The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking

Z-WAVE INCLUSION 1. Install batteries and bring the 4-in-1 sensor within direct range of your Z-Wave gateway controller 2. Put your Z-Wave controller in inclusion mode 3. Press and release the Z-Wave button TWICE quickly 4. A new 4-in-1 sensor should appear on your controller's device list Troubleshooting Tips If you are unable to include the Z-Wave sensor to your controller, please try one of the following: Bring the 4-in-1 sensor closer to your ZWave controller Press and release the Z-Wave button quickly several times once you put the controller in the inclusion mode to ensure the command has gone through Put your controller in EXCLUSION mode and press and release the Z-Wave button TWICE quickly, then try adding it to your network again Make sure you are clicking the Z-Wave button located in the small opening on the bottom of the sensor and NOT the tamper switch located above the battery slot Z-WAVE EXCLUSION 1. Bring the 4-in-1 sensor within direct range of your Z-Wave gateway controller 2. Put your Z-Wave controller in exclusion mode 3. Press and release the Z-Wave button TWICE quickly 4. The device should disappear from your controller's device list. The LED indicator will flash 3 times when you take the batteries out and put them back in to indicate the device has been successfully excluded. Please repeat the process following all steps carefully if the LED indicator blinks only once when you re-insert the batteries.

User's Manual for

BACKGROUND
There is much uncertainty about the effects of early lowering of elevated blood pressure (BP) after acute intracerebral haemorrhage (ICH). Our aim was to assess the safety and efficiency of this treatment, as a run-in phase to a larger trial.


METHODS
Patients who had acute spontaneous ICH diagnosed by CT within 6 h of onset, elevated systolic BP (150-220 mm Hg), and no definite indication or contraindication to treatment were randomly assigned to early intensive lowering of BP (target systolic BP 140 mm Hg; n=203) or standard guideline-based management of BP (target systolic BP 180 mm Hg; n=201). The primary efficacy endpoint was proportional change in haematoma volume at 24 h; secondary efficacy outcomes included other measurements of haematoma volume. Safety and clinical outcomes were assessed for up to 90 days. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00226096.


FINDINGS
Baseline characteristics of patients were similar between groups, but mean haematoma volumes were smaller in the guideline group (12.7 mL, SD 11.6) than in the intensive group (14.2 mL, SD 14.5). From randomisation to 1 h, mean systolic BP was 153 mm Hg in the intensive group and 167 mm Hg in the guideline group (difference 13.3 mm Hg, 95% CI 8.9-17.6 mm Hg; p<0.0001); from 1 h to 24 h, BP was 146 mm Hg in the intensive group and 157 mm Hg in the guideline group (10.8 mm Hg, 95% CI 7.7-13.9 mm Hg; p<0.0001). Mean proportional haematoma growth was 36.3% in the guideline group and 13.7% in the intensive group (difference 22.6%, 95% CI 0.6-44.5%; p=0.04) at 24 h. After adjustment for initial haematoma volume and time from onset to CT, median haematoma growth differed between the groups with p=0.06; the absolute difference in volume between groups was 1.7 mL (95% CI -0.5 to 3.9, p=0.13). Relative risk of haematoma growth >or=33% or >or=12.5 mL was 36% lower (95% CI 0-59%, p=0.05) in the intensive group than in the guideline group. The absolute risk reduction was 8% (95% CI -1.0 to 17%, p=0.05). Intensive BP-lowering treatment did not alter the risks of adverse events or secondary clinical outcomes at 90 days.


INTERPRETATION
Early intensive BP-lowering treatment is clinically feasible, well tolerated, and seems to reduce haematoma growth in ICH. A large randomised trial is needed to define the effects on clinical outcomes across a broad range of patients with ICH.


FUNDING
National Health and Medical Research Council of Australia.

Intensive blood pressure reduction in acute cerebralhaemorrhage trial (INTERACT): a randomised pilot trial

Urinary tract infections (UTIs) are among the most common bacterial infections and account for a significant part of the workload in clinical microbiology laboratories. Enteric bacteria (in particular, Escherichia coli) remain the most frequent cause of UTIs, although the distribution of pathogens that cause UTIs is changing. More important is the increase in resistance to some antimicrobial agents, particularly the resistance to trimethoprim-sulfamethoxazole seen in E. coli. Physicians distinguish UTIs from other diseases that have similar clinical presentations with use of a small number of tests, none of which, if used individually, have adequate sensitivity and specificity. Among the diagnostic tests, urinalysis is useful mainly for excluding bacteriuria. Urine culture may not be necessary as part of the evaluation of outpatients with uncomplicated UTIs, but it is necessary for outpatients who have recurrent UTIs, experience treatment failures, or have complicated UTIs, as well as for inpatients who develop UTIs.

Laboratory diagnosis of urinary tract infections in adult patients. Authors' reply

Importance Racial disparities in use of analgesia in emergency departments have been previously documented. Further work to understand the causes of these disparities must be undertaken, which can then help inform the development of interventions to reduce and eradicate racial disparities in health care provision. Objective To evaluate racial differences in analgesia administration, and particularly opioid administration, among children diagnosed as having appendicitis. Design, Setting, and Participants Repeated cross-sectional study of patients aged 21 years or younger evaluated in the emergency department who had an International Classification of Diseases, Ninth Revision diagnosis of appendicitis, using the National Hospital Ambulatory Medical Care Survey from 2003 to 2010. We calculated the frequency of both opioid and nonopioid analgesia administration using complex survey weighting. We then performed multivariable logistic regression to examine racial differences in overall administration of analgesia, and specifically opioid analgesia, after adjusting for important demographic and visit covariates, including ethnicity and pain score. Main Outcomes and Measures Receipt of analgesia administration (any and opioid) by race. Results An estimated 0.94 (95% CI, 0.78-1.10) million children were diagnosed as having appendicitis. Of those, 56.8% (95% CI, 49.8%-63.9%) received analgesia of any type; 41.3% (95% CI, 33.7%-48.9%) received opioid analgesia (20.7% [95% CI, 5.3%-36.0%] of black patients vs 43.1% [95% CI, 34.6%-51.4%] of white patients). When stratified by pain score and adjusted for ethnicity, black patients with moderate pain were less likely to receive any analgesia than white patients (adjusted odds ratio = 0.1 [95% CI, 0.02-0.8]). Among those with severe pain, black patients were less likely to receive opioids than white patients (adjusted odds ratio = 0.2 [95% CI, 0.06-0.9]). In a multivariable model, there were no significant differences in the overall rate of analgesia administration by race. However, black patients received opioid analgesia significantly less frequently than white patients (12.2% [95% CI, 0.1%-35.2%] vs 33.9% [95% CI, 0.6%-74.9%], respectively; adjusted odds ratio = 0.2 [95% CI, 0.06-0.8]). Conclusions and Relevance Appendicitis pain is undertreated in pediatrics, and racial disparities with respect to analgesia administration exist. Black children are less likely to receive any pain medication for moderate pain and less likely to receive opioids for severe pain, suggesting a different threshold for treatment.

/pdf/racial-disparities-in-pain-management-of-children-with-3v1cf7i66o.pdf

Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments

https://nuhem.com/emlinks/LLSA%20Articles%202011/2011-LLSA-A-Systematic-Review-of-Medical-Therapy-to-Facilitate-Passage-of-Ureteral-Calculi.pdf

A Systematic Review of Medical Therapy to Facilitate Passage of Ureteral Calculi

The burden of caring for critically ill patients in the United States is massive, currently accounting for nearly 1% of the gross domestic product and affecting large sectors of the U.S. healthcare system including the emergency department (ED) (1–3). The majority of critical care in the United States are provided to patients over the age of 65, and this population is predicted to grow by 50% from 2000 to 2020 (4, 5). The rising demand for critical care in the face of already insufficient capacity has become an area of concern for clinicians, hospital administrators, and policymakers (6–9). In 2000, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine Committee on Manpower for Pulmonary and Critical Care Societies forecast large shortfalls in the critical care workforce. A 2006 Health Resources and Services Administration report to Congress not only confirmed the predicted shortages, but also projected worsening shortages into the future (4). There currently exist little data on how system-wide increases in the demand for critical care are affecting U.S. EDs.

Most patients, critically ill patients in the United States are admitted from an ED (10). These patients typically require medically complex and resource intensive care often begins outside the ICU in the ED (2, 3, 10, 11). The provision of critical care in the ED is a potentially important factor in ED crowding. The Institute of Medicine report “Hospital-Based Emergency Care: At The Breaking Point” identified that the inability to promptly admit critically ill ED patients to inpatient beds can lead to boarding and contributes to ED crowding (12). Several studies suggest that the proportion of critically ill patients presenting to U.S. EDs is increasing (13–15). Additionally, other studies have questioned the ability of many EDs to provide optimal care for critically ill patients in crowded conditions and linked prolonged ED stays by critically ill patients with increased mortality (16–18).

This study investigates changes in the total hours of ED care provided to patients ultimately admitted to an ICU from U.S. EDs between 2001 and 2009. To evaluate the hypothesis that EDs are providing an increasing amount of critical care, we examined both trends in ED visit ICU admissions and trends in the median ED length of stay (EDLOS) for these patients. Additionally, we analyzed trends in the national ED capacity to estimate changes in the average daily hours of care provided to patients admitted to an ICU at an average U.S. ED.

Increasing Critical Care Admissions From U.S. Emergency Departments, 2001–2009*

Background Acute alcohol withdrawal syndrome (AAWS) is encountered in patients presenting acutely to the Emergency Department (ED) and often requires pharmacologic management. Objective We investigated whether a single dose of intravenous (i.v.) phenobarbital combined with a standardized lorazepam-based alcohol withdrawal protocol decreases intensive care unit (ICU) admission in ED patients with acute alcohol withdrawal. Methods This was a prospective, randomized, double-blind, placebo-controlled study. Patients were randomized to receive either a single dose of i.v. phenobarbital (10 mg/kg in 100 mL normal saline) or placebo (100 mL normal saline). All patients were placed on the institutional symptom-guided lorazepam-based alcohol withdrawal protocol. The primary outcome was initial level of hospital admission (ICU vs. telemetry vs. floor ward). Results There were 198 patients enrolled in the study, and 102 met inclusion criteria for analysis. Fifty-one patients received phenobarbital and 51 received placebo. Baseline characteristics and severity were similar in both groups. Patients that received phenobarbital had fewer ICU admissions (8% vs. 25%, 95% confidence interval 4–32). There were no differences in adverse events. Conclusions A single dose of i.v. phenobarbital combined with a symptom-guided lorazepam-based alcohol withdrawal protocol resulted in decreased ICU admission and did not cause increased adverse outcomes.

https://emcrit.org/wp-content/uploads/2009/09/phenobarb-for-etoh-withdrawal.pdf

Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study.

Intravenous Magnesium as an Adjuvant in Acute Bronchospasm: A Meta-Analysis

OBJECTIVE: To evaluate trends in and factors associated with computed tomography (CT) use among children presenting to the emergency department (ED) with abdominal pain. METHODS: This study was a cross-sectional, secondary analysis of the National Hospital Ambulatory Medical Care Survey data from 1998 to 2008. We identified ED patients aged RESULTS: Of all pediatric ED visits, 6.0% were for abdominal pain. We noted a rise in the proportion of these patients with CT use, from 0.9% in 1998 to 15.4% in 2008 ( P CONCLUSIONS: There was a dramatic increase in the utilization of CT imaging in the ED evaluation of pediatric patients with abdominal pain. Some groups of children may have a differential likelihood of receiving CT scans.

Harrison J. Alter

Papers

A Systematic Review of Medical Therapy to Facilitate Passage of Ureteral Calculi

Increasing Critical Care Admissions From U.S. Emergency Departments, 2001–2009*

Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study.

Intravenous Magnesium as an Adjuvant in Acute Bronchospasm: A Meta-Analysis

Computed Tomography Use Among Children Presenting to Emergency Departments With Abdominal Pain