Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study

INTRODUCTION

Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population.

OBJECTIVE

To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility.

DESIGN

Retrospective cohort study.

SETTING

An acute rehabilitation hospital associated with a community-based tertiary medical center.

PATIENTS

A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022.

MAIN OUTCOME MEASURE

The study outcome measure was readmission to acute care from an acute rehabilitation unit.

RESULTS

Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006).

CONCLUSIONS

This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.

Changes to same day discharge after minimally invasive hysterectomy throughout COVID-19 pandemic

BACKGROUND

Minimally invasive hysterectomy is a common gynecologic procedure. Numerous studies have found that a same day discharge (SDD) is safe following this procedure. Research has found that SDDs decrease resource strain, nosocomial infections, and financial burden for both the patient and healthcare system. Due to the recent COVID-19 pandemic, the safety of hospital admissions and elective surgeries was called into question.

OBJECTIVE

To assess the rates of SDD among patients who underwent a minimally invasive hysterectomy before and during the COVID-19 pandemic.

STUDY DESIGN

A retrospective chart review was performed from September 2018 to December 2020 on 521 patients, who met inclusion criteria. Descriptive analysis, chi-square tests of association, and multivariable logistic regression were used for analysis.

RESULTS

There was a significant difference between rate of SDDs pre-COVID-19 (12.5%) versus during the COVID-19 period (28.6%) (p < 0.001). Surgical complexity was predictive of not being discharged the same day of surgery (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 2.2-8.8), as was surgical completion time after 4 p.m. (OR = 5.2, 95% CI = 1.1-25.2). There was no difference in readmissions (p = 0.209) and emergency department (ED) visits (p = 0.973) between SDD and overnight stay.

CONCLUSION

Rates of SDD for patients undergoing minimally invasive hysterectomy were significantly increased during the COVID-19 pandemic. SDDs are safe; the number of readmissions and ED visits did not increase among patients who were discharged on the same day.

POS1237 SARS-CoV-2 mRNA VACCINE IMMUNOGENICITY IN CHRONIC INFLAMMATORY ARTHRITIS ON DMARD THERAPY

Background

Patients with chronic inflammatory arthritis (CIA) are at increased risk for the development and mortality from COVID-191. Vaccinations are integral to the management of these conditions. Disease-modifying antirheumatic drugs (DMARDs) used to treat CIA have the potential to blunt the immune response and efficacy of vaccinations2. There is little data on the effect of DMARDS used for CIA on the response to novel mRNA vaccines, limiting guidelines to direct therapy.

Objectives

Assess the antibody response (ABR) to the SARS-CoV-2 mRNA vaccines in patients with CIA on treatment with either methotrexate (MTX), tumor necrosis factor inhibitors (TNFi), or both with healthy controls. Determine the effect of interrupting therapy after vaccination in patients with CIA on the ABR to the vaccine.

Methods

63 patients with rheumatoid or psoriatic arthritis on MTX, TNFi or both were recruited from a community-based rheumatology practice. All subjects received two doses of a mRNA COVID vaccine. Use of hydroxychloroquine (HCQ), NSAID’s, and prednisone (Pred) ≤10mg daily were allowed. Those with prior COVID infection were excluded, as determined by SARS-CoV-2 nucleocapsid assay. 26 healthy age-matched controls were obtained from banked blood from Labcorp. IRB approval was obtained, and patients were consented to participate in the study. SARS anti-receptor binding domain IgG antibodies were measured by electro chemiluminescent immunoassay 90-120 days post initial vaccine dose. Patients were divided into 3 groups based on therapy:

1. MTX monotherapy

2. TNFi with eternacept (ETN) or adalimumab (ADA)

3. A combination of MTX with either ETN or ADA

Each of the groups were subdivided into two categories:

1. Continued treatment uninterrupted at the time of each of the two vaccines.

2. Held treatment for two weeks after each vaccine. Statistical significance (p<.005) determined using one way ANOVA with Scheffe procedure and Student’s T-test.

Results

The 63 patients with CIA had a significantly lower ABR to vaccine compared with healthy controls (p=0.001). Further analysis was limited by sample size: The MTX held group had a higher ABR than the MTX continued group (mean IgG=35.5 vs 21.74; p=0.14), demonstrating a trend toward increased immunogenicity. There was a similar ABR to vaccine between those on TNFi who held vs continued therapy (mean IgG 20.83 vs 28.65; p=0.525). Combination MTX +TNFi held vs continued groups demonstrated a trend toward increased immunogenicity when holding therapy post vaccine (mean IgG 42.4 vs 22.7; p=0.44). All treatment groups were comparable in Pred, HCQ, NSAID use, age, Rapid 3 score, and time between vaccination and blood draw for antibody levels (VI).

Table 1.

Antibody response to Vaccination

VariableMTXTNFMTX + TNFiControlsp valueTestMSDMSDMSDMSDIgG28.9530.0123.9614.7735.2738.8166.3138.060.001ANOVADrugVariableHeldContinuedp valuenMSDnMSDMTXAge2267.957.332071.311.070.251T-testIgG2235.529.922021.7429.130.14VI2297.2713.712098.1510.190.817TNFiAge664.510.19470.2513.770.467IgG620.8310.07428.6520.90.525VI698.6722.24493.7512.290.701MTX + TNFiAge763.866.36462.7511.530.839IgG742.4345.11422.7524.920.448VI710019.09497.7522.590.864VariableCIAControlsp valuenMSDnMSDAge6363.059.612652.318.840.001T-testVI6397.7914.312688.655.430.002

M: Mean; VI: Vaccine Interval in days

Conclusion

The ABR in patients with CIA to the mRNA vaccine appeared to be blunted by ongoing therapy with MTX. This effect was attenuated by holding MTX post-vaccine. There was no significant difference in the ABR to vaccine in patients on TNFi who held vs continued these agents after vaccine, due to small sample size. Patients with CIA on DMARD therapy had a significantly lower ABR to the vaccine compared to healthy controls. Our findings need further validation in a larger cohort. Clinicians may consider holding MTX for two weeks post vaccination to optimize the immune response to the vaccine.

References

[1]Sepriano A, et al. Ann Rheum Dis. 2020;79(6):760-770

[2]Hua C, et al. Arthritis Care Res 2014;66(7):1016-1026

Acknowledgements

We would like to thank Jamie Reidy and Judy Wolf for their efforts in the Arnot laboratory, Dr. Manav Bandlamudi and Dr. Frank Edwards for their research support.

Disclosure of Interests

None declared

Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists vs Neurointerventional Physicians

PURPOSE

To test the hypothesis that interventional radiologists (IR) have outcomes for endovascular stroke thrombectomy (EVT) similar to Neurointerventional (NI) physicians and could be used to improve availability of thrombectomy.

MATERIALS AND METHODS

Eight hospitals providing EVT performed by IR and NI in the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcome (90 day modified Rankin score 0-2) and successful revascularization (modified Thrombolysis in Cerebral Infarction score > 2b) were compared between specialties, adjusted for treating hospital, patient age, stroke severity, Alberta Stroke Program Early CT Score (ASPECTS), time from symptom onset to door, and clot location. Propensity score matching was used to compare outcomes. A total of 1009 patients were entered (622 treated by IR and 387 treated by NI).

RESULTS

Median stroke onset to puncture was 245 vs 253 minutes (p=.49), technically successful revascularization was 81.8% vs 82.4% (p=.81), and good clinical outcome was 45.5% vs 50.1% (p=.16), respectively. After adjusting, physician specialty was not a significant predictor of good clinical outcome (odds ratio 1.028 [95% CI 0.760-1.390]; p=.86). After matching, mRS 0-2 was 47.7% for IR and 51.1% for NI (p=0.366).

CONCLUSION

There was no significant difference in successful revascularization and good clinical outcomes between IR and NI physicians. Outcomes by IR were similar to NI outcomes from previously published trials and registries. This may be useful to address coverage and access to stroke interventions.

Impact of adrenaline dose and timing on out-of-hospital cardiac arrest survival and neurological outcomes

STUDY OBJECTIVE

The 2015 ILCOR Advanced Cardiovascular Life Support Guidelines recommend intravenous adrenaline (epinephrine) as a crucial pharmacologic treatment during cardiac arrest resuscitation. Some recent observational studies and clinical trials have questioned the efficacy of its use and suggested possible deleterious effects on overall survival and long-term outcomes. This study aimed to describe the association between time and dose of adrenaline on return of spontaneous circulation (ROSC) and neurologic function.

METHODS

We performed a retrospective analysis of the Penn Alliance for Therapeutic Hypothermia (PATH) data registry. The timing of the first dose of adrenaline and the total dose of adrenaline during cardiac arrests was compared between survivors to discharge and non-survivors for arrests lasting greater than 10 min.

RESULTS

The registry contained 5594 patients. After excluding patients with an in-hospital cardiac arrest, a non-shockable rhythm, or no adrenaline administration, 1826 were included in the final analysis. Survivors to discharge received adrenaline sooner (median 5.0 vs. 7.0 min, p = 0.022) and required a lower total dose than non-survivors (2.0 vs. 3.0 mg, p < 0.001). For survivors, there was no significant association between the time to first adrenaline dose and favorable neurological outcome as measured by Cerebral Performance Category (CPC). Among survivors, those that received less than 2 mg of adrenaline had a more favorable neurologic outcome than those administered > 3 mg. (CPC 1-2 16.6% vs. 12.5%, p = 0.004).

CONCLUSION

Early adrenaline administration is associated with a higher percentage of survival to discharge but not associated with favorable neurological outcome. Those patients with a favorable neurologic outcome received a lower total adrenaline dose prior to ROSC.

Exploring nurses' and patients' perceptions of hope and hope-engendering nurse interventions in an eating disorder facility: A descriptive cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Individuals with eating disorders (EDs) experience hopelessness, suicidal thoughts and behaviours at elevated rates compared to the general population. Current knowledge of recovery from EDs does not address nurse engendered hope. This study aimed to explore differences between patients' and nurses' perceptions of hope-engendering nurse actions and the relationship actions have with patients' perception of hope. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to explore differences between patients' and nurses' perceptions of hope-engendering nurse actions in an inpatient ED facility and find significant differences; nurses' scores were higher than patients' scores. The study explored the relationship perceived self-reported nurse hope-engendering actions have with patients' and nurses' perception of hope. There were no significant relationships. This study provides additional evidence to support that there are common patient needs for nurse hope-engendering practices such as caring and providing for patients; supporting and encouraging patients' connection to others; facilitating patients' adaptive belief systems; and helping to set goals and attain resources for patients. WHAT ARE THE IMPLICATIONS FOR MENTAL HEALTH NURSING PRACTICE?: Nurses who work with patients who have EDs should be prepared to work with patients who are feeling hopeless about their future. Thus, nursing continuing education should focus on strategies that enable nurses to deliver care that reduces hopelessness, improves connection, and inspires hope in those who are recovering from EDs. The results revealed that nurses perceived that they offered patients with EDs hope-engendering actions more often and effectively than patients believed; this finding pinpoints a future direction for research that may improve care for patients. Patient feedback identified ways nurses may improve care to engender hope: providing an open caring environment, nurse presence, comfort/pain relief, and involving patients in their care. Actions by nurses aimed to enhance interpersonal connection and nurse presence could facilitate hope in patients with ED. ABSTRACT: Introduction Individuals with eating disorders (EDs) experience suicidal thoughts and behaviours at elevated rates compared to the general population. Hope-engendering nursing actions may increase patients' levels of hope for the future, improve coping self-efficacy, and possibly reduce suicidality. Although nursing staff are integral ED treatment team members, little is known about nursing actions targeting hopefulness. Aim Explore differences between patients' and nurses' perceptions of hope-engendering nurse actions and the relationship actions have with patients' perception of hope. Methods Descriptive, cross-sectional, comparative, correlational research design was used. Responses for 97 ED patients and 10 nurses were entered into analysis. Hope-engendering nurse intervention and hope questionnaires were administered and analysed. Results Nurses' total hope-engendering nurse intervention and hope scores were higher than patients' scores. Discussion Patients reported that the most effective nursing actions were providing an open caring environment, comfort/pain relief, and involving patients in their care and treatment. Nurses perceived that they offered patients hope-engendering actions more often and effectively than the patients believed. Implications for Practice Findings indicate that patients with EDs have low levels of hope. Nursing educators should further develop strategies that enable nurses to deliver care that inspires hope and improves connectedness in those who have EDs.

A Pragmatic Clinical Trial to Compare the Real-World Effectiveness of V-Go versus Standard Delivery of Insulin in Patients with Advanced Type 2 Diabetes

BACKGROUND

Many patients with type 2 diabetes mellitus (T2DM) do not have adequate glycemic control, leading to poor patient outcomes and high healthcare costs.

OBJECTIVE

This prospective pragmatic clinical trial evaluated V-Go, a wearable insulin delivery device, compared with standard treatment optimization (STO) among insulin-treated patients with T2DM in a real-world, community-based practice setting.

METHODS

Study sites, rather than individual patients, were randomized to V-Go or STO via cluster randomization. Patients were treated according to routine clinical practice and followed up to 4 months. T2DM medications and supplies were purchased utilizing usual insurance and co-pay systems. The primary analysis was an unadjusted treatment group comparison of glycosylated hemoglobinA1c (HbA1c) change from baseline to end of study (EOS). A cost of therapy analysis was completed on patients who had received comparable baseline T2DM treatment with multiple daily basal-bolus insulin injections (MDI).

RESULTS

Analysis included 415 patients (169 V-Go, 246 STO) enrolled from 52 US sites. Mean baseline HbA1c (9.6%) was higher in V-Go (9.9%, range 8.0% - 14.2%) than STO (9.3%, range 7.9% - 13.9%, p <.001). HbA1c decreased from baseline to EOS in both V-Go (-1.0%, p<.001) and STO (-0.5%, p<.001); V-Go had significantly larger decrease (p=.002). V-Go had a significant reduction (p<.001) in mean insulin total daily dose (TDD; 0.76 U/kg baseline, 0.57 U/kg EOS), not seen in STO (0.72 U/kg baseline and EOS). The MDI group included 95 (56.2%) V-Go and 113 STO (45.9%) patients. Mean baseline HbA1c was significantly higher in V-Go (9.9%) than STO (9.4%). V-Go also experienced larger decrease in HbA1c from baseline (-1.0%) than STO (-0.36%) (p=.006) with a decrease in TDD, while STO TDD remained unchanged. EOS mean per patient per day cost of diabetes treatment was lower for V-Go ($30.59) vs STO ($32.20) (p=.006). V-Go was more cost effective than STO ($24.02 per 1% drop in HbA1c vs $58.86, respectively).

CONCLUSIONS

This pragmatic clinical trial demonstrated improved HbA1c levels, lower cost, and decreased insulin dose in patients with T2DM initiating V-Go vs STO in a real-world community-based practice setting. Observed baseline HbAlc indicated use of V-Go in more difficult to manage diabetes patients.

Interventions to Increase Physician Efficiency and Comfort with an Electronic Health Record System

Objective: To determine comfort when using the Electronic Health Record (EHR) and increase in documentation efficiency after an educational intervention for physicians to improve their transition to a new EHR.

Methods: This study was a single-center randomized, parallel, non-blinded controlled trial of real-time, focused educational interventions by physician peers in addition to usual training in the intervention arm compared with usual training in the control arm. Participants were 44 internal medicine physi cians and residents stratified to groups using a survey of comfort with electronic media during rollout of a system-wide EHR and order entry system. Outcomes were median time to complete a progress note, notes completed after shift, and comfort with EHR at 20 and 40 shifts.

Results: In the intervention group, 73 education sessions averaging 14.4 (SD: 7.7) minutes were completed with intervention group participants, who received an average of 3.47 (SD: 2.1) interventions. Intervention group participants decreased their time to complete a progress note more quickly than controls over 30 shifts (p < 0.001) and recorded significantly fewer progress notes after scheduled duty hours (77 versus 292, p < 0.001). Comfort with EHRs increased significantly in both groups from baseline but did not differ significantly by group. Intervention group participants felt that the intervention was more helpful than their standard training (3.47 versus 1.95 on 4-point scale).

Conclusion: Physicians teaching physicians during clinical work improved physician efficiency but not comfort with EHRs. More study is needed to determine best methods to assist those most challenged with new EHR rollouts.

Pre-admission functional status impacts the performance of the APACHE IV model of mortality prediction in critically ill patients

BACKGROUND

Functional status (FS) before intensive care unit (ICU) admission is associated with short-term and long-term outcomes among critically ill patients. However, measures of FS are generally not integrated into ICU-specific mortality prediction models.

METHODS

This retrospective cohort study used prospectively collected data from 9638 consecutive patients admitted to a single ICU between 1 October 2005 and 30 September 2015. For each ICU admission, FS was prospectively determined and classified into three discrete categories based on performance of basic daily living activities (FS1 - fully independent; FS2 - partly dependent; FS3 - completely dependent). We prospectively calculated Acute Physiology and Chronic Health Evaluation (APACHE) IV predicted mortality percentage (APIV PM) for each admission and calculated observed-expected mortality ratios (OEMR), stratified by FS category and APIV PM. We calculated area under the receiver operator characteristic curve (AUC) for APIV PM and mortality for the entire cohort and the three FS categories.

RESULTS

Patients had a median (IQR) age of 67 (52-80) years and mean (SD) APIV PM was 18.3% (24.3%). Of these, 7714 (80.0%) were classified as FS1, 1728 (17.9%) as FS2 and 196 (2.0%) as FS3. FS1 patients were younger, had less comorbid disease, and lower APIV PM compared to FS2 and FS3. The OEMR were significantly lower for FS1 (0.67) than FS2 (0.93) or FS3 (0.90) (p < 0.0001 for both comparisons). Among patients with APIV PM 0-10%, 10-25%, 25-50% and ≥50% the OEMR for FS1 were 0.33, 0.49, 0.61 and 0.86. The AUC (95% CI) for APIV PM and mortality for FS1, FS2 and FS3 were 0.924 (0.914-0.933), 0.837 (0.816-0.858) and 0.775 (0.705-0.8456), respectively (p < 0.001 for each comparison). Multivariable analysis demonstrated that FS2 (OR 2.18 (1.84-2.57) (p < 0.0001)) and FS3 (OR 1.99 (1.34-2.96) (p = 0.0006)) were independently associated with increased risk of mortality.

CONCLUSIONS

Baseline FS prior to critical illness is a strong independent predictor of mortality and impacts the relationship between observed and APIV PM in those with lower illness severity. Future iterations of mortality prediction models should integrate a baseline measure of FS to improve performance.

Internal Medicine Program Directors' Perceptions of the "All In" Match Rule: A Cross-Sectional Survey

BACKGROUND

Since 2013, the National Resident Matching Program (NRMP) has asked all programs to declare themselves to be "all in" or "all out" for the NRMP. Before this rule was enacted, program directors who were surveyed expressed concerns about what they anticipated with the change, including resources for increased applications and potential delays with residency start times.

OBJECTIVE

This study investigated the positive and negative effects of the rule change on recruiting seen from the perspective of internal medicine (IM) program directors.

METHODS

In this mixed model cross-sectional survey, Accreditation Council for Graduate Medical Education-accredited IM program directors were surveyed regarding their impressions of the impact of the policy change. Data were aggregated using constant comparative analysis.

RESULTS

A total of 127 of 396 (32%) IM program directors responded, and 122 of 127 (96%) identified their program as "all in." A total of 110 respondents expressed impressions of the rule change, with 48% (53 of 111) reporting positive responses, 28% (31 of 111) neutral responses, and 24% (27 of 111) negative responses. Programs with higher percentages of visa-holding residents had lower positive responses (37% [22 of 60] versus 61% [31 of 51]). Resident quality was felt to be unchanged or improved by most program directors (93%, 103 of 111), yet 24% (27 of 112) reported increases in delayed start times for visa-holding residents. Qualitative analysis identified increased fairness, at the expense of an increase in program resources as a result of the change.

CONCLUSIONS

A slight majority of residency programs reported a neutral or negative impression of the rule change. Since the rule change, program directors noted increased application volume and delayed residency starts for visa-holding residents.

Magnetic Resonance Angiography and Duplex Scanning Concordance in Detecting Severe Carotid Stenosis

In this meta-analysis, the authors examine published studies on the consistency (homogeneity) of study outcomes of magnetic resonance angiography (MRA), conventional angiography (XRA), and duplex ultrasound (DU) scanning in assessment of the degree of carotid artery disease.

The sensitivity, specificity, and accuracy of the MRA as a noninvasive diagnostic test are exceptional. Given an adequate two-dimensional time-of-flight (2D-TOF) study, it provides a robust test for the evaluation of carotid stenosis. The authors conclude from this meta-analysis that MRA is at least as accurate as DU in a selected group of patients. The question of superiority for all patients with suspected carotid artery disease is not, however, answered by this meta-analysis. Another question not answered is the question of DU/MRA-XRA concordance/discordance. If DU and MRA were concordant across all, rather than a selected group of patients, would the clinical decision tree be in favor of elimination of XRA? The cost for a DU scan is approximately one third of the cost of an MRA and, from an economic point of view, one could not argue the use of MRA over DU. However, as MRA technology and accuracy improve and when the cost of MRA approaches that of DU, MRA may replace DU as a screening method.

Clearly, a consecutive series of all patients suspected of having carotid artery disease needs to be evaluated by use of the best available diagnostic technologies. A comprehensive protocol would include an evaluation of the sources of difficulties in conducting these tests.

RS3PE revisited: a systematic review and meta-analysis of 331 cases

OBJECTIVES

Remitting seronegative symmetrical synovitis with pitting oedema (RS(3)PE) syndrome is a rare inflammatory arthritis, characterised by symmetrical distal synovitis, pitting oedema of the hands and feet, absence of rheumatoid factor, and favourable response to glucocorticoids. The aim of our study is to further delineate the clinical and laboratory features, and response to treatment.

METHODS

We performed a systematic electronic search of Medline, PubMed, EMBASE, ACR and EULAR databases for case reports, case series, and related articles of RS(3)PE. Statistical analysis was done comparing categorical variables with Chi-square tests and frequencies of means via t-tests. Binary logistic regression analysis was performed to identify predictors of erosions, recurrence, malignancy and rheumatologic disorders.

RESULTS

331 cases of RS(3)PE were identified from 121 articles. RS(3)PE was found in older patients (71±10.42 years) predominantly in males (n= 211, 63.36%), was symmetrical (n=297/311, 95.50%) involved the hands (n=294/311, 94.53%) A concurrent rheumatologic condition was reported in 22 cases (6.65%), and malignancy in 54 cases (16.31%). Radiographic joint erosions were found in 5.5%. Most patients responded to medium-dose glucocorticoids (16.12±9.5 mg/day). Patients with concurrent malignancy requiring non-significantly higher doses of prednisone (18.12 vs. 15.76 mg, p 0.304) and higher likelihood of recurrence of disease (OR 4.04, 95% CI 1.10-14.88, p=0.03).

CONCLUSIONS

The symptoms and unique findings that make up RS(3)PE appear to represent a steroid-responsive disease that may be a harbinger of an underlying malignancy. More study is needed to understand the molecular origins of RS(3)PE in order to determine whether it is a separate disease process. Patients with concurrent cancer tend to have more severe presentations and higher rates of recurrence.

Initial Validation of the Daily Spiritual Experiences Scale in Chinese Immigrants With Cancer Pain

CONTEXT

Evaluating religious/spiritual influences in the growing Chinese-American population may inform the development of culturally relevant palliative care interventions.

OBJECTIVES

We assessed the psychometric properties and acceptability of the Daily Spiritual Experiences Scale-Chinese (DSES-C) in Chinese Americans with cancer-related pain.

METHODS

The translated 16-item DSES-C was administered as part of a symptom intervention for Chinese-American cancer patients. Patients were recruited from four New York community oncology practices.

RESULTS

Of 321 patients, 78.7% were born in Mainland China, 79.1% spoke Cantonese, and 70.2% endorsed a religious affiliation (Ancestor worship, 31.7%; Chinese God worship, 29.8%; Buddhism, 17.1%; Christianity, 14.0%). In total, 82.6% completed the DSES-C (mean age = 57.7 years; 60.8% women) and 17.4% declined (mean age = 59.3 years; 52.0% women). Reasons for declining included low religiosity or perceived relevance of the scale items and difficulties separating spirituality from religiosity terms. Individuals having a religious affiliation were more likely to complete the DSES-C, whereas those not engaging in individual spiritual/religious practices or frequent group spiritual/religious practices tended to decline (all P < 0.05). The DSES-C (mean total score = 43.6, SD = 19.3) demonstrated high reliability (alpha = 0.94). Exploratory factor analysis suggested a one-factor solution, with significant loadings (>0.40) across items except Item 14 ("Accept others"). Construct validity was suggested by a positive association between DSES-C scores and having a religious affiliation (P < 0.05).

CONCLUSION

In Chinese Americans with cancer pain, the DSES-C demonstrated acceptable psychometrics. Some participants experienced linguistic or cultural barriers preventing completion. Future investigations should provide additional validation in different Asian subgroups and those with varied medical conditions.

Correlation between MMI performance and OSCE performance - a pilot study

OBJECTIVE

The multiple mini-interview (MMI) has been shown to have a positive correlation with early medical school performance, clerkship evaluations, and national licensing examinations. There is limited data on its predictive validity at the postgraduate level.

METHODS

Six hundred and nineteen internship candidates were interviewed using the MMI format by the internal medicine residency program of The Reading Health System, between September 2011 and February 2014. Fifty-two interns were recruited. Each intern participated in an objective structured clinical examination (OSCE) 3-4 months after the start of the program. The OSCE score of each intern was used as the independent variable to test the relationship with both the MMI interpersonal score and the MMI overall score.

RESULTS

There was a moderate positive correlation between the average MMI interpersonal score and the communication score on the OSCE, r=0.384, n=52, p=0.005, and a negligible relationship between the average MMI overall score and the communication score on the OSCE, r=0.175, n=52, p=0.214.

CONCLUSION

The MMI is a useful tool for residency programs to assess interpersonal and communication skills prior to matriculation into residency training. This study provides evidence for its validity in assessing these competencies.

Using 'big data' to validate claims made in the pharmaceutical approval process

Big Data in the healthcare setting refers to the storage, assimilation, and analysis of large quantities of information regarding patient care. These data can be collected and stored in a wide variety of ways including electronic medical records collected at the patient bedside, or through medical records that are coded and passed to insurance companies for reimbursement. When these data are processed it is possible to validate claims as a part of the regulatory review process regarding the anticipated performance of medications and devices. In order to analyze properly claims by manufacturers and others, there is a need to express claims in terms that are testable in a timeframe that is useful and meaningful to formulary committees. Claims for the comparative benefits and costs, including budget impact, of products and devices need to be expressed in measurable terms, ideally in the context of submission or validation protocols. Claims should be either consistent with accessible Big Data or able to support observational studies where Big Data identifies target populations. Protocols should identify, in disaggregated terms, key variables that would lead to direct or proxy validation. Once these variables are identified, Big Data can be used to query massive quantities of data in the validation process. Research can be passive or active in nature. Passive, where the data are collected retrospectively; active where the researcher is prospectively looking for indicators of co-morbid conditions, side-effects or adverse events, testing these indicators to determine if claims are within desired ranges set forth by the manufacturer. Additionally, Big Data can be used to assess the effectiveness of therapy through health insurance records. This, for example, could indicate that disease or co-morbid conditions cease to be treated. Understanding the basic strengths and weaknesses of Big Data in the claim validation process provides a glimpse of the value that this research can provide to industry. Big Data can support a research agenda that focuses on the process of claims validation to support formulary submissions as well as inputs to ongoing disease area and therapeutic class reviews.

Prevalence of suicidal ideation in patients with chronic non-cancer pain referred to a behaviorally based pain program

BACKGROUND

Patients with chronic pain often experience co-occurring depression and in some cases suicidal ideation. It is critical to discover risk factors for suicide in this vulnerable patient population.

OBJECTIVE

To assess the prevalence of suicidal ideation and identify potential risk factors in patients with chronic non-cancer pain.

STUDY DESIGN

Retrospective chart review.

SETTING

Four hundred and sixty-six patients with chronic non-cancer pain referred to a behaviorally based pain program in a community health system.

METHODS

Data collected included pain intensity and level of pain interference (Brief Pain Inventory), pain duration, pain site, depression level (Beck Depression Inventory Fast Screen for Medical Patients), anxiety (Beck Anxiety Inventory), personal and family psychiatric and substance use disorder history, level of isolation, and demographic data. Univariate and logistic regression analyses were performed.

RESULTS

Results showed a high rate of suicidal ideation in this patient population (28%). Univariate analyses stratified by level of suicide (no suicidal ideation or passive/active suicidal ideation) revealed statistically significant group differences on pain location (extremity P = 0.046, generalized P = 0.047), work disruption (P = 0.049), social withdrawal (P < 0.001), pre-pain history of depression (P < 0.001), family history of depression (P < 0.001), and history of sexual/physical abuse (P < 0.001). Logistic regression revealed that history of sexual/physical abuse (Beta = 0.825; P = 0.020; OR = 2.657 [95% CI = 1.447 - 4.877]), family history of depression (Beta = 0.471; P = 0.006; OR = 1.985 [95% CI = 1.234 - 3.070]), and being socially withdrawn (Beta = 0.482; P < 0.001; OR = 2.226 [95% CI = 1.431 - 3.505]) were predictive of suicidal ideation.

LIMITATIONS

Measure of depression was not included in data analysis to reduce effect of co-linearity. Also the study population was a specialty pain clinic allowing for possible subject selection bias.

CONCLUSIONS

Results of this study are consistent with the prevailing literature on pain and suicide demonstrating a high prevalence of suicidal ideation in the chronic pain population. Novel predictive variables were also identified that will provide the basis for developing a risk stratification model that can be further tested prospectively in chronic pain patients.

An initiative to improve adherence to evidence-based guidelines in the treatment of URIs, sinusitis, and pharyngitis

Background

Upper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues.

Methods

The primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines.

Results

After the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7–57.58% (p=0.086) and 24.0–25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed.

Conclusions

Passive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.

Self-directed study using MP3 players to improve auscultation proficiency of physicians: a randomized, controlled trial

INTRODUCTION

Studies of physicians at all levels of training demonstrate significant deficiencies in cardiac auscultation skills. The best instructional methods to augment these skills are not known.

METHODS

This study was a randomized, controlled trial of 83 noncardiologist volunteers exposed to a 12-week lower cognitive load self-study group using MP3 players containing heart sound audio files compared to a group receiving a 1-time 1-hour higher cognitive load multimedia lecture using the same audio files. The primary outcome measure was change in 15-question posttest score at 4 and 12 weeks as compared to pretest on recognition of identical audio files introduced during training. In the self-study group, the association of total exposure and deliberate practice effort (estimated by standard deviation of files played/mean) to improvement in test score was measured as a secondary end point.

RESULTS

Self-study group participants improved as compared to pretest by 4.42 ± 3.41 answers correct at 12 weeks (5.09-9.51 correct, p < .001), while those exposed to the multimedia lecture improved by an average of 1.13 ± 3.2 answers correct (4.48-5.61 correct, p = .03). In the self-study arm, improvement in the posttest was positively associated with both total exposure (β = 0.55, p < .001) and deliberate practice score (β = 0.31, p = .02).

DISCUSSION

A lower cognitive load self-study of audio files improved recognition of cardiac sounds, as compared to multimedia lecture, and deliberate practice strategies improved study efficiency. More investigation is needed to assess transfer of learning to a wider range of cardiac sounds in both simulated and clinical environments.

Reliability and acceptability of a five-station multiple mini-interview model for residency program recruitment

Background

Standard interviews are used by most residency programs in the United States for assessment of aptitude of the non-cognitive competencies, but variability of interviewer skill, interviewer bias, interviewer leniency or stringency, and context specificity limit reliability.

Aim

To investigate reliability and acceptability of five-station multiple mini-interview (MMI) model for resident selection into an internal medicine residency program in the United States.

Setting

One independent academic medical center.

Participants

Two hundred and thirty-seven applicants and 17 faculty interviewers.

Program description

Five, 10-min MMI stations with five different interviewers blinded to the candidate's records and one traditional 20-min interview with the program director. Candidates were rated on two items: interpersonal and communication skills, and overall performance.

Program evaluation

Generalizability data showed that the reliability of our process was high (>0.9). The results of anonymous surveys demonstrated that both applicants and interviewers consider the MMI as a fair and more effective tool to evaluate non-cognitive traits, and prefer the MMI to standard interviews.

Discussion

The MMI process for residency interviews can generate reliable interview results using only five stations, and it is acceptable and preferred over standard interview modalities by the applicants and faculty members of one US residency program.

Lack of efficacy of ergocalciferol repletion

INTRODUCTION

Vitamin D has become an area of intensive scrutiny, both in medical and lay literature. However, there are limited data to suggest proper repletion regimens for those patients who have hypovitaminosis D. Consequently, various methods are used in clinical practice. The aim of this study was to assess the efficacy of various treatment strategies for hypovitaminosis D in an ambulatory internal medicine practice.

METHODS

A retrospective chart review between October 2005 and June 2010 of a suburban internal medicine practice was performed via query of the electronic medical record (Centricity, General Electric Healthcare, UK). Patients with a 25-hydroxyvitamin D concentration less than 32 mg/dl were identified and treated. Treatment success was defined as 25-hydroxyvitamin D concentrations greater than 32 mg/dl. Statistical analysis to assess changes in vitamin D level controlling for season, comorbidities, and demographics were used.

RESULTS

A total of 607 treatment episodes were identified, with 395 excluded due to lack of follow-up vitamin D level within 16 weeks, no treatment documented, topical treatment, doxercalciferol treatment, or non-compliance. Of the remaining patients, there were 212 treatment instances on 178 patients. Ergocalciferol 50,000 international units (IU) was used most frequently (71.4% of the time.). A higher initial vitamin D level was positively associated with treatment success (adjusted odds ratio = 1.11, p=0.002). Increased doses of ergocalciferol increased the likelihood of treatment success (p=0.0011). Seasonal variation was related to posttreatment 25-hydroxyvitamin D concentration as was body mass index (BMI) (p=0.003 and p=0.044).

CONCLUSION

Pretreatment levels of 25-hydroxyvitamin D, BMI, season, and vitamin D dose are predictors of successful hypovitaminosis D treatment. Our data suggest that patients with initial 25-hydroxyvitamin D concentrations of <20 should be treated with a higher total dose of ergocalciferol than 50,000 IU for 8 weeks. Further studies, including prospective, randomized trials, are needed to determine an optimal treatment protocol to account for the numerous variables.

Integrating palliative medicine and critical care in a community hospital

Our objective was to describe the rationale and implementation of educational, environmental, clinical, and communication interventions designed to maximize indicators of improved palliative care in a community hospital intensive care unit. Surveys were used to develop educational content and methods for all levels of clinical staff and medical education. All clinical staff expressed confidence in clinical palliative processes but not in communication and psycho-spiritual issues shared with patient/families. An ambassador program and expanded visiting hours turned the waiting room into part of the therapeutic environment. New palliative order sets and practice guidelines were introduced. Interdisciplinary care planning was guided by a family communication record. Communication with families was enhanced by the use of the ambassadors, comprehensive care planning and sharing with the family within 24-48 hrs of admission, and ongoing meetings triggered by care plan changes. Quality indicators for intensive care unit-based palliative care proposed by experts provided a benchmark for evaluating the completeness of our intervention. Although not easily measured or demonstrated, it is our implicit assertion that this set of process and education interventions changed the daily nature of discourse in the intensive care unit among staff and between the staff, patients, and families.

Impact of cirrhosis on outcomes in trauma

BACKGROUND

Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality.

STUDY DESIGN

The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test.

RESULTS

Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS.

CONCLUSIONS

The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.

The use of standing lateral tibial-calcaneal angle as a quantitative measurement of Achilles tendon contracture in adult acquired flatfoot

BACKGROUND

To quantitate the association of Achilles tendon contracture (ATC) with adult acquired flatfoot, the authors hypothesized that the standing lateral tibial-calcaneal angle increases because of ATC.

METHODS

The standing lateral tibial-calcaneal angle, talo-first metatarsal angle, lateral talocalcaneal angle, lateral standing medial cuneiform, arch height, and anteroposterior talonavicular coverage angle were measured in 21 patients (25 feet) with clinical diagnoses of ATC and adult acquired flatfoot (AAF) and compared to the same measurements in a control group of 15 patients (30 feet) with no foot deformities or previous foot surgeries.

RESULTS

The mean lateral tibial-calcaneal angle in the control group was 64.43 degrees and in the AAF group 71.24 degrees (p < 0.001). The mean lateral talo-first metatarsal angle in the control group was 11.77 degrees, and in the AAF group with ATC it was 25.80 degrees (p < 0.001). The mean arch height in the control group was 17.90 mm and in the AAF group, 8.48 mm (p < 0.001). In the ATC and AAF group an increasing standing lateral tibial-calcaneal angle was correlated with a decreasing lateral talo-calcaneal angle (p = 0.044), and a decreasing arch height was correlated to an increasing lateral talo-first metatarsal angle (p < 0.001).

CONCLUSION

Adults with flatfeet and Achilles tendon contracture may have a statistically significant increase in the standing lateral tibial-calcaneal angle. This angle may be a reproducible measure of ATC. An increase in the standing lateral tibial-calcaneal angle may confirm and quantitate the clinical diagnosis of Achilles tendon contracture. Further studies with more patients are needed.

Radiographic comparison of standing medial cuneiform arch height in adults with and without acquired flatfoot deformity

BACKGROUND

Adult acquired flatfoot (AAF) is characterized by decreased arch height, talar depression, medial arch depression and elongation, and forefoot abduction. We have measured standing arch height in AAF patients and in a control group of patients using the standing lateral medial cuneiform arch height radiographic measurement.

METHODS

Fifteen (25 feet) patients were selected with the clinical diagnosis of symptomatic AAF with no secondary diagnoses. A control group consisted of 36 (72 feet) patients with no foot deformities or prior foot surgeries. Arch height was measured in millimeters using the standing medial cuneiform height on the lateral radiographic view.

RESULTS

The mean standing medial cuneiform arch height in the control group was 18.38 mm. The mean arch height in the AAF group was 11.04 mm (p < 0.001). There were no differences between right and left feet in the control group or symptomatic and contralateral feet in the AAF group. Body mass index (BMI) in the control group was 26.17 and in the AAF 33.74. (p = 0.007).

CONCLUSION

These data provide a control value for the arch height using the medial cuneiform as reference. The decrease in arch height is a strong indicator of AAF. A study with larger numbers of patients is necessary.

How do medical student self-assessments compare with their final clerkship grades?

The purpose of this study was to determine how a medical student's self-assessment at the completion of the third-year Ob/gyn clerkship compares with the institution's final grades at Lehigh Valley Hospital. From November 2002 to November 2003 at completion of each six-week Ob/gyn clerkship rotation, 47 medical students assessed themselves on the following parameters: fund of knowledge, personal attitude, clinical problem-solving skills, written/verbal skills, and technical skills. Additionally, they were asked to predict their performance on the NBME Shelf Exam. Their assessments were then compared with their final clerkship grades in each of the above parameters. Chi-squared and Kendall-tau tests were used to analyse the data for degree of agreement and association, respectively. There was a statistically significant weak to moderate, positive correlation between students' self-assessment and final clerkship grade for written/verbal skills (p = 0.002, r = 0.390). A statistically significant agreement between raters was also revealed for written/verbal skills (p = 0.003). Weak, non-statistically significant, positive relationships were revealed for fund of knowledge, clinical problem-solving and technical skills. A weak, negative, non-significant relationship was revealed for personal attitudes, and there was no statistically significant relationship between students' prediction of NBME score and categorized true score (p = 0.717, r = 0.49). At the end of their Ob/gyn clerkship, third-year medical students are better at assessing their technical and written/verbal skills than their global fund of knowledge and personal attitudes. These results may suggest that students are not aware of their own personal attitudes and communication skills and how they can affect their effectiveness as a physician.

The effect of body mass index on patient outcomes in a medical ICU

STUDY OBJECTIVES

To examine the effect of patient body mass index (BMI) on outcome in intensive care.

DESIGN

In a prospective study, the patients were classified into groups based on the calculated BMI, as follows: BMI < 19.0 (n = 350), > or = 19.0 and < 25.0 (n = 663), > or = 25.0 and < 29.9 (n = 585), > or = 30.0 and < 40.0 (n = 396), and > or = 40.0 (n = 154). Groups were compared by age, APACHE (acute physiology and chronic health evaluation) II score, mortality, ICU length of stay (LOS), hospital LOS, number receiving ventilation, and ventilator-days. Adverse events including nosocomial pneumonia, ventilator-days per patient, failed extubations, and line-related complications were recorded.

SETTING

The study was conducted in a 9-bed medical ICU of a 650-bed tertiary care hospital.

MEASUREMENTS

Height and weight were prospectively recorded for the first ICU admission during a hospital stay.

RESULTS

Between January 1, 1997, and August 1, 2001, 2,148 of 2,806 patients admitted to the ICU had height and weight recorded. There were no differences in APACHE II score, mortality, ICU LOS, hospital LOS, number receiving ventilation, ventilator-days, average total cost, or average variable cost among the five groups. However, the severely obese patients were more frequently female and younger than those who were overweight and obese (p < 0.001). Adverse events were infrequent, but there were no differences between the obese/very obese compared with others.

CONCLUSION

BMI has minimal effects on ICU outcome after patients are admitted to a critical care unit.

Evaluation and Recommendations from a Study of a Critical-Care Waiting Room

The intensive care unit (ICU) waiting room is a dynamic place that influences the satisfaction of families of critically ill patients. Waiting-room comfort and amenities are important, because families often spend a great deal of nonvisiting time there. A quality improvement evaluation of the ICU waiting room at Lehigh Valley Hospital, Allentown, PA, was conducted. Methods included distribution of an 18-item family survey, ethnographic observations, interviews, and assessment of the physical environment. Findings suggest that the role of the receptionist and access to food and other services were important to families and influenced their assessment of the quality of services provided by the ICU.

The Vibration Quantitation Scale (VQS): A Simple, Reproducible Bedside Measure of Sensory Function in Multiple Sclerosis

Objectives:

To assess the utility of a bedside measure of sensation (the Vibration Quantitation Scale (VQS)) in patients with multiple sclerosis (MS) and in normal controls. To correlate the VQS with the Kurtzke Expanded Disability Severity Score (EDSS) and sensory abnormalities in these patients.

Methods:

We developed the VQS and tested its performance in patients with MS of various ages, MS types, and EDSS scores. We compared this with controls (normal volunteers or patients with other neurological diseases) who did not have sensory symptoms. In a subgroup, two examiners measured VQS independently at the same patient visit. Astandard C-128 tuning fork was used for the VQS measurement.

Results:

The VQS had a good inter-observer reproducibility (r=0.920, p<0.001). The VQS fell with increasing age in normals consistent with declining sensory function. The VQS was significantly lower in the multiple sclerosis patients compared with age - matched controls (p<0.001). Abnormalities in VQS were present in patients with brief duration of MS (<5 years) and low EDSS scores, correlating with the presence of sensory abnormalities early in the disease course in some patients. There was a strong correlation between the VQS and EDSS (r=-0.509). The VQS correlated with abnormal sensation in the hands (r=0.310), but did not meet statistical significance for abnormal sensation in the feet or face. Asecond cohort of MS patients was studied using a modified VQS measure (single stimulation, omitting forehead measurement). This reconfirmed the correlation between the modified VQS and EDSS as well as with age. The modified VQS may be useful in clinical practice since it takes little time and is strongly correlated with the EDSS (r=0.578).

Conclusion:

The VQS provides a continuous sensory scale applicable in most patients with MS, which is measurable with standard bedside equipment, and which may avoid some of the pitfalls of sensory scoring in MS.

Initial head computed tomographic scan characteristics have a linear relationship with initial intracranial pressure after trauma

BACKGROUND

Despite current recommendations by the Brain Trauma Foundation regarding the placement of intracranial pressure (ICP) monitoring devices, advances in computed tomographic (CT) scan technology have led to the suggestion that increased ICP may be predicted by findings on admission head CT scan and that patients without such findings do not require such monitoring. A linear relationship exists between characteristics of admission head CT scan and initial ICP level, allowing for selective placement of ICP monitoring devices.

METHODS

From 1997 to 2001, a retrospective review of patients admitted with a Glasgow Coma Scale (GCS) score < 8 and head CT scan who underwent ventriculostomy placement at our institution, was conducted. Patients undergoing craniotomy with evacuation of mass lesions before ventriculostomy placement were excluded. Age, sex, mechanism of injury, anoxia, osmotic treatment, presence of drugs/alcohol, initial mean arterial pressure, initial GCS score, and initial ICP were recorded. Initial head CT scans were reviewed independently by two neuroradiologists who were blinded to ICP measurements, neurosurgical treatment, patient outcome, and each other's interpretation. Initial CT scans were evaluated and scored on a 1 (normal) to 3 (abnormal) scale with respect to ventricle size, basilar cistern size, sulci size, degree of transfalcine herniation, and gray/white matter differentiation. Initial ICP readings and CT scan findings were compared to determine whether a significant linear relationship existed between the above CT scan findings and ICPs. Logistic and univariate linear regression were used to compare averaged radiologist score versus dichotomized ICP at baseline.

RESULTS

Initial head CT scan characteristics show a linear relationship to baseline ICPs. These findings are associative, but are not uniformly predictive.

CONCLUSION

Therefore, the current Brain Trauma Foundation recommendation of ICP monitoring in those patients presenting with a GCS score < 8 with an abnormal CT scan or a normal CT scan with age > 40 years, systolic blood pressure < 90 mm Hg, or exhibiting posturing should be followed.

Establishing reliability and validity of the critical care family satisfaction survey

OBJECTIVE

To develop and validate the Critical Care Family Satisfaction Survey as a proxy for patient satisfaction.

DESIGN

Instrument validation study. SETTING AND TIME FRAME: The Medical Intensive Care, Shock Trauma, Acute Coronary Care, Central Nervous System, Surgical Intensive Care, and Special Care units of Lehigh Valley Hospital (Allentown, PA), for the period December 1997 through September 1998.

PATIENTS/PARTICIPANTS

One family member for each of 237 critical care patients.

INTERVENTION(S)

Content and construct validity were examined on 37 items and 6 constructs thought to measure family satisfaction with the quality of critical care in hospitals. Initially, 14 items and 1 construct were removed from the questionnaire based on this analysis. It was then administered to 237 family members.

MEASUREMENTS AND MAIN RESULTS

Factor analysis and confirmatory factor analysis using path models were performed. Internal consistency using Pearson correlations and Cronbach's alpha, and discriminant validation were also calculated. Factor analysis yielded a single eigenvalue >1 (3.712), whereas confirmatory factor analysis led to the final instrument being reduced to 20 items and 5 subscale constructs. One subscale ("Comfort") performed poorly, indicating the possible need for a four-factor model. Subsequently, internal consistency assessed by Cronbach's alpha was 0.9101 for the five-factor model and 0.9327 for the four-factor model. Subscale correlations were no lower than 0.750 for the five-factor model and 0.856 for the four-factor model.

CONCLUSIONS

This study provides support that the Critical Care Family Satisfaction Survey-which yields five subscales, "Assurance," "Information," "Proximity," "Support," and "Comfort"--is reliable and valid. Using five constructs rather than four is recommended because of the following: a) the internal consistency loss of 0.0226 for the "Comfort" subscale is not enough to warrant its removal, b) a four-factor questionnaire can be administered and totaled independently of this subscale, c) the need for the fifth construct is indicated by this study's results, and d) including the extra data may allow for more detailed analysis.

Impact of preinjury warfarin use in elderly trauma patients

BACKGROUND

This study examined the hypothesis that elderly trauma patients on warfarin before injury will have increased morbidity and mortality compared with elderly trauma patients not on warfarin.

METHODS

From 1993 to 1995, trauma patients were grouped by age and presence or absence of warfarin use before injury. Groups were analyzed with respect to Injury Severity Score, Trauma Registry and Injury Severity Score, Glasgow Coma Scale score, Intensive Care Unit days, hospital days, units of blood transfused, and mortality rates. Statistical analysis was completed by using the Student's t test.

RESULTS

Records of 61 patients administered warfarin and 800 patients not administered warfarin were available for analysis. There were no statistically significant differences between patients on prehospital warfarin and those not on prehospital warfarin.

CONCLUSION

This study indicates that elderly trauma patients on warfarin before injury do not have increased morbidity and mortality compared with elderly trauma patients not on warfarin.

The influence of airbag and restraining devices on the patterns of facial trauma in motor vehicle collisions

According to the National Highway Traffic Safety Administration (1990), there were more than 3 million motor vehicle collisions severe enough to lead to significant injury or fatality. Airbags may prevent brain and facial injury caused by these accidents. To date, however, no study has focused primarily on the correlation between facial injuries and the use of airbags and restraining devices. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission to the database included admission to the intensive care unit, death during hospitalization, hospitalization for >72 hours, or transfer to or from the receiving hospital. There were 15,450 patients who sustained facial trauma (identified by ICD-9 codes) and were analyzed for patterns of injury and the presence or absence of protective devices. Protective devices were categorized into four groups: airbag alone, airbag with seatbelt, seatbelt or car seat without airbag, and no restraining devices. Statistical analysis was performed using chi-squared test of association. For contingency tables with small expected frequencies, Fisher's exact test was used. There were 9408 male and 6042 female subjects, with a mean age of 38 years (range, 3 to 98 years). There were 11,672 drivers and 3778 passengers. Airbags were deployed in 429 instances. In 276 of these cases, additional restraint was provided with a seatbelt. Airbags were not deployed in 4866 cases when a seatbelt or a car seat was used. In 10,155 cases, no restraining device was employed. There was significantly more facial trauma in patients without protective devices (p < 0.001). Drivers sustained significantly fewer facial fractures when airbags were used, either alone or in combination with a seatbelt (p < 0.001); however, there was no difference in the number of facial lacerations. Among passengers, airbags provided protection from lacerations (p < 0.001) but had no impact on the incidence of facial fractures. In collisions in which airbags were deployed, the use of a seatbelt provided no additional protection from facial fractures or lacerations. In summary, the use of any protective device decreased the incidence of facial fractures and lacerations sustained in motor vehicle collisions (p < 0.001). Airbags provided the best protection of all currently available devices.

Ultrasonography in the diagnosis of acute appendicitis

The purpose of this study was to assess our results of using graded compression ultrasonography (US) to confirm the diagnosis of acute appendicitis. Graded compression US was performed on 94 patients who presented at the Lehigh Valley Hospital, Allentown, Pennsylvania with an equivocal clinical picture of acute appendicitis. When used to diagnose acute appendicitis, US provided a specificity of 93.7%, sensitivity of 74.2%, and accuracy of 87.2%. We conclude that graded compression US was useful to rule out the diagnosis of acute appendicitis and helped to avoid unnecessary appendectomies and reduced negative laparotomies. Our results proved to be comparable to previously reported studies.

The S factor--a new derived hemodynamic oxygenation parameter--a useful tool for simplified mathematical modeling of global problems of oxygen transport

We describe a new derived hemodynamic oxygenation parameter, the S factor (S). The factor is based on oxygen delivery and oxygen consumption and can range from -3 to 1. It allows simplified mathematical modeling of clinical problems of oxygen transport and can be applied to many clinical situations. A new hemodynamic oxygenation parameter, the S factor (S), is introduced as an aid to mathematical modeling. It is defined as follows: [formula: see text] (DO2 = oxygen delivery, VO2 = oxygen consumption) S can theoretically vary from -3 (DO2 = VO2) to +1 (VO2 = 0). When DO2/VO2 = 4 (ie. OER = 0.25), S = 0. An S < 0 implies utilization of reserve oxygen transport capacity. An S > 0 implies increased oxygen delivery in relation to oxygen consumption (ie. "shunted oxygen delivery"). By algebraic manipulation and substitution of the components of DO2 into Equation 1: DO2 = Q x Ca x 10 DO2 = Q [(Hb)(Sat)(1.36) + PaO2(.0031)] 10 (2) the following equations can be derived: [formula: see text] [formula: see text] Ca - Cv (Ca = arterial content, Cv = venous content) can be determined by substituting components of oxygen consumption: VO2 = Q (Ca - Cv) x 10 (5) into equation 1 and solving for Ca - Cv. [formula: see text] Equation 6 can be simplified to: [formula: see text] A previously defined relationship between mixed venous PO2 (PvO2) and DO2/VO2 (where calculated P50 is 26.6 +/- 1.0) can be used to modify S in a clinically relevant manner. PvO2 = 5.44D O2/VO2 + 18.16 (8) The relationship between S and PvO2 can be defined by substituting Equation 4 into Equation 1 and solving for PvO2 PvO2 = [21.76/(1-S)] + 18.16 (9) As an example, at a PvO2 of 28 torr (anaerobic threshold), S = -1.2. The relationship between PvO2 and S is shown in Figure 1. S, which can also be defined as 1-4(VO2/DO2) or 1-4(OER), is a useful tool for mathematical modeling of global problems of oxygen transport because the previously derived equations with the S value allow the components of oxygen transport to be interrelated in a clinically relevant manner. Additional advantages of using S in mathematical modeling are: 1. Conceptually it 'fits' in that in regards to the sign (+ or -), as a -S implies utilization of reserve oxygen transport capacity and a +S implies wasted or excess oxygen delivery (shunted). 2. These concepts are easily quantified using the S factor. 3. It 'spreads out' the difference between values for parameters (OER or S) integrating components of oxygen transport, ie. in the 'normal state' regarding oxygen transport, OER = 0.25 and S = 0. At the anaerobic threshold (PvO2 = 28 torr), OER = 0.55 and S = -1.2. Thus, the change in OER from 'normal state' to anaerobic threshold is 0.3 (0.55-0.25) and the change in S is 1.2. This represents a four-fold increase. Four examples of mathematical modeling of global problems of oxygen transport using the S factor are described below.

Defining "dead on arrival": impact on a level I trauma center

OBJECTIVE

To determine the potential impact of defining criteria for "dead on arrival" (DOA) on a Level I trauma center.

METHODS

From 1990 to 1994, trauma patients having cardiopulmonary resuscitation (CPR) performed by certified prehospital personnel were reviewed for time of CPR, outcome, and costs to determine whether any benefit would have been realized had DOA criteria been followed.

RESULTS

A total of 106 patients had prehospital CPR; 20 did not meet DOA criteria and underwent resuscitation, three survived (15%). Eighty-six patients met DOA criteria; 16 were pronounced dead without further resuscitative efforts (in-hospital costs of $200/patient), while 70 (81%) had continued resuscitation with no survivors (in-hospital costs of $4150/patient). The positive predictive value for criteria was 100%. Had criteria been implemented, total cost savings over the 5-year period would have been $290,000.

CONCLUSIONS

National DOA criteria could dramatically reduce the burden on trauma centers with an estimated minimum annual savings of $14 million.

Alcohol level at head injury and subsequent psychotropic treatment during trauma critical care

Alcohol intoxication at the time of traumatic brain injury (TBI) presents many complications for critical care treatment. This is the first reported data on psychotropic dosages administered to TBI patients in the critical care setting. In this study, the blood alcohol level (BAL)-positive patients (n = 14) tended to be older (P = 0.095), have lower admission Glascow Coma Scores (P = 0.031), and spent more days on respirators (P = 0.125) than the BAL-zero patients (n = 21). The BAL-positive group received more days of narcotics and benzodiazepines with markedly higher average daily doses, not statistically significant. These results are a basis for studying relationships between medication, treatment variables, and outcomes for TBI patients and then developing specific medication guidelines.

The utility of a bilateral breast pumping system for mothers of premature infants

Mothers of premature infants have difficulty maintaining their milk supply as a result of the separation that occurs between the mother and the baby. The hypothesis in the present investigation is that use of a bilateral (simultaneous) breast pumping system will increase the volume of milk expressed in these mothers. Thirty-two breastfeeding mothers of premature infants were randomly assigned to either the control (single) or the experimental (bilateral) breast pump group. Mothers pumped at least four times a day. Data collection included a daily milk production log, weekly serum prolactin levels, and a weekly State-Trait Anxiety Inventory (STAI). Participation lasted from four to six weeks. Data analysis included average STAI scores; average prolactin levels; and weekly averages for number of pumping sessions, hours of pumping, and milk production in milliliters. The two groups did not differ on several demographic characteristics, STAI scores, prolactin levels, number of pumping sessions per week, or weekly milk production. The amount of time spent pumping, however, was statistically less for mothers who used the bilateral pump (7.6 +/- 3.0 hours/week) versus those who used the single pump (11.1 +/- 3.1 hours/week) (p = .003). Although use of either the single pump or the bilateral electric pump resulted in similar milk production, the bilateral pump significantly reduced the time invested in pumping. Health professionals should advocate use of the bilateral pump for mothers of premature infants. Additional studies are needed to determine strategies for increasing milk production in this population.