Traumatic brain injury in the elderly with high Glasgow coma scale and low injury severity scores: Factors influencing outcomes.

BACKGROUND: Current trauma activation guidelines do not clearly address age as a risk factor when leveling trauma patients. Glasgow coma scale (GCS) and mode of injury play a major role in leveling trauma patients. We studied the above relationship in our elderly patients presenting with traumatic head injury. METHODS: This study was a retrospective analysis of patients who presented to the emergency department with traumatic brain injuries. We classified the 270 patients into two groups. Group A was 64 years and younger, and group B was 65 years and older. Their GCS, ISS, age, sex, comorbidities, and anticoagulant use were abstracted. The primary outcome was mortality and length of stay. The groups were compared using an independent student's t-test and Chi-square analysis. The Cox regression analysis was used to analyze differences in the outcome while adjusting for the above factors. RESULTS: There were 140 patients in group A, and 130 patients in group B who presented to the ED with a GCS of 14-15 and an ISS of below 15. The mean ISS significantly differed between group A (6.2 ± 6.8) vs (7.9 ± 3.2) in group B (p < 0.0001). The most common diagnosis in group A was concussion (57.3%), while in group B was subdural and subarachnoid hemorrhage (55%). In group B, 13.8% presented as a level one or level two trauma activation. The mean hospital and intensive care stay for group A was 2.1 (±1.9) days and 0.9 (±1.32) days, respectively, versus 4.2 (±3.04) days and 2.4 (±2.02 days) for the elderly group B. Mortality in group A was zero and in group B was 3.8%. Cox regression analysis showed age as an independent predictor of death as well as length of stay. CONCLUSION: Elderly traumatic brain injury patients presenting to the ED with minor trauma and high GCS should be triaged at a higher level in most cases.

Use of osteopathic manipulative treatment for low back pain patients with and without pain medication history.

CONTEXT: Low back pain is one of the most frequent diagnoses in primary care, and prescription pain medication is commonly used for management. Osteopathic physicians may use osteopathic manipulative treatment (OMT) as an additional tool to help alleviate pain. OBJECTIVE: To determine if nonpharmacological options can improve back pain with the use of OMT. METHODS: Two groups were studied: patients receiving OMT but not using prescribed pain medications (OMT-only group) and patients who received prescribed pain medication and began receiving OMT after three months of pharmacologic therapy (OMT + medication group). All patients were enrolled in the study for one year. The amount of time between treatments was determined by the physician performing the OMT and the patient's pain improvement. The Keele STarT survey and Oswestry Disability Index tool were used at each appointment to assess the patient's functionality and pain. RESULTS: Thirty-six patients enrolled in the study: 26 in the OMT-only group and 10 in the OMT + medication group. Each group reported improvement in low back pain (LBP) according to both scales used. The OMT-only group reported improvement according to the Keele STarT survey (30% relative decrease in the mean score) and the Oswestry Disability Index tool (18% relative decrease in disability index), while patients in the OMT + medication group also reported improvement according to the Keele STarT survey (29.5% relative decrease in the mean score) and the Oswestry Disability Index tool (18% relative decrease in disability index). A decrease in Cyclobenzaprine usage was also observed in the OMT + medication group. CONCLUSION: Both groups showed significant decreases in overall pain, and this similar effect in each group may indicate a lack of need for medications when OMT is used. Additional research on efficacy of OMT in this patient population is needed with larger, multicenter, randomized trials.

Impact of raising serum myoglobin on resuscitation of trauma patients with high injury severity score (ISS).

INTRODUCTION: Recent studies recommend limiting the amount of crystalloid perfused during resuscitation for trauma patients. Severely injured patients sustain extensive muscle damage with subsequent high serum myoglobin levels precipitating acute renal injury if not treated immediately. To timely identify patients at risk of acute renal injury, we proposed determining the strength of the correlation between the American College of Surgeons-defined injury severity score with serum and urine myoglobin level in the early hours of arrival to the emergency department to determine the patient at higher risk of raising serum myoglobin level and subsequent renal injury. METHOD: A retrospective analysis was conducted at a 400-bed community teaching hospital with a level 2 trauma section and annual admission of 750-800 patients using the data in the trauma registry (2010-2017). Patients with an injury severity score of 15 or above were selected, and Student t test and Pearson correlation 2-tailed analysis were used to identify the relationship with serum myoglobin. RESULT: There were 306 patients total, with 200 men (70.3%) and 106 women (29.7%) and a mean age of 60.64 (SD = 23.6) (range 18-96) years. The mean injury severity score was 22.3 (SD = 8.5) (range 16-75). The median level of serum myoglobin in the first 24 hours of admission was 848.56 ng/mL (range 22-11,197). There was a strong and significant correlation between the 2 variables (r = 0.397, P < .0001). CONCLUSION: The appearance of urine myoglobin with serum level of 39 ng/mL suggests that with higher injury severity score, the potential for acute kidney injury is likely and should be addressed early in the patient management.

Feasibility and Utility of a Cardiovascular Risk Screening Tool in Women Undergoing Routine Gynecology Evaluation.

Background: The goals of this multicenter survey were to examine the prevalence and patient awareness of cardiovascular risk factors, and the association between history of adverse pregnancy outcomes (APO­including gestational hypertension, gestational diabetes, and preeclampsia) and prevalence of cardiovascular risks among women presenting to outpatient obstetrics/gynecology (OB/GYN) clinics. Materials and Methods: We surveyed 2,946 female patients attending 16 outpatient OB/GYN clinics across the United States between January 2010 and January 2012. Main outcome measures were self-reported cardiovascular risk factors and symptoms such as angina and dyspnea. Results: Mean age of the patients was 51 ± 13.6 years. Cardiovascular risks and symptoms were highly prevalent (86.0% and 40.1%, respectively). Many patients did not know if they had common risk factors such as hypertension, hypercholesterolemia, or diabetes (18.4%, 32.0%, and 17.9%, respectively). Women with a history of APO were slightly more likely to be aware of common risk factors, including abnormal blood pressure (17% vs. 18.6%), high cholesterol (31.7% vs. 32%), and obesity/elevated body mass index (43.9% vs. 49.7%). Compared with patients with no history of APO, patients with APO (n = 380, 12.9%) were more likely to have risk factors (89.5% vs. 83.9%, p = 0.002) and symptoms (45.5% vs. 39.3%, p = 0.02). Conclusions: Awareness of cardiovascular risk factors and symptoms among all women surveyed in this study was poor, although awareness for some risk factors was relatively higher among patients with APO. This study demonstrates the feasibility of cardiovascular assessment in OB/GYN clinics using a simple questionnaire and its potential role for early recognition and timely intervention.

The Use of Paravertebral Analgesia in the Management of Pain in the Elderly Patient With Rib Fractures.

BACKGROUND: Elderly patients with rib fractures carry a high morbidity rate, particularly due to pulmonary complications as decreased respiratory efforts ensue secondary to pain. Risk of bleeds in the elderly on anticoagulant therapy is high. The effort to reduce narcotic use in patients is now a health care priority. We propose that the use of paravertebral analgesia (PVA) pumps is an alternative pain control method with less risk and easy placement. METHODS: Two hundred and seventy-nine patients were admitted with multiple fractured ribs to the Trauma Center of Community Hospital and treated with the application of continuous PVA via a pump (72 patients). Pain scores were recorded before and after the initiation of the pump. These patients were compared with a group of the remaining 207 patients who received intravenous narcotics only. RESULTS: The mean change from baseline in pain scores for all patients was 1.43 (SD = 2.75). The mean change in pain for the treatment group was 1.93 (SD = 2.60), and the change in pain for the control group was 1.24 (SD = 2.79). Change in pain differed between groups (1.3 vs 1.8; P = .01) although it was a small difference. After adjusting for age, gender, Injury Severity Score, Glasgow Coma Scale, number of fractures, and comorbid conditions, there was no significant difference in pain post-procedure (odds ratio = 0.75; P = 0.39) with an effect size of 30% and total sample size of 279. CONCLUSION: The PVA pump using bupivacaine is an effective safe and alternative method for managing elderly patients with rib fractures eliminating the serious side effects associated with narcotics.

Traumatic Brain Injury in the Elderly: Can We Reduce Readmissions? : A Community Hospital Experience.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of mortality and long-term morbidity in trauma patients, with a growing incidence among the elderly. Injury-related disability has many costs, and rehospitalization is a significant part of that. The current study was carried out in an elderly population with TBI to identify risk factors and measures associated with rehospitalization. METHODS: We performed a retrospective analysis of 299 patients with a primary diagnosis of TBI admitted between 2016 and 2018. Variables selected for analysis encompassed the following: patient age, sex, comorbidities, diagnosis, length of stay, use of anticoagulants, 6-month readmission rate, and diagnosis for readmission. Chi-square analysis was used to identify potential risk factors, and multiple regression analysis was conducted to model the relationship. RESULTS: 209 patients met inclusion criteria, with a mean age of 69 years (SD ± 18.6 years), with (51.5%) males and (48.5%) females. 188 (62.9%) patients were on anticoagulant therapy. 120 patients were discharged to home (40.1%). 79 patients (26.4%) were readmitted within 6 months of discharge, the majority of whom (48 patients, 60.8%) presented with a subdural hematoma (SDH). 38 readmitted patients (49%) came from home, and 57 patients (80%) were on anticoagulant therapy. CONCLUSION: In elderly patients with TBI, discharge to a home setting correlates with a higher risk of readmission within 6 months, a majority with a diagnosis of recurrent SDH. Anticoagulant therapy and frequent past readmissions also correlated with a higher risk of subsequent readmission.

Elevated 1-Year Mortality Rate in Males Sustaining Low-Energy Proximal Femur Fractures and Subgroup Analysis Utilizing Age-Adjusted Charlson Comorbidity Index.

INTRODUCTION: Low-energy proximal femur fractures are common in the aging population and the ability to identify patients at increased mortality risk provides surgeons information to improve informed decision-making with patients and families. We evaluated for gender differences in 1-year mortality after sustaining low-energy proximal femur fractures with subgroup analysis to identify the impact of fracture location, age, and comorbidities on mortality. MATERIALS AND METHODS: Patients ≥40 years of age sustaining a low-energy proximal femur fracture identified at our institution between January 1, 2014, and December 31, 2017. International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes were used to identify comorbidities for calculation of the age-adjusted Charlson comorbidity index (ACCI). The county clerk database was searched to identify mortality within 1 year of injury. One-year mortality rates were calculated and multiple comparisons were made between genders controlling for age, fracture location, and/or ACCI. RESULTS: Women presented with low-energy proximal femur fractures at a rate of almost 3:1 to men at our institution (P = .001). Men demonstrated a significantly increased ACCI at presentation (5.35 ± 2.55 vs 4.86 ± 1.77, P = .03). Men had an increased 1-year mortality rate for all (31.3% vs 21.5%, P = .004) and intertrochanteric (IT) fractures (36.2% vs 22.9%, P = .008). Controlling for ACCI, gender, and fracture location, men demonstrated increased mortality rate with IT fractures (P = .002) and trended toward but did not reach significance with femoral neck fractures (P = .07). DISCUSSION: Men presenting with low-energy femur fractures are at an increased mortality risk compared to women. On average, men present with an overall worse health status as identified by ACCI, which could predispose these patients not only to fractures themselves but also impair their ability to recover from injury. CONCLUSION: Men are at an increased 1-year mortality risk after sustaining proximal femur fractures.

Objective Assessment of Checklist Fidelity Using Digital Audio Recording and a Standardized Scoring System Audit.

OBJECTIVES: The use of the World Health Organization Surgical Safety Checklist (SSC) has been reported to significantly reduce operative morbidity and mortality rates. Recent findings have cast doubt on the efficacy of such checklists in improving patient safety. The effectiveness of surgical safety checklists cannot be fully measured or understood without an accurate assessment of implementation fidelity, most effectively through direct observations of the checklist process. Here, we describe the use of a secure audio recording protocol in conjunction with a novel standardized scoring system to assess checklist compliance rates. METHODS: We used a black box digital audio recording protocol to observe the execution of SSCs in real time. A novel checklist scoring system was used to quantify the implementation fidelity of a modified version of the SSC. Physician and staff perception of patient safety was also surveyed before and after implementation. RESULTS: Audio-recorded audits revealed a precisely executed checklist 73.6% of the time compared with a previously reported compliance rate of 97.6%. Implementation fidelity was highest during preanesthesia and preincision checklist sections, whereas postprocedure checklist compliance and fidelity was consistently the lowest. Positive attitudes on patient safety by surgical staff increased by 11% from baseline. CONCLUSIONS: The use of a secure digital audio recording protocol is a simple yet effective tool for observing checklist performance. Moreover, the implementation of a standardized scoring system allows for the objective evaluation of checklist fidelity. Together, they provide a powerful auditing tool for identifying improvement.

Critical appraisal of cardiology guidelines on revascularisation: clinical practice.

Evidence-based medicine (EBM) provides clinicians with beneficial information. Nonetheless, study findings are often arbitrary, speculative or provisional. The current state of misleading evidence exists in all applications, including those for guideline recommendations. We conductedan appraisal of the American College of Cardiologyand European Society of Cardiology Guidelines for revascularisation of complex coronary anatomy to determine the veracity of the evidence that recommendations were based on. Study-specific critical appraisals were conducted by the authors on the 5-year Synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) and future revascularisation evaluation in patients with diabetes mellitus: optimal management of multivessel disease (FREEDOM) Trials. Each appraisal was performed according the standard EBM practices. A thorough design and analytic critique was performed for each study and the results presented and explained. The guideline recommendations were reviewed in terms of the veracity of the evidence cited. The relative difference in major adverse cardiac and cerebrovascular event (MAACE) rates between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are not the 30% level reported by the SYNTAX Trial but closer to 11% difference when study limitations are factored in. Similarly, the 30% effect size in MAACE rates between procedures from the FREEDOM Trial is closer to a non-significant 5% relative difference when limitations are adjusted for. Based on the actual findings of each study, outcomes from procedures by CABG or PCI for multivessel revascularisation are similar and contradict the conclusions of the study authors as well as the recommendations. These recommendations fail to inform current clinical practice.

Overdiagnosis of COPD in hospitalized patients.

BACKGROUND: The diagnosis of chronic obstructive pulmonary disease (COPD) is usually made based on history and physical exam alone. Symptoms of dyspnea, cough, and wheeze are nonspecific and attributable to a variety of diseases. Confirmatory testing to verify the airflow obstruction is available but rarely used, which may result in substantial misdiagnoses of COPD. The aim of this study is to evaluate the use of confirmatory testing and assess the accuracy of the diagnosis. METHODS: From January 2011 through December 2013, 6,018 patients with COPD as a principal or leading diagnosis were admitted at a community teaching hospital. Of those, only 504 (8.4%) patients had spirometry performed during hospitalization. The studies were reviewed by two board-certified pulmonologists to verify presence of persistent airflow obstruction. Charts of these patients were then examined to determine if the spirometry results had changed the diagnosis or the treatment plan for these patients. RESULTS: Spirometry confirmed the diagnosis of COPD in 270 patients (69.2%) treated as COPD during their hospitalization. Restrictive lung disease was found to be present in 104 patients (26.6%) and normal in 16 patients (4.2%). Factors predictive of airflow obstruction included smoking status and higher pack-year history. Negative predictive factors included higher body mass index (BMI) and other medical comorbidities. These patients were significantly more likely to be misdiagnosed and mistreated as COPD. CONCLUSION: Up to a third of patients diagnosed and treated as COPD in the hospital may be inaccurately diagnosed as COPD based on confirmatory spirometry testing. Factors contributing to the inaccuracy of diagnosis include less smoking history, high BMI, and associated comorbidities.

Long-acting water-stable organosilane agent and its sustained effect on reducing microbial load in an intensive care unit.

BACKGROUND: Contaminated hospital surfaces contribute significantly to the transmission of health care-associated infections. Although disinfectants reduce bioburden by up to 99%, bacterial growth can rebound within hours to precleaning levels. We tested the effectiveness of an innovative, long-acting water-stable organosilane (WSO) to achieve sustained decreases in bioburden on hard surfaces. METHODS: A 5-month prospective, randomized, double-blind controlled study was performed. Eighteen intensive care unit rooms were randomly divided into placebo or treatment groups. Hard surfaces in all rooms were cleaned using the same protocol, except the placebo surfaces were cleaned with an inert saline solution and the treatment surfaces were treated with the WSO. Binomial regression with repeated measures were used to assess mean reductions in total bioburden as measured by colony forming units. RESULTS: The placebo resulted in average reductions in total colony forming units of 35% to 40% (relative risk reduction [RRR], 0.65; P < .01) and the WSO group averaged reductions of colony forming units by 66% to 99% (RRR, 0.55; P < .001). Total Staphylococcus aureus increased among the placebo rooms 30% (RRR, 0.69; P < .001), whereas in treatment rooms there was a reduction of 50%-60% (RRR, 0.57; P < .01). Although both sets of rooms saw reductions in bioburden or colony forming units, application of the WSO resulted in larger reductions. There was also greater variability in reductions in the placebo arm. CONCLUSION: This is the first randomized, double-blind controlled study of an innovative WSO on high-touch hard surfaces at risk for high bioburdens. Sustained reductions of bioburden with the monthly application of this unique WSO may be associated with significant reductions in the risk of health care-associated infections.

Analysis of safety outcomes for radial versus femoral access for percutaneous coronary intervention from a large clinical registry.

OBJECTIVE: Using a multisite, contemporary registry of 58 862 percutaneous coronary intervention (PCI) procedures in a national healthcare system, the present study compared radial access with femoral access on safety and efficacy outcomes. METHODS: This is a real-world, large-scale, retrospective study using clinical data from a 137-hopsital System and reported to a multisite clinical registry. All patients undergoing a cardiac catheterisation procedure were included in this database. The primary end points were major bleeding and radiation exposure. Multivariate logistic regression modelling was used to compare access groups. RESULTS: Femoral access (n=55 729) accounted for 94.7% and radial access (n=3137) for 5.3%. There were fewer bleeding events in the radial group (n=28, 0.9%) than those in the femoral group (n=1234, 2.2%) in the unadjusted analysis. For patients receiving bivalirudin, bleeding occurred in 337 patients (1.6%), and there was no difference in rates between radial access (n=13, 1.1%) and femoral access (n=327, 1.7%) (OR=0.65, CI 0.40 to 1.22, p=0.19). The radial technique resulted in higher radiation exposure in each case, but particularly for procedures involving prior coronary artery bypass graft history and non-ST-elevated myocardial infarction patients. The mean fluoroscopy time among femoral access procedures was 15.68 min (SD=11.7) versus 19.86 min (SD=13.8) for radial access procedures (p<0.0001). CONCLUSIONS: Radial access for PCI is associated with higher fluoroscopy times but not with less major bleeding when bivalirudin is used. Our analysis, combined with other study findings, suggest that the safest route for PCI may be the use of femoral access with bivalirudin.

Validity of a PCI Bleeding Risk Score in patient subsets stratified for body mass index.

OBJECTIVE: An accurate tool with good discriminative for bleeding would be useful to clinicians for improved management of all their patients. Bleeding risk models have been published but not externally validated in independent clinical data set. We chose the National Cardiovascular Data Registry (NCDR) percutaneous coronary intervention (PCI) score to validate within a large, multisite community data set. The aim of the study was validation of this Bleeding Risk Score (BRS) tool among a subgroup of patients based on body mass index. METHODS: This is a large-scale retrospective analysis of a current registry utilising data from a 37-hospital health system. The central repository of patients with coronary heart disease undergoing PCI between 1 June 2009 and 30 June 2012 was utilised to validate the NCDR PCI BRS among 4693 patients. The primary end point was major bleeding. Validation analysis calculating the receiver operating characteristic curve was performed. RESULTS: There were 143 (3%) major bleeds. Mean BRS was 14.7 (range 3-42). Incidence of bleeding by risk category: low (0.5%), intermediate (1.7%) and high risk (7.6%). Tool accuracy was poor to fair (area-under-the curve (AUC) 0.78 heparin, 0.65 bivalirudin). Overall accuracy was 0.71 (CI 0.66 to 0.76). Accuracy did not improve when confined to just the intermediate risk group (AUC 0.58; CI 0.55 to 0.67). Tool accuracy was the lowest among the low BMI group (AUC 0.62) though they are at increased risk of bleeding following PCI. CONCLUSIONS: Bleeding risk tools have low predictive value even among subgroups of patients at higher risk. Adjustment for anticoagulation use resulted in poor discrimination because bivalirudin differentially biases outcomes toward no bleeding. The current state of bleeding risk tools provide little support for diagnostic utility in regards to major bleeding and therefore have limited clinical applicability.

Value of extended warming in patients undergoing elective surgery.

Perioperative temperature management is imperative for positive surgical outcomes. This study assessed the clinical and wellbeing benefits of extending normothermia by using a portable warming gown. A total of 94 patients undergoing elective surgery were enrolled. They were randomized pre-operatively to either a portable warming gown or the standard warming procedure. The warming gown stayed with patients from pre-op to operating room to postrecovery room discharge. Core temperature was tracked throughout the study. Patients also provided responses to a satisfaction and comfort status survey. The change in average core temperature did not differ significantly between groups (P = 0.23). A nonsignificant 48% relative decrease in hypothermic events was observed for the extended warming group (P = 0.12). Patients receiving the warming gown were more likely to report always having their temperature controlled (P = 0.04) and significantly less likely to request additional blankets for comfort (P = 0.006). Clinical outcomes and satisfaction were improved for patients with extended warming.

The effect of bivalirudin and closure device on bleeding outcomes after percutaneous coronary interventions.

INTRODUCTION: Studies have demonstrated bivalirudin efficacy in some patients at increased risk of bleeding. The aim of this study was to determine the extent to which bleeding reduction is achieved among all patients using bivalirudin as compared with a heparin with or without 2B3A inhibitor strategy. METHODS: This is a real-world, large-scale retrospective study utilising the American College of Cardiology (ACC) data from a 37-hospital Ascension Health System. The registry represents routine clinical practice between 1 June 2009 and 30 June 2012. End points included major bleeding, major adverse cardiac events and death. Multivariate regression analysis modelled on predictors of end points. RESULTS: This study included 58 862 PCI procedures. Major bleeding rates were lowest for bivalirudin plus closure device overall (OR=0.53, CI 0.21 to 0.84, p=0.001). The use of a device for access closure contributed to the greatest declines in major bleeding. Compared with heparin with device, bivalirudin with device had a significantly lower rate of bleeding (OR=0.37, CI 0.18 to 0.74, p=0.005). The use of device had a greater effect on decreasing bleeding among patients receiving bivalirudin compared with heparin, especially among women (p=0.001). After adjustment for 2B3A use, this advantage was no longer significant in ST segment elevation myocardial infarction patients (OR=1.8, CI 0.5 to 6.0, p=0.34). CONCLUSIONS: All risk groups in this real world database representing current clinical practice benefited from the use of bivalirudin and device closure with lower risk groups benefiting the most. This robust analysis of real-world clinical data supports a combined treatment strategy of bivalirudin and closure device.

Sports-related head injuries in students: parents' knowledge, attitudes, and perceptions.

The short- and long-term neurologic impairment of children sustaining sports-related head injuries has recently entered the forefront of medical literature, resulting in new guidelines on concussion management being provided to clinicians, coaches, and trainers. Yet, most parents have not been formally educated on head injuries. The purpose of this article is to share the findings of a study conducted with 235 parents that identified their knowledge, attitudes, and perceptions of sports-related head injuries in school-age students. The study found that 51% of respondents were unaware that head trauma was more serious in children, 80% were uninformed as to whether the school district had a policy on sports-related head injuries, 44% did not know if there were medical guidelines for return to play, and 35% did not know that repeated head trauma could cause dementia. Results of this research implore school nurses to improve patient and parental education when they care for and monitor students with head injuries.

Tetanus seropositive prevalence and perceived protection from emergency admissions.

BACKGROUND: Emergency physicians see many people who present to the emergency department stating that they are immunized against tetanus, when in fact, they are not. The patient history is not dependable for determining true tetanus status and simple patient surveys do not provide actual prevalence. The objective of this study was to determine the prevalence of tetanus status by antibody titer seropositivity and quantify such status among patients reporting tetanus protection. METHODS: This study is a single center prospective convenience sample of patients presenting to the emergency department 12 years of age or older. Patients deemed study candidates and willing to be in the study filled out an eight-question questionnaire that included the question 'is your tetanus shot up to date'. A blood sample was then drawn for tetanus antibody titer and quantified according to a pre-determined cutoff for protection. RESULTS: A total of 163 patients were enrolled. Of patients responding yes to the query 'is your tetanus shot up to date' 12.8% (N=5) of them were not seropositive. Of the 26 people who were seronegative in the study all had been to a doctor in the past year and 88.5% (N=23) had been to their family physician. CONCLUSION: The study suggests that it may be difficult to trust the tetanus immunization history given by patients presenting to the emergency room. The study also observed that a large percentage of patients who were serenegative were seen by a primary care physician and not had a necessary tetanus immunization.

Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients.

BACKGROUND: Tachycardia and tachyarrhythmias are associated with increased morbidity and mortality in adult patients in the ICU. This study examines the effects of nebulized bronchodilator therapy (albuterol and ipratropium) on heart rate and arrhythmias in this population and tests the proposition that levalbuterol is safer than albuterol in that regard. METHODS: The design was a randomized, single-blind, crossover, prospective study in 70 critically ill adult patients treated with nebulized bronchodilators. Patients were randomized to nebulized albuterol alternating with levalbuterol every 4 to 6 h. Group A received albuterol 2.5 mg alternating with levalbuterol 0.63 mg. Group B received albuterol 2.5 mg alternating with levalbuterol 1.25 mg. All patients received nebulized ipratropium bromide with each treatment. Heart rate was recorded before and after each treatment. Cardiac rhythm was continuously monitored using electronic telemetry units. RESULTS: In group A, mean ± SD change in heart rate after albuterol 2.5 mg (n = 303) was 0.89 ± 4.5 beats/min compared with 0.85 ± 5.3 beats/min after levalbuterol 0.63 mg (n = 301) (P = .89). In group B (n = 114), heart rate decreased 0.16 ± 5.1 beats/min after albuterol 2.5 mg compared with an increase of 1.4 ± 5.4 beats/min after levalbuterol 1.25 mg (n = 118) (P = .03). Five events of arrhythmias (0.6%) occurred during the course of 836 treatments. Four consisted of occasional premature ventricular contractions. Only one patient stopped treatment because of a 5-beat run of ventricular tachycardia (one in 70 patients [1.4%]). CONCLUSIONS: In critically ill adult patients, nebulized albuterol and ipratropium does not cause significant tachycardia or tachyarrhythmias. Substitution of levalbuterol for albuterol to avoid tachycardia and tachyarrhythmias is unwarranted. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01151579; URL: www.clinicaltrials.gov.

The influence of spinal needle orientation during administration of subarachnoid blocks on discharge criteria in same-day surgical patients.

Cost containment is a critical factor in today's healthcare industry, so finding ways to decrease length of stay is essential in anesthesia practice. We rely on rapid induction, recovery, and discharge to control cost in outpatient surgery. Subarachnoid block (SAB) is an acceptable anesthetic choice for many outpatient procedures. It is often underused because it may result in delayed discharge. The purpose of this study was to determine if orientation of the spinal needle during administration of SAB affects the time required to meet discharge criteria in a same-day surgical unit. Patients undergoing surgical procedures deemed appropriate for short-acting lidocaine spinal anesthetic were recruited for this randomized, posttest, prospective study. All patients received a hyperbaric lidocaine spinal administered using a 25-gauge Whitacre needle. The needle was oriented in a cephalad (group A) or a lateral (group B) direction. Time to discharge was determined by calculating time elapsed between administration of the SAB and the time when the patient met discharge criteria. The statistical analysis included 50 patients (group A, n = 30; group B, n = 20). Demographics (except weight) were not statistically different between the groups. Total hospital time did not differ between the groups. Regardless of needle orientation, patients in both study groups achieved discharge criteria in similar amounts of time.