Showing papers by "Lincoln Hospital published in 2017"

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review

Abstract: Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. Theemergency department (ED) offers a unique opportunity to address AUD with brief screening tools andearly intervention. We undertook a systematic review of the effectiveness of ED brief interventions forpatients identified through screening who are at risk for AUD, and the effectiveness of these interventionsat reducing alcohol intake and preventing alcohol-related injuries.Methods: We conducted systematic electronic database searches to include randomized controlled trialsof AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Twoauthors graded and abstracted data from each included paper.Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD.Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a controlintervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significantdifferences between control and intervention groups in their main alcohol-outcome criteria of number ofdrink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumptionin both the control and intervention groups; of those, seven studies did not identify a significant interventioneffect for the main outcome criteria, but nine observed some significant differences between BI and controlconditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking anddriving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g.reduction in driving while intoxicated).Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction inalcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury),and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the EDappears to have a short-term effect in reducing at-risk drinking.

Multicenter Study of Outcomes with Ceftazidime-Avibactam in Patients with Carbapenem-Resistant Enterobacteriaceae Infections.

Abstract: Ceftazidime-avibactam is a novel cephalosporin-beta-lactamase inhibitor combination that is active against many carbapenem-resistant Enterobacteriaceae (CRE). We describe a retrospective chart review for 60 patients who received ceftazidime-avibactam for a CRE infection. In-hospital mortality was 32%, 53% of patients had microbiological cure, and 65% had clinical success. In this severely ill population with CRE infections, ceftazidime-avibactam was an appropriate option.

Identifying augmented renal clearance in trauma patients: Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system.

Abstract: BACKGROUND Augmented renal clearance (ARC) is common in trauma patients and associated with subtherapeutic antimicrobial concentrations. This study reported the incidence of ARC, identified ARC risk factors, and described a model to predict ARC (i.e., ARCTIC) that is specific to trauma patients. METHODS Consecutive trauma patients who were admitted to the intensive care unit between March 2015 and January 2016 and had a measured creatinine clearance (CrCl) were considered for inclusion. Patients were excluded if their serum creatinine (SCr) was greater than 1.3 mg/dL. ARC was defined as a measured CrCl of 130 mL/min or greater. Demographic and trauma-specific variables were then compared, and multivariate analysis was performed. Using these results, a weighted scoring system was constructed and evaluated using receiver operating characteristic curve analysis. ARCTIC score cutoffs were chosen based on sensitivity, specificity, positive predictive value, and negative predictive value. The derived scoring system was then compared to a previously published scoring system for accuracy. RESULTS There were 133 patients with a mean age of 48 ± 19 years and SCr of 0.8 ± 0.2 mg/dL. The mean measured CrCl was 168 ± 65 mL/min, and the incidence of ARC was 67%. Multivariate analysis revealed the following risk factors for ARC (age, <56: odds ratios [OR], 58.3; 95% confidence interval [CI], 5.2-658.9; age, 56 to 75: OR, 13.5; 95% CI, 1.2-151.7), SCr less than 0.7 mg/dL (OR, 12.5; 95% CI, 3-52.6), and male sex (OR, 6.9; 95% CI, 1.9-24.9). Using these results, the ARCTIC scoring system was: 4 points if younger than 56 years, 3 points if aged 56 years to 75 years, 3 points if SCr less than 0.7 mg/dL, and 2 points if male sex. Receiver operating characteristic curve analysis revealed an area (95% CI) of 0.813 (0.735-0.892) (p < 0.001). An ARCTIC score of 6 or higher had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.843, 0.682, 0.843, and 0.682, respectively. CONCLUSION The incidence of ARC in trauma patients is high. The ARCTIC score represents a practical, pragmatic system that can be easily applied at the bedside. An ARCTIC score of 6 or higher represents an appropriate cutoff to screen for ARC where antimicrobial adjustments should be considered. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations.

Abstract: Objectives Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents’ progress during their residency training which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents’ use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. Methods This study is a prospective stratified cluster sample survey of all United States EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. Results There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access and diagnosis of pericardial effusion and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural-guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. Conclusions EM resident physicians’ opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training. This article is protected by copyright. All rights reserved.

Health effectiveness of community health workers as a diabetes self-management intervention:

Abstract: Objective:To evaluate the health effectiveness of community health workers among three groups (intervention, attentional control and control groups) of Hispanic adults with uncontrolled (HbA1c >8%) type 2 diabetes mellitus.Methods:This was a randomized clinical trial involving 180 English- and Spanish-speaking Hispanic individuals with uncontrolled type 2 diabetes mellitus, 40–74 years of age, who received diabetes care at an outpatient, public, urban hospital. Repeated-measures analysis of variance was used to evaluate the effect of time and group on the primary outcome measure and secondary outcomes. Group differences in the percentage of participants achieving at least 1% reduction in HbA1c levels were assessed using chi-square tests.Results:Patients’ ages ranged from 44 to 74 years, 40% were male, 97% preferred Spanish and seven Spanish-speaking countries were identified as country of origin. Relative to the control and attentional control groups, the intervention group showed greater HbA1c reduction ...

Transitions From Pediatric to Adult Care.

Abstract: Transitions from Pediatric to Adult Care from the National Diabetes Education Program (NDEP) helps teens with diabetes make a smooth transition to adult health care. Families and health care professionals will also find these materials very helpful. The online tool contains the following materials:  Transition Planning Checklist: suggests a timeline, topics to review, and key action steps to support various aspects of the transition process  Patient Clinical Summary: provides a summary of the teen’s health status to be completed by the pediatric health care team and provided to the adult health care team  Resource List: offers hyperlinks to additional resources such as videos, message boards, social networks, workbooks, checklists, guides, and books and can be viewed by category

Prevalence and predictors of positive screening for postpartum depression in minority parturients in the South Bronx

Abstract: It is reported that the rates of perinatal depressive disorders are high in ethnic minority groups from non-English speaking countries. However, very few studies have compared the prevalence of positive screening for postpartum depression (PPD) in minority communities living in an inner city. The goal of this study is to determine the prevalence and the predictors of positive screening for postpartum depression in minority parturients in the South Bronx. The study is a chart review of 314 minority parturients, Black or Hispanic, screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) tool. The overall prevalence of a positive EPDS screen among Black and Hispanic women was similar, 24.04 and 18.75%, respectively. The Black immigrant cohort had comparable positive screens with 23.81 as African Americans. Hispanic women born in the USA had the least prevalence of positive screens, 7.14%, and those who moved from the Dominican Republic and Puerto Rico had a prevalence of 17.24% of positive screens. The women who immigrated from Mexico, Central America, or South America had the highest prevalence of positive screens for PPD, 32.26%. As to the socioeconomic status (SES), there was a significant increase of 27.04 vs. 13.95% (P < 0.019) in positive screens for PPD for the unemployed mothers. Overall, Black and Hispanic parturients had similar rates of positive screens for PPD. Among the Hispanic women, immigrants had higher rates of positive screens, with those from Mexico, Central, and South America as the highest. The hospital experience did not affect the rates of positive screens. Neither did the SES with one exception; those unemployed had the higher rates of positive screens.

A Multidisciplinary Patient Navigation Program Improves Compliance With Adjuvant Breast Cancer Therapy in a Public Hospital.

Abstract: Cancer health disparities affecting low-income and minority patients have been well documented to lead to poor outcomes. This report examines the impact of patient navigation on adherence to prescribed adjuvant breast cancer treatment. A multidisciplinary patient navigation program was initiated at a public safety net hospital to improve compliance with 3 National Quality Forum measures: (1) administration of combination chemotherapy for women with Stage (defined by the American Joint Committee on Cancer [AJCC]) T1c, II, or III hormone receptor-negative breast cancer within 120 days; (2) administration of endocrine therapy for women with AJCC Stage T1c, II, or III hormone receptor-positive breast cancer within 365 days; and (3) radiation therapy for women receiving breast-conserving surgery within one year. Implementation of a multidisciplinary patient navigation program reduced time to treatment and improved compliance with adjuvant therapy for breast cancer in an underserved minority community.

Profound hypotension and bradycardia in the setting of synthetic cannabinoid intoxication - A case series.

Abstract: Cannabinoids are the most commonly used illegal substances in the world [1]. Synthetic Cannabinoids (SCB) are also known as "Spice", "K2", "Spike", "herbal incense", "Cloud 9", "Mojo" and many others are becoming a large public health concern due to their increasing use, unpredictable toxicity, and abuse potential [2]. The most common reported toxicities with SCB use based on studies using Texas Poison control record are tachycardia, agitation and irritability, drowsiness, hallucinations, delusions, hypertension, nausea, confusion, dizziness, vertigo, chest pain, acute kidney injury, seizures, heart attacks and both ischemic and hemorrhagic strokes [3]. The Emergency Department (ED) here at Lincoln Medical Center has certainly seen a sizeable volume of K2 abusers who present displaying a spectrum of symptoms as noted above. However, during a concentrated outbreak of K2 use in the summer of 2015, a large cohort of patients presented with a toxidrome not previously described in any published literature. This included marked bradycardia and hypotension while maintaining global neurologic function. Although these patients were drowsy and sleepy at presentation, tactile stimuli would arouse these patients to awaken and participate in an interview. The patients described in this case series, appeared to be on the brink of cardiovascular collapse. The vital signs however normalized with intravenous fluid (IVF) hydration only, over the course of 6 to 7h, allowing a safe discharge from the ED.

Atypical Amniotic Fluid Embolism Managed with a Novel Therapeutic Regimen

Abstract: Amniotic fluid embolism (AFE) is the second leading cause of maternal mortality in the USA with an incidence of 1 : 15,200 births. The case fatality rate and perinatal mortality associated with AFE are 13–30% and 9–44%, respectively. This rare but devastating complication can be difficult to diagnose as many of the early signs and symptoms are nonspecific. Compounding this diagnostic challenge is a lack of effective treatment regimens which to date are mostly supportive. We present the case of a 26-year-old woman who suffered from suspected AFE and was successfully treated with the novel regimen of Atropine, Ondansetron, and Ketorolac (A-OK). The authors acknowledge that this case does not meet the new criteria proposed, by Clark in 2016, but feel that it is important to share this case report, due to dramatic patient response to the provided supportive therapy presented in this case report. We hope this case report will prompt further research into this novel approach to treating AFE with Atropine, Ondansetron, and Ketorolac.

Lentigo maligna melanoma with a history of cosmetic treatment: Prevalence, surgical outcomes and considerations

Abstract: Introduction Lentigo maligna (LM) is melanoma in situ on sun-damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions Cosmetic treatments may be inadvertently performed on LM The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes Study Design and Methods Retrospective review of biopsy-proven LM presenting over a 10-year-period (2006–2015) Prior cosmetic treatment and biopsies were recorded Records were reviewed for demographic data, clinical characteristics, and surgical outcomes Results 37/503 (74%) patients with LM reported prior cosmetic therapy Most (95%) were on the head and neck; mean size 19 cm Most patients reported cryotherapy (73%), followed by laser (297%), topical bleaching agents (189%), and electrodessication, and/or curettage (53%) Ten patients (27%) received two or more modalities Eight patients (216%) reported prior benign biopsies Six patients (16%) had invasive disease, two on initial biopsy and 4/34 (117%) upstaged upon excision Average margin for clearance was 91 mm Conclusion Prior cosmetic treatment of LM is not uncommon, and may delay diagnosis and obscure borders, resulting in wider surgical margins Clinicians should consider a biopsy confirming the benign nature of equivocal lesions prior to cosmetic treatment Lasers Surg Med © 2017 Wiley Periodicals, Inc

The impact of pre-injury direct oral anticoagulants compared to warfarin in geriatric G-60 trauma patients.

Abstract: Pre-injury oral anticoagulants are associated with worse outcomes in geriatric (G-60) trauma patients, but there are limited data comparing warfarin with direct oral anticoagulants (DOAC) We sought to compare outcomes in G-60 trauma patients taking pre-injury DOACs vs warfarin All trauma patients, age ≥60 who were admitted to the hospital and taking an oral anticoagulant pre-injury were retrospectively identified Patients were excluded if their reason for admission was a suicide attempt or penetrating extremity injury Outcome measures included blood transfusions, hospital LOS, and mortality A second analysis was performed, whereby patients were matched using ISS and age There were 3,941 patients identified; 331 had documentation of anticoagulant use, pre-injury (warfarin, n = 237; DOAC, n = 94) Demographics were similar, but ISS [9 (4–13) vs 8 (4–9), p = 027], initial INR [22 (18–29) vs 12 (11–15), p < 001], and the use of pharmacologic reversal agents (48 vs 14%, p < 001) were higher in the warfarin group There was no difference in the use of blood transfusions (24 vs 17%, p = 164) or mortality (59 vs 43%, p = 789) between warfarin and DOAC groups, respectively However, LOS was longer in the warfarin group [5 (3–75) vs 4 (2–63) days, p = 02] Matched analysis showed no difference in blood transfusions (23 vs 17%, p = 276), mortality (21 vs 43%, p = 682) or LOS [5 (3–7) vs 4 (2–63) days, p = 158] between warfarin and DOAC groups, respectively Pre-injury DOACs are not associated with worse clinical outcomes compared to warfarin in G-60 trauma patients Higher use of pharmacologic reversal agents with warfarin may be related to differences in mechanism of action and effect on INR

Evaluation of the "medication fall risk score".

Abstract: Purpose Results of a study evaluating the predictive validity of a fall screening tool in hospitalized patients are reported. Methods Administrative claims data from two hospitals were analyzed to determine the discriminatory ability of the “medication fall risk score” (RxFS), a medication review fall-risk screening tool that is designed for use in conjunction with nurse-administered tools such as the Morse Fall Scale (MFS). Through analysis of data on administered medications and documented falls in a population of adults who underwent fall-risk screening at hospital admission over a 15-month period ( n = 33,058), the predictive value of admission MFS scores, alone or in combination with retrospectively calculated RxFS-based risk scores, was assessed. Receiver operating characteristic (ROC) curve analysis and net reclassification improvement (NRI) analysis were used to evaluate improvements in risk prediction with the addition of RxFS data to the prediction model. Results The area under the ROC curve for the predictive model for falls compromising both MFS and RxFS scores was computed as 0.8014, which was greater than the area under the ROC curve associated with use of the MFS alone (0.7823, p = 0.0030). Screening based on MFS scores alone had 81.25% sensitivity and 61.37% specificity. Combined use of RxFS and MFS scores resulted in 82.42% sensitivity and 66.65% specificity (NRI = 0.0587, p = 0.0003). Conclusion Reclassification of fall risk based on coadministration of the MFS and the RxFS tools resulted in a modest improvement in specificity without compromising sensitivity.

A Rare Case of Septic Shock Secondary to Emphysematous Hepatitis.

Abstract: Objective. To describe a case of emphysematous hepatitis which is a rare clinical entity, characterized by a fatal, rapidly progressive infection of the liver with a radiological appearance simulating emphysematous pyelonephritis and to help provide more data about the causative organisms and precipitating factors of this pathology. Data Sources and Synthesis. Relevant literature was reviewed and, to the best of our knowledge, there is limited data regarding the pathogenesis, causative organisms, and management of this condition. Conclusion. Emphysematous hepatitis is a rapidly progressive infection that can be fatal in the absence of appropriate therapeutic intervention. Initial clinical manifestations are usually subtle and thus high clinical suspicion is required for early diagnosis and management of this condition to help decrease the mortality rates.

Role of Pediatric Emergency Physicians in Identifying Bullying

Abstract: Background Bullying is an important public health issue with broad implications. Although this issue has been studied extensively, there is limited emergency medicine literature addressing bullying. The emergency department (ED) physician has a unique opportunity to identify children and adolescents that are victims of bullying, and make a difference in their lives. Objective Our aim is to discuss the role of the emergency physician (EP) in identifying patients who have been victims of bullying and how to provide effective management as well as referral for further resources. Discussion This document provides a framework for recognizing, stabilizing, and managing children who have experienced bullying. With the advent of social media, bullying behavior is not limited to in-person situations, and often occurs via electronic communication, further complicating recognition because it may not impart any physical harm to the child. Recognition of bullying requires a high level of suspicion, as patients may not offer this history. After the stabilization of any acute or overt indications of physical injury, along with obtaining a history of the mechanism of injury, the EP has the opportunity to identify the existence of bullying as the cause of the injury, and can address the issue in the ED while collaborating with “physician-extenders,” such as social workers, toward identifying local resources for further support. Conclusions The ED is an important arena for the assessment and management of children who have experienced bullying. It is imperative that EPs on the front lines of patient care address this public health epidemic. They have the opportunity to exert a positive impact on the lives of the children and families who are the victims of bullying.

Congenital Hepatic Cyst.

Abstract: Congenital hepatic cyst is a rare and nonsymptomatic condition in infants and children. Its incidence is 2.5% in the postnatal life with a much lower incidence in the prenatal period. Incidental finding on antenatal imaging is the most common presentation. We present a case of a newborn in whom fetal ultrasound detected a cyst within the fetal liver. Postnatal imaging revealed a liver cyst in the right lobe of the liver, with no other intrahepatic structure affected. Liver function tests were abnormal, but the patient was asymptomatic. Posterior follow-up imaging showed a minor decrease in size. Management of congenital hepatic cyst is usually conservative, done with periodic ultrasound monitoring. However, surgical treatment is the mainstay of treatment when hydrops, progressive enlargement, hemorrhage, torsion, or compression of adjacent structures occurs. Malignant transformation can occur, but it is extremely rare. Partial or total removal of the cyst is the preferred treatment in neonates with a large lesion.

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review

Abstract: Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. Theemergency department (ED) offers a unique opportunity to address AUD with brief screening tools andearly intervention. We undertook a systematic review of the effectiveness of ED brief interventions forpatients identified through screening who are at risk for AUD, and the effectiveness of these interventionsat reducing alcohol intake and preventing alcohol-related injuries.Methods: We conducted systematic electronic database searches to include randomized controlled trialsof AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Twoauthors graded and abstracted data from each included paper.Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD.Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a controlintervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significantdifferences between control and intervention groups in their main alcohol-outcome criteria of number ofdrink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumptionin both the control and intervention groups; of those, seven studies did not identify a significant interventioneffect for the main outcome criteria, but nine observed some significant differences between BI and controlconditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking anddriving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g.reduction in driving while intoxicated).Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction inalcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury),and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the EDappears to have a short-term effect in reducing at-risk drinking.

Paradoxical Association of Postoperative Plasma Sphingosine-1-Phosphate with Breast Cancer Aggressiveness and Chemotherapy.

Abstract: Sphingosine-1-phosphate (S1P) is a bioactive lipid mediator that has been shown to serve an important regulatory function in breast cancer progression. This study analyzes plasma S1P levels in breast cancer patients undergoing adjuvant therapy as compared to healthy control volunteers. 452 plasma S1P samples among 158 breast cancer patients, along with 20 healthy control volunteers, were analyzed. Mean S1P levels did not significantly differ between cancer patients and controls. Smoking was associated with higher S1P levels in cancer patients. Baseline S1P levels had weak inverse correlation with levels of the inflammatory mediator interleukin- (IL-) 17 and CCL-2 and positive correlation with tumor necrosis factor alpha (TNF-α). Midpoint S1P levels during adjuvant therapy were lower than baseline, with near return to baseline after completion, indicating a relationship between chemotherapy and circulating S1P. While stage of disease did not correlate with plasma S1P levels, they were lower among patients with Her2-enriched and triple-negative breast cancer as compared to luminal-type breast cancer. Plasma S1P levels are paradoxically suppressed in aggressive breast cancer and during adjuvant chemotherapy, which raises the possibility that postoperative plasma S1P levels do not reflect S1P secretion from resected breast cancer.

Introduction of a quality improvement curriculum in the Department of Internal Medicine, Lincoln Medical Center.

Abstract: Community hospitals with limited resources struggle to engage physicians in Quality improvement initiatives. We introduced Quality Improvement (QI) curriculum for residents in response to ACGME requirements and surveyed the residents understanding of QI and their involvement in QI projects before and after the introduction of the curriculum. The current article describes our experiences with the process, the challenges and possible solutions to have a successful resident led QI initiative in a community hospital. Methods: A formal QI curriculum was introduced in the Department of Internal Medicine from September to October 2015 using the Model for Improvement from Institute for Health care Improvement (IHI). Learners were expected to read the online modules, discuss in small group sessions and later encouraged to draft their QI projects using the Charter form and PDSA form available on the HI website. Online surveys were conducted a week prior and 3 months after completion of the curriculum Results: 80% (100/117) of residents completed the pre-curriculum survey and 52% (61/117) completed the survey post curriculum. 96.7% of residents report that physicians should lead QI projects and training rather than the hospital administrators. Residents had 20% increase in understanding and confidence in leading quality improvement projects post curriculum once initiated. Most Residents (72%) feel QI should be taught during residency. Active involvement of residents with interest was seen after the initiation of Open School Institute of health improvement (IHI) curriculum as compared to Institutional led QI's. The resident interventions, pitfalls with change processes with an example of PDSA cycle are discussed. Conclusion: A Dedicated QI curriculum is necessary to prepare the physicians deliver quality care in an increasing complex health care delivery system. The strength of the curriculum is the ease of understanding the material, easily available to all, and can be easily replicated in a Community Hospital program with limited resources. Participation in QI by residents may promote constructive competitiveness among related hospitals in public system to improve delivery of safe care. Abbreviations: ACGME: Accreditation Council for Graduate Medical Education; IHI: Institute of Healthcare Improvement; PDSA: Plan-Do-Study-Act; PGY: QI: Quality improvement.

Peri-intubation factors affecting emergency physician choice of paralytic agent for rapid sequence intubation of trauma patients

Abstract: Introduction No study has assessed predictors of physician choice between the succinylcholine (Succ) and rocuronium (Roc) for rapid sequence intubation (RSI) during the initial resuscitation of trauma patients in the emergency department (ED). Methods We retrospectively evaluated of the use of Succ and Roc for adult trauma patients undergoing RSI at a Level 1 trauma center. The primary outcome was to identify factors affecting physician choice of paralytic agent for RSI analyzed by cluster analysis using pre-intubation vital signs and early mortality. The secondary outcome was to identify factors influencing physician choice of paralytic agent using a logistic regression model reported as adjusted odds ratios (aOR). Results The analysis included 215 patients, including 148 receiving Succ and 67 receiving Roc. The two groups were similar in regard to age, provider level of training, mean GCS (10 vs. 10) and median ISS (27 vs. 27). Cluster analysis using peri-intubation patient vital signs and early mortality indicates that patients with predominantly abnormal vital signs and early mortality were more likely to receive Roc (74%) than those without abnormal vital signs prior to intubation or early mortality (24%). Hypoxemia prior to RSI (aOR 12.3 [2.5–60.9]) and the use of video laryngoscopy (VL) (aOR 5.5 [1.2–24.6]) were associated with the choice to use Roc. Conclusions Roc was more frequently chosen for paralysis in the patient cluster with predominantly abnormal peri-intubation vital signs and higher rate of early ED mortality. The use of Roc was associated with hypoxemia prior to RSI and VL.

Trauma Primary Survey

Abstract: The primary survey is designed to assess and treat any life-threatening injuries quickly. It should be completed very rapidly. The main causes of death in a trauma patient are airway obstruction, respiratory failure, massive hemorrhage, and brain injuries. Therefore, these are the areas targeted during the primary survey. The following are some of, but not all, the specific injuries that may be identified during a primary survey, which may be potentially life-threatening: Airway obstruction Tension pneumothorax Massive internal or external hemorrhage Open pneumothorax Flail chest Cardiac tamponade Intracranial bleed Increased intracranial pressure

Non-surgical and Surgical Management of Pelvic Organ Prolapse in the Older Woman

Abstract: Purpose of Review Pelvic organ prolapse (POP) is a common condition that can adversely affect quality of life in older women. With the current trend in longevity, the number of women with this problem will exceed the availability of subspecialists in Female Pelvic Medicine and Reconstructive Surgery. The purpose of this paper is to aid primary care physicians, geriatricians, and general gynecologists in the evaluation, referral, and treatment of women with POP. Women can be quickly evaluated and offered therapy prior to referral to a subspecialist.

Otitis Media in Fully Vaccinated Preschool Children in the Pneumococcal Conjugate Vaccine Era.

Abstract: Objectives. To evaluate the effect of pneumococcal conjugate vaccine (PCV13) on the burden of acute otitis media (AOM) and to evaluate the characteristics of AOM versus otitis media with effusion (...

Cardiac tamponade as an initial presentation for systemic lupus erythematosus.

Abstract: Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease which follows a relapsing and remitting course that can manifest in any organ system. While classic manifestations consist of arthralgia, myalgia, frank arthritis, a malar rash and renal failure to name a few, cardiac tamponade, however, is a far less common and far more dangerous presentation. We highlight the case of a 61year-old male with complaints of acute onset shortness of breath and generalized body aches associated with a fever and chills in the ER. A bedside echocardiogram revealed a significant pericardial effusion concerning for pericardial tamponade. An emergent pericardiocentesis performed drained 800mL of serosanguinous fluid. While denying a history of any rash, photosensitivity, oral ulcers, or seizures, his physical examination did reveal metacarpal phalangeal joint swelling along with noted pulsus paradoxus of 15-200mmHg. Subsequent lab work revealed ANA titer of 1:630 and anti-DS DNA antibody level of 256IU/mL consistent with SLE. This case highlights cardiac tamponade as a rare but life-threatening presentation for SLE and raises the need to keep it in the differential when assessing patients presenting with pertinent exam findings.

Hemolysis, Elevated Liver Enzymes, and Low Platelets, Severe Fetal Growth Restriction, Postpartum Subarachnoid Hemorrhage, and Craniotomy: A Rare Case Report and Systematic Review.

Abstract: Introduction. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a relatively uncommon but traumatic condition occurring in the later stage of pregnancy as a complication of severe preeclampsia or eclampsia. Prompt brain computed tomography (CT) or magnetic resonance imaging (MRI) and a multidisciplinary management approach are required to improve perinatal outcome. Case. A 37-year-old, Gravida 6, Para 1-0-4-1, Hispanic female with a history of chronic hypertension presented at 26 weeks and 6 days of gestational age. She was noted to have hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome accompanied by fetal growth restriction (FGR), during ultrasound evaluation, warranting premature delivery. The infant was delivered in stable condition suffering no permanent neurological deficit. Conclusion. HELLP syndrome is an uncommon and traumatic obstetric event which can lead to neurological deficits if not managed in a responsive and rapid manner. The central aggravating factor seems to be hypertension induced preeclamptic or eclamptic episode and complications thereof. The syndrome itself is manifested by hemolytic anemia, increased liver enzymes, and decreasing platelet counts with a majority of neurological defects resulting from hemorrhagic stroke or subarachnoid hemorrhage (SAH). To minimize adverse perinatal outcomes, obstetric management of this medical complication must include rapid clinical assessment, diagnostic examination, and neurosurgery consultation.

The effect of the apneic period on the respiratory physiology of patients undergoing intubation in the ED.

Abstract: Objectives We sought to examine the physiological impact the apneic period has on the respiratory physiology of patients undergoing intubation in the emergency department and whether DAO, the delivery of 15L oxygen by nasal cannula during apnea, can affect the development of respiratory acidosis. Methods This was a prospective observational cohort study conducted at an urban academic level 1 trauma center. A convenience sample of 100 patients was taken. Timed data collection forms were completed during the periintubation period. We report the mean ABG and end-tidal CO2 (EtCO2) values between those with normal and prolonged apnea times (> 60 s) and between those who received DAO and those who did not. Results 100 patients met our inclusion criteria. There were no significant differences in the pre-RSI ABG values between those who received DAO and those who did not and between those with apnea times less than or > 60 s. Only in the group of patients with apnea times > 60 s did significant changes in respiratory physiology occur. DAO did not alter the trend in respiratory acidosis during the periintubation period. EtCO2 increased as apnea times were prolonged, and DAO altered this trend. Conclusions Post-RSI EtCO2 increased as apnea times were prolonged. DAO may alter this trend. Statistically significant changes in pH and PaCO2 (mean differences of 0.15 and 12.5, respectively) occurred in the group of patients who had mean apnea times of > 60 s but not in those with apnea times