded to compare with population density and clustering analysis. Results: Over a 2-year period, 179 patients presented with moderate to severe traumatic brain injury (TBI). Mapping the rate and frequency of TBI patients presenting to the trauma center delineated at-risk populations for moderate to severe head injury. Four zip codes had higher incidences of TBI than the rest, with one zip code having a very high rate of 80 per 100,000 population. Conclusions: Geospatial techniques and hospital data records can be used to characterize potential subjects and delineate a high-risk population to inform directed CC and public disclosure strategies. ACADEMIC EMERGENCY MEDICINE 2011; 18:1-5 © 2011 by the Society for Academic Emergency Medicine. Language: en

Characteristic of victims of family violence seeking care at health centers in Maputo, Mozambique.

Abstract: Background : Family violence (FV) is a common, yet often invisible, cause of violence. To date, most literature on risk factors for family, interpersonal and sexual violence is from high-income countries and might not apply to Mozambique. Aims : To determine the individual risk factors for FV in a cohort of patients seeking care for injuries at three health centers in Maputo, Mozambique. Setting and Design : A prospective multi-center study of patients presenting to the emergency department for injuries from violence inflicted by a direct family member in Maputo, Mozambique, was carried out. Materials and Methods : Patients who agreed to participate and signed the informed consent were verbally administered a pilot-tested blank-item questionnaire to ascertain demographic information, perpetrator of the violence, historical information regarding prior abuse, and information on who accompanied the victim and where they received their initial evaluation. De-identified data were entered into SPSS 13.0 (SPSS, version 13.0) and analyzed for frequencies. Results : During the 8-week study period, 1206 assault victims presented for care, of whom 216 disclosed the relationship of the assailant, including 92 being victims of FV (42.6%). The majority of FV victims were women (63.0%) of age group 15-34 years (76.1%) and were less educated (84%) compared to national averages. Of the patients who reported assault on a single occasion, most were single (58.8%), while patients with multiple assaults were mostly married (63.2%). Most commonly, the spouse was the aggressor (50%) and a relative accompanied the victim seeking care (54.3%). Women most commonly sought police intervention prior to care (63.2%) in comparison to men (35.3%). Conclusion : In Mozambique, FV affects all ages, sexes and cultures, but victims seeking care for FV were more commonly women who were less educated and poorer.

Treatment, Services and Follow-up for Victims of Family Violence in Health Clinics in Maputo, Mozambique.

Abstract: BACKGROUND: Family violence (FV) is a global health problem that not only impacts the victim, but the family unit, local community and society at large. OBJECTIVE: To quantitatively and qualitatively evaluate the treatment and follow up provided to victims of violence amongst immediate and extended family units who presented to three health centers in Mozambique for care following violence. METHODS: We conducted a verbally-administered survey to self-disclosed victims of FV who presented to one of three health units, each at a different level of service, in Mozambique for treatment of their injuries. Data were entered into SPSS (SPSS, version 13.0) and analyzed for frequencies. Qualitative short answer data were transcribed during the interview, coded and analyzed prior to translation by the principal investigator. RESULTS: One thousand two hundred and six assault victims presented for care during the eight-week study period, of which 216 disclosed the relationship of the assailant, including 92 who were victims of FV. Almost all patients (90%) waited less than one hour to be seen, with most patients (67%) waiting less than 30 minutes. Most patients did not require laboratory or radiographic diagnostics at the primary (70%) and secondary (93%) health facilities, while 44% of patients received a radiograph at the tertiary care center. Among all three hospitals, only 10% were transferred to a higher level of care, 14% were not given any form of follow up or referral information, while 13% required a specialist evaluation. No victims were referred for psychological follow-up or support. Qualitative data revealed that some patients did not disclose violence as the etiology, because they believed the physician was unable to address or treat the violence-related issues and/or had limited time to discuss. CONCLUSION: Healthcare services for treating the physical injuries of victims of FV were timely and rarely required advanced levels of medical care, but there were no psychological services or follow-up referrals for violence victims. The healthcare environment at all three surveyed health centers in Mozambique does not encourage disclosure or self-report of FV. Policies and strategies need to be implemented to encourage patient disclosure of FV and provide more health system-initiated victim resources. Language: en

Pharmaceutical advertising policy of Academic Emergency Medicine was incompletely reported and mischaracterized in the statement of EMA's new no-pharmaceutical ads policy.

Abstract: Dear Editor, In a recent commentary by Jelinek and Brown, it was announced that the Editors and Editorial Board of Emergency Medicine Australasia (EMA) had agreed that EMA would no longer publish pharmaceutical advertising. These authors condemned certain practices of pharmaceutical marketing, and cited for support a commentary authored by Chisholm et al. in the journal Academic Emergency Medicine (AEM). However, Jelinek and Brown omitted any reference to the accompanying commentary, which we co-authored. Our commentary detailed several reasons to support pharmaceutical advertising in AEM, while providing a means of ensuring the academic and scientific integrity of AEM. Although we take no issue with the decision to exclude pharmaceutical advertisements from EMA, we do feel compelled to inform your readers of a ‘process’ issue. In their commentary, Jelinek and Brown made reference to only one side of the debate that was undertaken among the Editorial Board of AEM, and therefore presented an incomplete reporting of the facts. Our commentary, entitled ‘Academic Emergency Medicine can print pharmaceutical advertising while not compromising its mission or its integrity’, and an accompanying introduction by the Editor-in-Chief of AEM appeared in the same issue of AEM as the Chisholm et al. commentary. We believe that by failing to make clear to the readers of EMA that the Chisholm et al. commentary was only one side of the debate, Jelinek and Brown presented an incomplete and potentially misleading statement regarding the opinions of the Editorial Board of AEM regarding the issue of pharmaceutical advertising. EMA readers should also know that after the development of these commentaries, the Editorial Board of AEM was polled, and by a large margin, the Editorial Board supported our position over that of Chisholm et al. Thus, the leadership of AEM has decided that the journal will accept pharmaceutical advertising (although no such ads have yet appeared). The fact that AEM will be willing to place paid pharmaceutical advertising within its pages in a manner that does not co-mingle advertising among peer-reviewed content is not evident from the editorial by Jelinek and Brown. We agree with the opinion voiced in the commentary by Jelinek and Brown that the primary goals of pharmaceutical advertising (promotion of a product for sale) differ significantly from the general goals of a medical journal (dissemination of peer-reviewed medical knowledge and findings). However, we concluded that these goals can be managed independently in medical journals. Indeed, large pharmaceutical firms and medical device firms have designed and developed many drugs and devices, which have improved the lives of our patients. This has improved our ability as physicians to prescribe and recommend products that are expected to improve the health of our patients. Advertising in the medical journals provides an avenue to inform healthcare providers of these advances. In our commentary, we cited three main themes that provide an ethical and reasonable rationale for advertising by pharmaceutical and medical device companies in AEM. The themes were: 1. Policies exist to ensure separation of academic content from advertising and its sponsors. AEM can develop and implement similar policies. 2. Advertising facilitates increased physician awareness of new products. 3. Advertising revenue can encourage new publishing initiatives by AEM through increased financial stability of the journal. The readers of EMA are encouraged to read our commentary, where these themes were developed in significant detail. By their omission of a reference to our commentary and the current policy of AEM towards pharmaceutical advertising, we fear Jelinek and Brown have introduced bias to the readers of EMA via their incomplete reporting of the debate within the AEM Editorial Board and the eventual decision of AEM.