Showing papers by "Lincoln Hospital published in 2005"

Eligibility criteria for HIV clinical trials and generalizability of results: the gap between published reports and study protocols.

Abstract: Objective:Applicability of randomized controlled clinical trial (RCT) results to ‘real world' situations is dependent on the comparability of trial participants to general patient populations. A full disclosure of criteria employed for trial enrollment is necessary for clinicians to assess generaliz

Predicting the difficult laryngoscopic intubation: are we on the right track?

Abstract: REDICTION and forecasting an outcome is a tough business. In the movie "Matrix", even the Oracle made the "wrong prediction" when she postulated that Neil was not the ONE who could save them from the Matrix, and she was supposed to know the future! Predicting a difficult laryngoscopic intubation employing a myriad of measurements and observations has not demonstrated itself to be predictable or even reliable. Over the years, many univariate and multivariate predictors of difficult laryngoscopic intubation have been explored. However, as difficult laryngoscopic intubation is so uncommon, none of these predictors when studied has been reliably able to yield a high positive predictive value for difficult laryngoscopic intubation. 1 In this issue, Merah et al. 2 studied the potential of five airway measurements to predict a difficult direct laryngoscopic intubation in a West African population. The investigators found that the combination of a modified Mallampati score, the thyromental distance and the inter-incisor gap appeared to be the best predictors of a difficult laryngoscopic intubation with an 84.9% sensitivity, 94.6% specificity, and 35.5% positive predictive value. In light of the current state of knowledge with respect to airway evaluation, the investigators concluded that this prediction tool would behave similarly in Caucasians and West Africans. From a practical point of view with all of the shortcomings attending the prediction of difficult laryngoscopy and intubation, this type of multivariate airway assessment is probably about as good as it gets in predicting a difficult laryngoscopic intubation. While a difficult direct laryngoscopy may be considered uncommon, a grade II or III laryngoscopic view requiring multiple attempts and/or blades still occurs between 1 and 18% of the time. 3 Failed laryngoscopic intubation is really quite uncommon (0.05‐0.35%) and the cannot intubate cannot ventilate situation is even more rare (1:2250 in nonparturients and as high as 1:280 in parturients), but carries the high probability of an unfavourable outcome. 3 Will it ever be possible to devise a system that will identify, with a reliability approaching 100%, patients who should be intubated awake and those who can safely be intubated post induction? It doesn’t appear so. The real issue, however, is a broader one: ventilation and oxygenation, rather than ‘intubatability’. The important question thus becomes, ‘what factors contribute to the inability to effect gas exchange in the induced, paralyzed patient to the extent that life may be threatened?’ We need to change how we think about airway management. Rather than focusing only on predicting “intubatability”, we must focus on the broader issue of ‘ventilatability’. We should devise a framework that permits us to reliably predict our ability to provide oxygenation and ventilation for a specific patient. With gas exchange being the focus of airway management, we believe that there are four ‘dimensions’ to this functional and anatomic evaluation: 1) Will I be able to oxygenate this patient using bag mask ventilation (BMV)? The inability to effect a mask seal, overcome upper airway obstruction, or ventilate in the presence of a reduced pulmonary compliance and increased airways resistance all come into play; 4 2) Is it possible to ventilate the patient using a supraglottic device (SGD)? The use of a SGD may be difficult in the presence of a restricted mouth opening, upper or lower airway obstruction, a distorted or disrupted airway or a reduction in the pulmonary compliance; 3) Will I be able to place a tube in the trachea of the patient using a laryngoscope or other alternative techniques? Research has delineated anatomic predictors of difficult direct laryngoscopy. Other anatomic and pathologic predictors

Malaria among refugee children at arrival in the United States.

Abstract: Background: Malaria infects 70% of children at any given time in highly disease-endemic areas, such as parts of West Africa. Many infected children are asymptomatic. There are no published data regarding the prevalence of malaria among refugee children arriving in the United States from highly disease-endemic areas. This study was performed to determine the prevalence of malaria among asymptomatic children from West Africa. Methods: A retrospective chart review for Liberian refugee children arriving in the United States was conducted from 1997 to 2000. Results: Fifty-seven charts were reviewed. There were 28 (64%) positive thick and thin blood smears among the 44 children who had malaria smears performed during refugee medical screening examinations. There were 3 children who had been treated recently for malaria. An additional 3 children had splenomegaly and were treated for presumed malaria. Overall, the prevalence rate was 60% (34 of 57 cases). No sign or symptom, singly or in combination, was sufficient to predict the presence or absence of malaria. However, splenomegaly, fever and thrombocytopenia were highly specific for malaria and should alert clinicians to the likelihood of the diagnosis. Twenty-nine percent of children with malaria were asymptomatic. Conclusion: The results of this study suggest that refugee children arriving from West Africa have a significant burden of malaria. It is recommended that children who arrive in the United States as refugees from West Africa be subjected to a thorough physical examination, complete blood count and malaria blood smear.

Evidence-based medicine applied to sentinel lymph node biopsy in patients with breast cancer.

Abstract: Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based medicine (EBM) Specifically, likelihood ratios have not been used to assess the validity of SLNB The Surveillance, Epidemiology, and End Results (SEER) public database of the National Cancer Institute was used to establish the baseline or pretest probability of finding a positive lymph axillary node for each stage of breast cancer Rates of false negative results of SLNB for all breast cancer stages were determined from the surgical literature Positive and negative likelihood ratios (LR) were calculated For each stage of breast cancer, the Bayesian nomogram was used to find the post-test probability of missing a metastatic axillary node when the SLN was negative The SEER database of 213,292 female patients with breast cancer yielded the following rates of positivity of axillary lymph nodes for each breast tumor size: T1a, 78 per cent; T1b, 133 per cent; T1c, 285 per cent; T2, 502 per cent; T3, 701 per cent The combined data from 13 published studies of SLNB (6444 successful SLNBs) demonstrated a false negative rate of 85 per cent The LR of a negative test is 0086 According to the nomogram, the chances of missing a positive node for stage of cancer are as follows: T1a, 07 per cent; T1b, 15 per cent; T1c, 30 per cent; T2, 7 per cent; T3, 18 per cent The risk of missing a positive axillary node can accurately be estimated for each stage of breast cancer using the LR, which is much more useful than the simple false negative rate Surgeons should use this information when deciding whether to perform SLNB and in their informed consent discussions

Giant bulla mimicking pneumothorax

Abstract: It is usually thought by emergency physicians that the diagnosis of a pneumothorax is straightforward and easy to make and to treat, but the diagnosis may sometimes pose a challenge. The present report describes a case of a giant pulmonary bulla in a 40-year-old man that progressed to occupy almost the entire left hemithorax and also subsequently ruptured to produce a large left pneumothorax. The giant bulla was diagnosed only as a pneumothorax, and initially managed with a chest tube only. The differentiation between pneumothorax and a giant bulla can be very difficult, and often leads to inaccurate diagnosis and management. This case report demonstrates the clinical presentation of giant bulla and its complications such as pneumothorax and also highlights the difficulty in making this diagnosis and appropriately treating it. In this article, we emphasized how to differentiate between giant bulla and pneumothorax utilizing history, physical examination, and radiological studies including computed tomography (CT) scan.

A Multicenter Study of Complementary and Alternative Medicine Usage among ED Patients

Abstract: Objectives To estimate the prevalence of complementary and alternative medicine (CAM) usage among emergency department (ED) patients. Methods This study was a cross-sectional study in four Boston-area EDs. For two 24-hour periods, the authors interviewed consecutive patients age 18 and older about whether they had ever used or had recently (within the past year) used CAM "remedies" (e.g., herbal treatments) or "therapies" (e.g., chiropractic). The authors also asked about the patient's disclosure of CAM usage to allopathic health care providers. Results Of 978 patients, 752 patients were eligible. Among these, 539 (72%) were interviewed. Of these patients, ever having used CAM was reported by 57% (95% CI = 52% to 61%), and 37% (95% CI = 33% to 41%) reported use in the past year. In a multivariate model of recent CAM usage, independent predictors were younger age, higher education level, and chronic pain. Patients who spoke Spanish as their primary language were less likely to report CAM usage. Disclosure of CAM usage to allopathic providers was low, yet >80% reported that they would be comfortable discussing their CAM usage with allopathic providers. Conclusions CAM usage was common among ED patients enrolled in our study, despite underreporting to ED staff. Given the growing evidence of benefits and hazards from popular CAM remedies and therapies, ED staff should consider raising this health issue with their patients.

The effect of pesticide spraying on the rate and severity of ED asthma

Abstract: We report on the incidence of emergency department (ED) asthma presentations and admissions to the Lincoln Hospital, located in the South Bronx of New York City, during the 1999 eradication program of the mosquito vector for West Nile virus. Spraying of Malathion and Resmethrin occurred in the hospital's geographic area over 4 days in September 1999. During that time, 1318 pediatric and adult patients were seen in the ED for asthma-related symptoms. Of these, 222 (16.8%) were hospitalized. Emergency department visits, during days when spraying occurred, were compared with visits during days when no spraying occurred. Comparisons were made with previous years as a reference point. Findings showed that the spraying of insecticides did not increase the rate or severity of asthma presentations as measured by the Lincoln Hospital's ED asthma census or hospital admissions for asthma.

Asymmetric crying facies: a possible marker for congenital malformations.

Abstract: Asymmetric crying facies (ACF) is caused by agenesis or hypoplasia of the depressor anguli oris muscle on one side of the mouth. Though it is an isolated finding in most cases, ACF can be associated with other congenital malformations especially of the cardiovascular system. We report a case of ACF that was subsequently diagnosed as Cayler syndrome based on associated tetralogy of Fallot (TOF) and deletion of chromosome 22q11.

"Doctor" or "Doctora": Do Patients Care?

Abstract: Background:The topic of gender and medical care is receiving increased attention but has not been studied in children. We noticed that several children undergoing laceration repair in emergency department requested to be sutured by a female physician. This study attempted to find gender preferences

Research opportunities in the management of acute exacerbations of chronic obstructive pulmonary disease

Abstract: Acute exacerbations of chronic obstructive pulmonary disease are a common problem in the emergency department. Despite considerable research involving the management of this disease over the past decade, much remains unclear from an emergency medicine perspective. Increased research would better guide the management of these complex patients from the perspectives of the patient, the caregiver, and society. The major areas of research can be divided into diagnosis, therapy, and education. The reliability and validity of different definitions of acute exacerbations of chronic obstructive pulmonary disease need to be assessed. The utility and performance characteristics of diagnostic testing need to be determined for this difficult patient population. Specific diagnostic tests include measures of dyspnea, spirometry and exercise tolerance, measures of gas exchange, airway inflammation, and chest imaging. It remains unclear which patient-specific therapies (oxygen, bronchodilators, corticosteroids, antibiotics, noninvasive positive pressure ventilation, and methylxanthines) should be used and monitored. Finally, the utility of education of both health care providers and patients and how it may be applied to the acute setting need to be addressed.

Use of a sedation-analgesia datasheet in closed shoulder reductions

Abstract: A three-page conscious sedation (CS) monitoring datasheet and sedation-analgesia policy were implemented at the Lincoln Hospital Emergency Department (LHED) to maintain compliance with JCAHO and New York State standards on CS monitoring. The datasheet included areas for physical examination, medications, and vital signs. To determine effects of the new datasheet and policy, charts containing all closed shoulder reductions done at LHED from April 3, 1996 to June 30, 1999 (n = 237) were reviewed for use of CS, defined as the use of an analgesic and sedative-hypnotic concurrently. Utilization of CS during equal time periods of 591 days before and after datasheet implementation was analyzed and compared. Before use of the datasheet, 64.3% received CS before closed shoulder reduction, compared with 41.8% after its use began (p < 0.05). A subsequent survey was conducted to determine physician perception of the CS datasheet. Attending-level LHED physicians suggested that use of the datasheet increased charting time and liability.

Mckusick-kaufman syndrome (MK catalogue #236700) presenting prenatally as fetal abdominal mass

Abstract: McKusick-Kaufman Syndrome (MK catalogue #236700) Presenting Prenatally as Fetal Abdominal Mass

Sleep-disordered breathing, cardiac arrhythmia, and panic disorder.

Abstract: Sleep-disordered breathing often presents as a cardiac or psychiatric problem. Such presentation may lead to suboptimal diagnostic and therapeutic decisions. The authors present a case in which a patient's condition improved only after the primary disorder was diagnosed and properly managed.

Limping child with profound weakness.

Abstract: A n acute limp is a common reason for a child to present to the emergency department (ED). Limping takes many forms, and the cause is not always obvious. Limping is never normal, and both benign and life-threatening illnesses can present with limp. The provisional diagnosis can be a challenge to establish even after history, physical, and laboratory examinations. The few causes of limp in the weak pediatric patient help narrow the focus of the ED evaluation. A representative case is provided.

Two teenagers with syncope.

Abstract: We report the cases of 2 teenagers with syncope and headaches who were subsequently found, on head computed tomography examinations, to have central nervous system etiologies (arteriovenous malformation and arachnoid cyst) of their syncope. These cases highlight the importance of a focused history and physical examination when evaluating patients who present with syncope.