The association between paramedic service system hospital offload time and response time.

OBJECTIVE: To address an important care issue in Canada, we tested the association between paramedic system hospital offload and response time, while considering the impact of other system-level factors. METHODS: Data from Calgary, Alberta (2014-2017), included median offload (exposure) and response (outcome) time aggregated by hour, with covariates paramedic system episodes of care-dispatch and arrival of a response unit-and hospital transport arrivals (collectively called volume), time of day, and season. Analyses used linear regression and modified Poisson models. RESULTS: 301,105 EMS episodes of care over 26,193 1-h periods were included. For any given 1-h period, the median (IQR) across all episodes of care for offload time, response time, episodes of care, and hospital transport arrivals were 55.3 (45.7, 66.3) min, 8.6 (7.6, 9.8) min, 12 (8, 16) episodes, and 8 (5, 10) hospital arrivals, respectively. Multivariable modelling revealed a complex association differing over levels of exposure and covariates, requiring description using "light stress" and "heavy stress" system scenarios. The light scenario was defined as median offload of 30 min and volume < 10th percentile (six episodes and four hospital arrivals), in the summer, and the heavy scenario as median offload of 90 min and volume > 90th percentile (17 episodes and 13 hospital arrivals), in the winter. An increase is reported in minutes:seconds for median hourly response time between scenarios by time of day: 1:04-4:16 (0000-0559 h.), 0:42-2:05 (0600-1159 h.), 0:57-3:01 (1200-1759 h.), and 0:18-2:21 (1800-2359 h.). CONCLUSIONS: Increasing offload is associated with increased response time; however the relationship is complex, with a greater impact on response time noted in select situations such as high volume in the winter. These observations illustrate the interdependence of paramedic, ED, and inpatient systems and provide high-yield targets for polices to mitigate the risk to community availability of paramedic resources at times of high offload delay/system stress.

ABSTRAIT: OBJECTIF: Afin de régler un problème important de soins au Canada, nous avons testé l'association entre le déchargement du système paramédical et le temps de réponse, tout en tenant compte de l'incidence d'autres facteurs au niveau du système. MéTHODES: Les données de Calgary, en Alberta (2014-2017) incluent le temps médian de déchargement (exposition) et de réponse (résultat) agrégé par heure, qui s'agit co-variables épisodes de soins du système paramédical - répartition et arrivée d'une unité d'intervention - et arrivées de transport hospitalier (collectivement appelé volume), l'heure et la saison. Les analyses ont utilisé la régression linéaire et des modèles de Poisson modifiés. RéSULTATS: 301105 épisodes de soins médicaux d'urgence sur 26193 périodes d'une heure ont été inclus. Pour une période d'une heure donnée, la médiane (QRI) pour tous les épisodes de soins pour le temps de déchargement, le temps de réponse, les épisodes de soins et les arrivées par transport à l'hôpital était de 55,3 (45,7, 66,3) minutes, 8,6 (7,6, 9,8) minutes, 12 (8, 16) épisodes et 8 (5, 10) arrivées à l'hôpital, respectivement. La modélisation multi-variable a révélé une association complexe qui varie selon les niveaux d'exposition et les co-variables, et qui nécessite une description à l'aide de scénarios de systèmes de « stress léger ¼ et de « stress lourd ¼. Le scénario léger a été défini comme un déchargement médian de 30 minutes, volume inférieur au 10e percentile (six épisodes et quatre arrivées à l'hôpital), pendant l'été. Le scénario lourd comme déchargement médian de 90 minutes, volume > 90e percentile (17 épisodes et 13 arrivées à l'hôpital), en hiver. Une augmentation est rapportée en minutes: secondes pour le temps de réponse horaire médian entre des scénarios par heure du jour : 1:04-4:16 (0000-0559 h.), 0:42-2:05 (0600-1159 h.), 0:57-3:01 (1200-1759 h.), et 0:18-2:21 (1800-2359 h.). CONCLUSIONS: L'augmentation du déchargement est associée à une augmentation du temps de réponse, mais la relation est complexe, avec un impact plus important sur le temps de réponse noté dans certaines situations, comme un volume élevé en hiver. Ces observations illustrent l'interdépendance des systèmes paramédicaux, des services d'urgence et des services aux patients hospitalisés et fournissent des cibles à haut rendement pour les politiques afin d'atténuer le risque pour la disponibilité des ressources paramédicales dans la collectivité en période de retard élevé ou de stress systémique.

Computed tomography analysis of the anterior ethmoid genu of the frontal recess in non-diseased sinuses.

OBJECTIVE: Knowledge of anatomical variations of the frontal recess and frontal sinus and recognition of endoscopic landmarks are vital for safe and effective endoscopic sinus surgery. This study revisited an anatomical landmark in the frontal recess that could serve as a guide to the frontal sinus. METHOD: Prevalence of the anterior ethmoid genu, its morphology and its relationship with the frontal sinus drainage pathway was assessed. Computed tomography scans with multiplanar reconstruction were used to study non-diseased sinonasal complexes. RESULTS: The anterior ethmoidal genu was present in all 102 anatomical sides studied, independent of age, gender and race. Its position was within the frontal sinus drainage pathway, and the drainage pathway was medial to it in 98 of 102 cases. The anterior ethmoidal genu sometimes extended laterally and formed a recess bounded by the lamina papyracea laterally, by the uncinate process anteriorly and by the bulla ethmoidalis posteriorly. Distance of the anterior ethmoidal genu to frontal ostia can be determined by the height of the posterior wall of the agger nasi cell rather than its volume or other dimensions. CONCLUSION: This study confirmed that the anterior ethmoidal genu is a constant anatomical structure positioned within frontal sinus drainage pathway. The description of anterior ethmoidal genu found in this study explained the anatomical connection between the agger nasi cell, uncinate process and bulla ethmoidalis and its structural organisation.

Linkage of Emergency Medical Services and Hospital Data: A Necessary Precursor to Improve Understanding of Outcomes of Prehospital Care.

Objective: Linking emergency medical services (EMS) data to hospital outcomes is important for quality assurance and research initiatives. However, non-linkage due to missing or incomplete patient information may increase the risk of bias and distort findings. The purpose of this study was to explore if an optimization strategy, in addition to an existing linkage process, improved the linkage rate and reduced selection and information bias. Methods: 4,150 transported patients in a metropolitan EMS system in Alberta, Canada from 2016/17 were linked to two Emergency Department (ED) databases by a standard strategy using a unique health care number, date/time of ED arrival, and hospital name. An optimized strategy added additional linkage steps incorporating last name, year of birth, and a manual search. The strategies were compared to assess the rate of linkage, and to describe event and patient-level characteristics of unlinked records. Results: The standard strategy resulted in 3,650 out of 4,150 (88.0%) linked records (95% CI 86.9%-88.9%). Of the 500 non-linked records, an additional 381 were linked by the optimized strategy (n = 4,031/4,150 [97.1%; 95% CI: 96.6%-97.6%]). There were no false positive linkages. The highest linkage failure was in 25 to 34 year-old patients (n = 93/478, 19.5%), males (n = 236/1975, 12.0%), Echo level events (n = 15/77, 19.5%), and emergency transport (45/231, 19.5%). The optimized strategy improved linkage in these groups by 68.8% (64/93), 79.2% (187/236), 40.0% (6/15), and 51.1% (23/45) respectively. For dispatch card, the highest linkage failure occurred in Card 24-Pregnancy/Childbirth/Miscarriage (n = 30/44, 68.2%), Card 27-Stab/Gunshot/Penetrating Trauma (n = 6/17, 35.3%), and Card 9-Cardiac/Respiratory Arrest/Death (n = 12/46, 26.1%). The optimized strategy improved linkage by 10.0% (3/30), 83.3% (5/6), and 41.7% (5/12) respectively. For the 119 unlinked records, 71 (59.7%) had sufficient information for linkage, but no appropriately matching records could be found. Conclusion: An optimized sequential deterministic strategy linking EMS data to ED outcomes improved the linkage rate without increasing the number of false positive links, and reduced the potential for bias. Even with adequate information, some records were not linked to their ED visit. This study underscores the importance of understanding how data are linked to hospital outcomes in EMS research and the potential for bias.

Design, Development and Optimization of S (-) Atenolol Floating Sustained Release Matrix Tablets Using Surface Response Methodology.

The objective of this present investigation was to develop and formulate floating sustained release matrix tablets of s (-) atenolol, by using different polymer combinations and filler, to optimize by using surface response methodology for different drug release variables and to evaluate the drug release pattern of the optimized product. Floating sustained release matrix tablets of various combinations were prepared with cellulose-based polymers: Hydroxypropyl methylcellulose, sodium bicarbonate as a gas generating agent, polyvinyl pyrrolidone as a binder and lactose monohydrate as filler. The 3(2) full factorial design was employed to investigate the effect of formulation variables on different properties of tablets applicable to floating lag time, buoyancy time, % drug release in 1 and 6 h (D1 h,D6 h) and time required to 90% drug release (t90%). Significance of result was analyzed using analysis of non variance and P < 0.05 was considered statistically significant. S (-) atenolol floating sustained release matrix tablets followed the Higuchi drug release kinetics that indicates the release of drug follows anomalous (non-Fickian) diffusion mechanism. The developed floating sustained release matrix tablet of improved efficacy can perform therapeutically better than a conventional tablet.

Differentiation between benign and malignant breast lesions using quantitative diffusion-weighted sequence on 3 T MRI.

AIM: To investigate the capability and diagnostic accuracy of diffusion-weighted imaging (DWI) in differentiating benign from malignant breast lesions using 3 T magnetic resonance imaging (MRI). MATERIALS AND METHODS: Women with suspicious or indeterminate breast lesions detected at MRI, mammogram and/or ultrasound were recruited for dynamic contrast-enhanced (DCE)-MRI and DWI prior to their biopsy. Image fusion of DCE-MRI with apparent diffusion coefficient (ADC) map was utilized to select the region of interest (ROI) for ADC calculation in the area that showed the most avid enhancement. DWI was performed using two sets of b-values at 500 and 1000 s/mm(2), respectively. RESULTS: Fifty women were recruited and the final analysis comprised 44 breast lesions, 31 of which were malignant and 13 were benign. Significant results were obtained between ADC values of benign and malignant lesions (p < 0.001). The cut-off ADC values for benign and malignant lesions were 1.21 × 10(-3) mm(2)/s for b = 500 s/mm(2) and 1.22 × 10(-3) mm(2)/s for b = 1000 s/mm(2), respectively. The sensitivity of DCE-MRI alone was 100% with a specificity of 66.7%. When DCE-MRI was combined with b = 1000 s/mm(2), the specificity rose to 100%, while only mildly affecting sensitivity (90.6%). No significant correlation was found between ADC values and prognostic factors, such as lymph node metastasis, tumour size, oestrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status, and tumour grades. CONCLUSION: The present study provides consistent evidence to support DWI as a diagnostic tool for breast lesion characterization. A combination of DCE-MRI with DWI is suggested to improve the sensitivity and specificity of lesion characterization.

Improved diagnostic accuracy in differentiating malignant and benign lesions using single-voxel proton MRS of the breast at 3 T MRI.

AIM: To investigate the diagnostic accuracy of single-voxel proton magnetic resonance spectroscopy (SV (1)H MRS) by quantifying total choline-containing compounds (tCho) in differentiating malignant from benign lesions, and subsequently, to analyse the relationship of tCho levels in malignant breast lesions with their histopathological subtypes. MATERIALS AND METHODS: A prospective study of SV 1H MRS was performed following dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in 61 women using a 3 T MR system. All lesions (n = 57) were analysed for characteristics of morphology, contrast-enhancement kinetics, and tCho peak heights at SV (1)H MRS that were two-times above baseline. Subsequently, the tCho in selected lesions (n = 32) was quantified by calculating the area under the curve, and a tCho concentration equal to or greater than the cut-off value was considered to represent malignancy. The relationship between tCho in invasive ductal carcinomas (IDCs) and their Bloom & Richardson grading of malignancy was assessed. RESULTS: Fifty-two patients (57 lesions; 42 malignant and 15 benign) were analysed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), of predicting malignancy were 100, 73.3, 91.3, and 100%, respectively, using DCE-MRI and 95.2, 93.3, 97.6, and 87.5%, respectively, using SV (1)H MRS. The tCho cut-off for receiver operating characteristic (ROC) curve was 0.33 mmol/l. The relationship between tCho levels in malignant breast lesions with their histopathological subtypes was not statistically significant (p = 0.3). CONCLUSION: Good correlation between tCho peaks and malignancy, enables SV (1)H MRS to be used as a clinically applicable, simple, yet non-invasive tool for improved specificity and diagnostic accuracy in detecting breast cancer.

Systemic cytomegalovirus infection complicating ulcerative colitis: a case report and review of the literature.

Cytomegalovirus is a common infection worldwide and in the immunocompromised individual it can be a major cause of morbidity and mortality. In patients with inflammatory bowel disease cytomegalovirus infection has been described in both immunocompetent and immunocompromised individuals. A 34 year old man with an exacerbation of his colitis was diagnosed as having both cytomegalovirus colitis and hepatitis. The diagnosis was made on the classical appearance of "owl's eye" inclusion bodies on colonic and hepatic biopsies and, in addition, viral serology and polymerase chain reaction (PCR) analysis of the cytomegalovirus DNA copy number. Fourteen days of treatment with ganciclovir led to a prompt improvement in the symptoms of colitis, resolution of the pyrexia, normalisation of the liver function tests, and clearance of the virus, as measured by a negative cytomegalovirus DNA PCR. Cytomegalovirus infection is a potentially fatal complication of treatment induced immunosuppression in patients with inflammatory bowel disease. As in this case, infection may be systemic and not confined to the intestine. Prompt diagnosis using histology, serology, and PCR analysis allows prompt introduction of therapy and an improved prognosis.

A prospective multicenter study of cervical spine injury in children.

OBJECTIVE: Pediatric victims of blunt trauma have developmental and anatomic characteristics that can make it difficult to assess their risk of cervical spine injury (CSI). Previous reports, all retrospective in nature, have not identified any cases of CSI in either children or adults in the absence of neck pain, neurologic symptoms, distracting injury, or altered mental status. The objective of this study was to examine the incidence and spectrum of spine injury in patients who are younger than 18 years and to evaluate the efficacy of the National Emergency X-Radiography Utilization Study (NEXUS) decision instrument for obtaining cervical spine radiography in pediatric trauma victims. METHODS: We performed a prospective, multicenter study to evaluate pediatric blunt trauma victims. All patients who presented to participating emergency departments underwent clinical evaluation before radiographic imaging. The presence or absence of the following criteria was noted: midline cervical tenderness, altered level of alertness, evidence of intoxication, neurologic abnormality, and presence of painful distracting injury. Presence or absence of each individual criterion was documented for each patient before radiographic imaging, unless the patient was judged to be too unstable to complete the clinical evaluation before radiographs. The decision to radiograph a patient was entirely at the physician's discretion and not driven by the NEXUS questionnaire. The presence or absence of CSI was based on the final interpretation of all radiographic studies. Data on all patients who were younger than 18 years were sequestered from the main database for separate analysis. RESULTS: There were 3065 patients (9.0% of all NEXUS patients) who were younger than 18 years in this cohort, 30 of whom (0.98%) sustained a CSI. Included in the study were 88 children who were younger than 2, 817 who were between 2 and 8, and 2160 who were 8 to 17. Fractures of the lower cervical vertebrae (C5-C7) accounted for 45.9% of pediatric CSIs. No case of spinal cord injury without radiographic abnormality was reported in any child in this study, although 22 cases were reported in adults. Only 4 of the 30 injured children were younger than 9 years, and none was younger than 2 years. Tenderness and distracting injury were the 2 most common abnormalities noted in patients with and without CSI. The decision rule correctly identified all pediatric CSI victims (sensitivity: 100.0%; 95% confidence interval: 87.8%-100.0%) and correctly designated 603 patients as low risk for CSI (negative predictive value: 100.0%; 95% confidence interval: 99.4%-100.0%). CONCLUSIONS: The lower cervical spine is the most common site of CSI in children, and fractures are the most common type of injury. CSI is rare among patients aged 8 years or younger. The NEXUS decision instrument performed well in children, and its use could reduce pediatric cervical spine imaging by nearly 20%. However, the small number of infants and toddlers in the study suggests caution in applying the NEXUS criteria to this particular age group.

Emergency department utilization by noninstitutionalized elders.

OBJECTIVES: To the best of the authors' knowledge, no nationally representative, population-based study has characterized the proportion of elders using the emergency department (ED) and factors associated with ED use by elders. This article describes the proportion of elder Medicare beneficiaries using the ED and identifies attributes associated with elder ED users as compared with nonusers. METHODS: The 1993 Medicare Current Beneficiary Survey was used, a national, population-based, cross-sectional survey of Medicare beneficiaries linked with Medicare claims data. The study population was limited to 9,784 noninstitutionalized individuals aged 66 years or older. The Andersen model of health service utilization was used, which explains variation in ED use through a combination of predisposing (demographic and social), enabling (access to care), and need (comorbidity and health status) characteristics. RESULTS: Eighteen percent of the sample used the ED at least once during 1993. Univariate analysis showed ED users were older; were less educated and lived alone; had lower income and higher Charlson Comorbidity Index scores; and were less satisfied with their ability to access care than nonusers (p < 0.01, chi-square). Logistic regression identified older age, less education, living alone, higher comorbidity scores, worse reported health, and increased difficulties with activities of daily living as factors associated with ED use (p < 0.05). Need characteristics predicted ED use with the greatest accuracy. CONCLUSIONS: The proportion of elder ED users is slightly higher than previously reported among Medicare beneficiaries. Need (comorbidity and health status) characteristics predict ED utilization with the greatest accuracy.

Does fluorescent urine indicate antifreeze ingestion by children?

OBJECTIVE: Fluorescent urine has been reported to indicate antifreeze ingestion. Recently, we evaluated a child who was suspected of ethylene glycol ingestion. Although she had fluorescent urine, subsequent studies showed that she had not ingested antifreeze. We tested whether fluorescent urine indicates antifreeze ingestion by children. METHODS: A convenience sample of urine specimens from 30 hospitalized children was obtained. All of the patients had been hospitalized for reasons unrelated to poisoning. The specimens were viewed with a Wood's lamp, and the samples were identified as fluorescent or not fluorescent. A second convenience sample of urine specimens from a group of 16 healthy children was obtained, and these specimens were identified as fluorescent or not fluorescent in a similar manner. RESULTS: The majority of urine specimens obtained from children are fluorescent. There is variation in the interpretation of urine fluorescence among observers. The type of container used may influence the finding of fluorescence. CONCLUSIONS: Fluorescent urine is not an indicator of ethylene glycol antifreeze ingestion by children.

Diffuse lamellar keratitis associated with epithelial defects after laser in situ keratomileusis.

PURPOSE: To describe the association between the presence of epithelial defects and the development of diffuse lamellar keratitis (DLK), "Sands of the Sahara" syndrome, following laser in situ keratomileusis (LASIK). SETTING: Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA. METHODS: In this retrospective study, the postoperative clinical course and surgical outcomes in 735 eyes of 358 consecutive patients who had myopic LASIK between December 1998 and August 1999 were reviewed. Of the 735 procedures, 680 were primary LASIK procedures and 55 were retreatments performed by lifting the existing flaps. The incidence and severity of DLK and the relationship of DLK to epithelial defects were tabulated. RESULTS: Diffuse lamellar keratitis developed in 9 of the 16 eyes that had postoperative epithelial defects. Seventeen eyes without epithelial defects also developed DLK. The presence of an epithelial defect increased an individual's risk of developing DLK 24 times (95% confidence interval, 13 to 45). In 8 eyes, the inflammation resolved following treatment with intense topical corticosteroids. One eye had irrigation under the flap because of dense central inflammation; the final outcome was mild inferior corneal steepening. All eyes recovered preoperative best spectacle-corrected visual acuities. CONCLUSION: Patients who have epithelial defects of any size following LASIK are at significantly increased risk of developing DLK.

A comparative, qualitative and quantitative antimicrobial efficacies of mouthrinses containing chlorhexidine gluconate and essential oils.

A project was launched to evaluate and compare antimicrobial efficacy of Hexidine and Listerine over placebo in 10 day human experimental gingivitis study. A rigid study schedule for subject compliance spanning well over 3 months was sorted out and volunteers recruited for study rinsed all the 3 assigned mouthrinses containing (a) chlorhexidine gluconate, (b) "essential oils" and (c) flavoured distilled water one after the other at certain prefixed intervals. After 10 days of assigned mouthrinse regimen, where the assigned mouthrinse was the only method practiced by the volunteers for oral hygiene, Supragingival Plaque was quantitatively and qualitatively assayed. Qualitatively supragingival plaque was assayed by Gram staining (Direct smear and Thioglycollate Broth) and growth characteristics i.e; Aerobic, Microaerophilic and Anaerobic growth was noted. Quantitatively plaque was assayed by calculating total microbial load per tooth by preparing Mafarland Nephelometer standard and Spectrophotometric analysis. It is concluded that Hexidine and Listerine exert similar antimicrobial efficacy in 10 days experimental gingivitis study. Hexidine and Listerine exert their antimicrobial influence through reduction of total Aerobes and Anaerobes reducing total microbial load per tooth by 58% and 53% respectively as compared to placebo.

A comparison of methods for the detection of myocardial ischemia during noncardiac surgery: automated ST-segment analysis systems, electrocardiography, and transesophageal echocardiography.

Clinicians often fail to detect intraoperative ischemic electrocardiographic (ECG) changes when viewing oscilloscopes. Automated ST-segment monitors promise to increase the detection of such ECG changes. We investigated the capacity of two commercially available ST-segment monitors to detect intraoperative myocardial ischemia in patients at high risk for developing intraoperative myocardial ischemia during vascular and other noncardiac procedures. The ST-segment monitors were compared with two reference monitors: (a) printed eight-lead ECGs, as interpreted by a cardiologist, and (b) the presence of segmental wall motion abnormalities and thickening abnormalities detected by transesophageal echocardiography (TEE). We also examined the capacity of the printed ECG to diagnose myocardial ischemia when compared with TEE. We studied 44 patients who underwent TEE, printed multilead ECG, oscilloscope monitoring of leads V5 and II, and measurement of ST-segment deviation from the baseline using an automated Hewlett Packard ST-segment device. The sensitivities for the Hewlett Packard system were 40% for TEE-diagnosed myocardial ischemia and 75% for ECG-diagnosed ischemia. Comparison of the printed ECG with TEE revealed that ST-segment changes in the printed ECG, as analyzed by a cardiologist, were 25% sensitive and 62% specific for the detection of TEE-diagnosed myocardial ischemia. When T-wave inversions were added to ST-segment depression as a criterion for the diagnosis of myocardial ischemia by the printed ECG, the sensitivity of ECG for the detection of intraoperative myocardial ischemia, as determined by TEE, was 40% and specificity was 58%. Twenty-three of the 44 patients were simultaneously monitored in leads I, II, and V5 with an automated Marquette ST-segment monitor.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult foregut duplication.

We report a gastric duplication in a 23-year-old man. The case is unique because the stomach is the rarest location for enteric duplication, the duplication almost never occurs in adults, and the duplication consisted exclusively of pancreatic tissue. This extreme example illustrates the close embryologic and anatomic association between stomach and pancreas. A case is made for the use of the general term of foregut duplication to avoid confusing nomenclature.