Severe hypoglycaemia and cognitive impairment in older patients with diabetes: the Fremantle Diabetes Study.

AIMS/HYPOTHESIS: The aim was to investigate the relationship between severe hypoglycaemia and cognitive impairment in older patients with diabetes. METHODS: A sample of 302 diabetic patients aged >/=70 years was assessed for dementia or cognitive impairment without dementia in 2001-2002 and a subsample of non-demented patients (n = 205) was followed to assess cognitive decline. A history of severe hypoglycaemia was determined from self-reports, physician assessments and records of health service use for hypoglycaemia (HSH). Prospective HSH was determined up to 2006. Data analysis, including multiple logistic and Cox regression models, was used to determine whether: (1) there were cross-sectional associations between hypoglycaemia and cognitive status, (2) historical hypoglycaemia predicted cognitive decline, and (3) baseline cognitive status predicted subsequent HSH. RESULTS: There were significant cross-sectional associations between both cognitive impairment and dementia and hypoglycaemia. Independent risk factors for future HSH included dementia (hazard ratio 3.00, 95% CI 1.06-8.48) and inability to self-manage medications (hazard ratio 4.17, 95% CI 1.43-12.13). However, there were no significant associations between historical hypoglycaemia, incident HSH and cognitive decline. CONCLUSIONS/INTERPRETATION: Dementia is an important risk factor for hypoglycaemia requiring health service utilisation. We found no evidence that hypoglycaemia contributes to cognitive impairment in older patients with diabetes.

The bacteriology of pneumonia diagnosed in Western Australian emergency departments.

We used Western Australian emergency department data linked to hospital morbidity, death and microbiology data to describe the bacteriology of pneumonia according to age. The 'atypical' organisms and viruses were not assessed. A total of 6908 patients over a 3-year period were given an emergency department diagnosis of pneumonia, 76.9% were admitted and 6.3% died in hospital. Blood was cultured from 52.9% of patients with 6.4% growing potential pathogens. Streptococcus pneumoniae was the most common organism isolated and accounted for 92% of pathogens in those aged <15 years. Isolation of Enterobacteriaceae species tended to increase with age and accounted for around 25% of isolates from the elderly. Sputum was cultured from 25.3% of patients and bacteria were isolated from 30.3% of samples, commonly Haemophilus influenzae and S. pneumoniae. Isolates from sputum showed no distinct trend across age groups. These patterns question the value of routine blood and sputum cultures and have implications for empiric therapy for the elderly.

Outcomes of out-of-hospital cardiac arrest patients in Perth, Western Australia, 1996-1999.

STUDY OBJECTIVE: To describe the epidemiology and survival from out-of-hospital cardiac arrest. DESIGN: Longitudinal follow-up study from the time of paramedic attendance to 12 months later. SETTING: Perth, Western Australia (WA), a metropolitan capital city with an adult population of approximately one million people. METHOD: The St John Ambulance Australia (WA Ambulance Service Incorporated) cardiac arrest database was linked to the WA hospital morbidity and mortality data using probabilistic matching. INCIDENCE: Of 3730 cardiorespiratory arrests in 1996-1999, the age standardised rate of arrests of presumed cardiac origin, where resuscitation was attempted (n=1293) was 32.9 per 100000 person-years and 7.1 per 100000 person-years for bystander-witnessed VF/VT arrests. SURVIVAL: Survival to 28 days was 6.8% following all bystander-witnessed cardiac arrests; 10.6% following bystander-witnessed VF/VT arrests and 33% for paramedic-witnessed cardiac arrests. Logistic regression analysis showed an inverse association between ambulance response time interval and survival following all bystander-witnessed cardiac arrests (and VF/VT arrests). ONE YEAR SURVIVAL: 89% of bystander-witnessed cardiac arrest survivors and 92% of paramedic-witnessed cardiac arrests were still alive at 1 year post-arrest. CONCLUSION: The trends in occurrence and survival following out-of-hospital cardiac arrest in Perth, WA, are similar to those found elsewhere. There is an opportunity to strengthen the chain of survival by reducing the response time interval and increasing the use of bystander cardiopulmonary resuscitation (CPR). First-responder programs and public access defibrillation will need to be considered in the light of local demographics, location and the epidemiologic features of out-of-hospital cardiac arrest.

NTS versus waiting time: an indicator without definition.

OBJECTIVE: The National Triage Scale versus waiting time is a key performance indicator for Australasian emergency departments. However, the point at which the clock starts to measure waiting time has not been defined. The aim of this study was to determine how this indicator is measured in Australia, as well as a number of other issues relating to the application of the National Triage Scale. METHODS: A postal survey was sent to the directors of emergency medicine at 147 emergency departments in Australia. RESULTS: There were 105 responses (71.4%). For measurement of the National Triage Scale versus waiting time indicator, 52 (49.5%) started the clock at the time of patient arrival, 33 (31.4%) at the start of triage, and 11 (10.5%) at the end of triage. Seventy-four emergency departments (70.5%) change the National Triage Scale (NTS) after it has been assigned, and approximately half use set codes for given presentations. Only 28 (26.7%) automatically upgrade children one NTS category. The age definition of a child ranged from 3 years to 18 years. CONCLUSIONS: The measurement of this key performance indicator is not consistent across Australia. Therefore, caution is advised when comparing such data between departments. The Australasian College for Emergency Medicine should produce operational definitions relating to the use of the National Triage Scale in order to provide meaningful comparative data.

The effect on hospital admission profiles of establishing an emergency department observation ward.

OBJECTIVE: To determine the effect of establishing an emergency department observation ward (OW) on admission numbers, average length of stay (ALOS) for the entire hospital and overall bed days for conditions commonly treated in the OW. SETTING: Sir Charles Gairdner Hospital (SCGH), Perth, a tertiary referral teaching hospital. DESIGN: Retrospective analysis of routinely collected hospital data for the 10 most common diagnosis-related group (DRG) categories of patients discharged from the OW for the financial years 1995-96 to 1998-99. Comparison of these data with those for adult patients at the other Perth teaching hospitals over the same period. MAIN OUTCOME MEASURES: For patients in the 10 most common DRGs: numbers of admissions to the OW compared with other inpatient wards; total number of patients admitted to the hospital compared with total bed days; ALOS at SCGH compared with other Perth teaching hospitals. RESULTS: Increased admissions to the OW were paralleled by a decrease in admissions for the same DRG codes to other inpatient wards. ALOS remained approximately the same from 1995-96 to 1998-99 for patients in the OW (one day) and other inpatient wards (4.38 to 4.20 days). However, overall ALOS for patients in these DRGs fell by over a third (from 3.97 to 2.59 days) over this time. The total number of patients in these DRGs treated by the hospital increased by 19% over the four years, but the total number of bed days fell by 23%. By contrast, the ALOS for patients in the same DRGs treated at the other Perth teaching hospitals rose 8% (from 2.12 to 2.28 days). CONCLUSION: Establishment of a formal emergency department OW results in the more efficient management of certain groups of patients, with a decrease in overall hospital bed days and length of stay.

Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time.

OBJECTIVE: To quantify the change in door to needle time when delivery of thrombolytic treatment of acute myocardial infarction was changed from the coronary care unit to the emergency department. DESIGN: A comparative observational study using prospectively collected data. SETTING: Coronary care unit and emergency department of an Australian teaching hospital. PARTICIPANTS: 89 patients receiving thrombolysis in coronary care unit between June 1994 and January 1996, and 100 patients treated in the emergency department between April 1997 and May 1998. INTERVENTIONS: From April 1997, by agreement between cardiology and emergency medicine, all patients with acute myocardial infarction receiving thrombolysis were treated by emergency physicians in the emergency department. MAIN OUTCOME MEASURE: Door to needle time measured from time of arrival at the hospital to start of thrombolysis. Other outcomes included pain to needle time and mortality. RESULTS: Median door to needle times were less for patients treated in the emergency department than in the coronary care unit (37 minutes, 95% confidence interval (CI) 33 to 44 v 80 minutes, 95% CI 70 to 89, respectively; p < 0.0001). Door to needle time was under 60 minutes in 83% of emergency department patients and 26% of coronary care unit patients (57% difference, 95% CI 45% to 69%; p < 0.0001). Median pain to needle time was less for emergency department patients than for coronary care unit patients (161 minutes, 95% CI 142 to 177 v 195 minutes, 95% CI 180 to 209; p = 0.004); times of less than 90 minutes occurred in 18% of emergency department patients v 1% of coronary care unit patients (17% difference, 95% CI 9% to 25%; p < 0.05). Overall mortality was similar in patients treated in the emergency department and the coronary care unit. CONCLUSIONS: With a collaborative interdepartmental approach, thrombolytic treatment of acute myocardial infarction was more rapid in the emergency department, without compromising patient safety. This should improve the outcome in patients with infarcts treated with thrombolytic agents.

A randomized controlled trial of buffered lidocaine for local anesthetic infiltration in children and adults with simple lacerations.

This study assessed the efficacy of buffered lidocaine in children and adults for the repair of simple lacerations. We compared plain lidocaine (PL) with buffered lidocaine (BL) in a prospective, randomized, double-blind, placebo controlled trial. Children had a 10-point pain score assessed by a nurse using predetermined behavior criteria, and a visual analog pain score (VAS) as perceived by the parent. Adult visual analog scores were self reported. In 135 adults, the median VAS was 2.1 for PL and 2.0 for BL. In 136 children, the median nurse-rated pain score was 4.5 for both PL and BL. The parent's median VAS was 4.5 for PL and 4.0 for BL. In contrast to previous studies, we conclude that buffered lidocaine does not reduce infiltration pain in children or adults.

Emergency department telephone advice.

OBJECTIVE: To evaluate telephone advice given in an emergency department. DESIGN: Prospective, observational study. SETTING: A community-based emergency department in a semi-rural/outer metropolitan setting, between August and November 1995. PARTICIPANTS: All people telephoning the emergency department for medical advice. METHODS: Details of all calls, callers and patients were recorded. Within 72 hours, a follow-up call was initiated seeking replies to a series of standardised questions. MAIN OUTCOME MEASURES: Number, timing and duration of calls; appropriateness of the advice given; compliance with the advice; and callers' satisfaction with the service. RESULTS: Over the four-month period, 1682 calls were received, 58% between 4pm and midnight. There were 33 telephone calls per 100 emergency department attendances. The mean call duration was 3.9 minutes (range, 0.25-25 minutes); 49% of patients were less than 14 years old, and 72% of callers phoned because of spontaneous illness. The advice given was considered inappropriate in only 1.4% of calls. Follow-up calls were made to 1132 people (67%), revealing a non-compliance rate of only 6.9% and a high level of caller satisfaction, with 99% of callers affirming a need for such a service. CONCLUSIONS: The provision of telephone advice by emergency department staff is rated highly by the community and compliance with the advice is strong. Paediatric problems, arising as a result of spontaneous illness, predominate and there is a large bias towards after-hours use of the service. Experienced staff provide better advice.

Proximally delivered dilute heparin does not improve circuit life in continuous venovenous haemodiafiltration.

OBJECTIVE: To assess the effect on circuit life in continuous venovenous haemodiafiltration (CVVHD) by manipulating heparin dilution and point of administration. DESIGN: Repeated crossover design. Cases were randomised for first circuit and heparin dilution, after which crossovers occurred until treatment was stopped. SETTING: A 24-bed combined general and surgical intensive care unit admitting 1900 patients a year. On average, 54 cases a year receive CVVHD. PATIENTS: 26 critically ill adult patients requiring CVVHD were enrolled, 18 of whom used at least one standard circuit and one modified circuit. INTERVENTIONS: Two circuit configurations and heparin dilutions were compared. In combination A, standard CVVHD blood lines and heparin concentration (100 units/ml) were used. In combination B, heparin was delivered in a more dilute volume (10 units/ml) via a modified circuit design with an administration port immediately adjacent to the venous access. MEASUREMENTS AND RESULTS: 18 randomised crossovers of circuits A and B occurred. Mean/median circuit life for the standard heparin/circuit combination A was 20.1/17.5 (SD 14.6) and for the modified combination B 21.4/15.4 (SD 19.2). There was no significant difference between circuits (paired t-test, p = 0.8175). To identify other factors which could have influenced circuit life (platelet count, heparin dose and pre- and post-filter activated partial thromboplastin time, APTT) all circuits terminated for the reasons identified (n = 105) were analysed using linear modelling. Survival analysis was used to determine the survival function of the circuit. Pre-heparin APTT was the only factor associated with an increase in filter life (p = 0.035). The hazard rate for filter failure was 0.049/h (95% confidence interval 0.04 to 0.06), the range of time until filters failed was 1.8 to 78.5 h. CONCLUSIONS: Proximally administered dilute heparin is not associated with a significant increase in circuit life.

The use of thrombolytic therapy in patients presenting to a peripheral metropolitan emergency department with acute myocardial infarction.

BACKGROUND: While use of thrombolytic therapy in the management of acute myocardial infarction has become accepted practice in major teaching hospitals, its use in peripheral metropolitan hospitals has not been well accepted. AIM: To evaluate the use of thrombolytic therapy in the management of acute myocardial infarction in the Emergency Department (ED) of a peripheral metropolitan hospital. METHODS: A mixed prospective and retrospective observational study of 69 patients with acute myocardial infarction, who received thrombolytic therapy during a three year period, was conducted in a community based ED. RESULTS: Demographic data, door to drug interval, complications occurring during administration of thrombolytics and subsequent interhospital transfer were recorded. The mean door to drug interval in 1992 was 79.7 minutes (95% CI: 50.7 to 109.1) and by 1994 this had fallen to 25.6 minutes (95% CI: 18.9 to 32.3). Hypertension (22%) was the most common complication of therapy observed and cardiac arrest occurred in two cases (3.2%). A single episode of hypotension and vomiting were the only complications that occurred during interhospital transfer. There were no deaths during therapy or transfer. CONCLUSION: Thrombolytic therapy can be undertaken in the EDs of peripheral metropolitan hospitals in a safe and timely manner. There is little justification for routine medical escorts in the clinically stable post thrombolysis patient.

A randomized, controlled trial of oral midazolam and buffered lidocaine for suturing lacerations in children (the SLIC Trial).

STUDY OBJECTIVE: To evaluate the efficacy of oral midazolam (0.3 mg/kg) and buffered lidocaine in reducing the anxiety associated with the repair of childhood lacerations. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Community-based emergency department. PARTICIPANTS: Children younger than 10 years. INTERVENTIONS: Each subject was randomized into one of four treatment groups: A, midazolam and buffered lidocaine (n = 25); B, placebo and buffered lidocaine (n = 27); C, midazolam and plain lidocaine (n = 32); and D, placebo and plain lidocaine (n = 23). RESULTS: Anxiety level was scored on a scale of 1 to 4 on the basis of predetermined behavior criteria before and during repair. Parents independently rated the child's distress using a visual analog scale. Vital signs were measured on admission and at discharge. There were no significant differences among the treatment groups for age, location and length of laceration, or initial anxiety scores. Midazolam decreased the number of children with anxiety levels 3 and 4 by 24% (95% CI, 7.5% to 41.3%). There was a 33% reduction of the parents' distress rating with midazolam (P < .01). Buffered lidocaine had no effect on anxiety level. CONCLUSION: Oral midazolam (0.3 mg/kg) is a safe and effective treatment for reducing anxiety during the suturing of lacerations in children less than 10 years of age. In this study, buffered lidocaine had no effect on anxiety level.

Radiologic placement of peritoneal dialysis catheters: preliminary experience.

The authors percutaneously placed 45 catheters for peritoneal dialysis in 32 patients, aged 31-83 years, in a radiology department. In all patients, the procedure was modified by use of the Hawkins needle, and in response to the high frequency of extrusion of the proximal cuff, the deep cuff of the 16th and each subsequent catheter was sutured to the rectus muscle or fascia. After 17 catheters were placed, the catheter was modified with a permanent bend, or "U" neck, between the two cuffs, which were then thickened. All procedures were performed with use of local anesthesia, and all catheters were successfully placed. Acute complications included bowel perforation associated with peritonitis in one patient (2%). Delayed complications included cuff extrusion in nine patients (20%), obstruction in nine patients (20%), and peritonitis requiring removal of the catheter in three patients (7%). This study shows the feasibility of percutaneous placement of peritoneal dialysis catheters by radiologists despite the need for improved technique and equipment.

A review of pre-hospital defibrillation by ambulance officers in Perth, Western Australia.

Ventricular fibrillation (VF) is the most common presenting rhythm in cardiac arrest occurring outside hospitals. All cases of VF treated with a defibrillation-only protocol by ambulance officers were reviewed. Of the 231 cases entered into the study, 40 (22.7%) patients survived to 28 days after discharge from hospital. The proportion of survivors in this study is similar to that receiving full paramedic services. Further, where time to defribillation is short, the chance of survival improves. The key determinant in survival from VF occurring outside hospital appears to be how rapidly defibrillation can be initiated.

Sonographic and Doppler features of infantile hepatic hemangiomas with pathologic correlation.

The sonograms of five patients with a diagnosis of infantile hepatic hemangioma were retrospectively reviewed to analyze their sonographic and Doppler characteristics. Three patients had single lesions, whereas two had multifocal involvement. All lesions except one were hypoechoic, well-circumscribed, and solid; the exception was hyperechoic. Findings of high flow, ie, large draining veins, an abrupt change in aortic caliber, and the presence of Doppler signal throughout the lesion were seen in three of five patients. The sonographic findings correlate well with the pathologic findings of multiple vascular channels separated by fibrous septa. The major differential diagnosis of infantile hepatic hemangioma includes hepatoblastoma and metastatic neuroblastoma. Although some of their sonographic features may simulate a hemangioma, large draining veins and changes in aortic caliber are not reportedly seen. Doppler flow was not seen in either of these malignant neoplasms in our study and, to date, has only been reported peripheral to three cases of hepatoblastoma and not at all in metastatic neuroblastoma. We propose an algorithmic approach dependent upon the sonographic-Doppler appearance.

Surface coil FLASH magnetic resonance imaging of the fasting and secretin-stimulated pancreas.

The purpose of this study is to investigate the response of the pancreas to secretin stimulation using magnetic resonance imaging (MRI). Using the Siemens 1.0 T Magnetom and a Helmholtz surface coil, single breath FLASH-MRI of the normal fasting pancreas was performed in the prone position, both before and after a 20-minute period after intravenous (IV) bolus injection of secretin (2 cu/kg). T2*-weighted fast low-angle shot sequences (TR = 150 mseconds; TE = 30 mseconds; flip angle = 10 degrees; matrix = 256 X 256; acquisitions = 2) demonstrated an immediate response manifested by a significant distension of the duodenum with fluid secreted by the pancreas, as well as a gradual decline of the pancreas/muscle signal intensity (SI) ratio over time. Twenty minutes after secretin administration, the mean percent decrease of the pancreas/muscle SI ratio in six volunteers was 11.6 +/- 6.4 (1-STD). This is statistically significant (P less than .003) given a mean percent increase of the pancreas/muscle SI ratio of 1.6 +/- 4.8 (1-STD) in five volunteers 20 minutes after bolus injection of saline (control). Although significant duodenal distension is easily demonstrated after secretin administration, the decrease of the relative pancreatic SI over time is visually subtle. Further work is needed to enhance imaging of the physiologic response of the pancreas using even more rapid imaging techniques.

Cocaine abuse: neurovascular complications.

In a review of the records of 3,712 drug abusers, 13 patients were identified with neurologic deficits attributable to the use of cocaine. Ischemic manifestations were the most frequent, occurring in seven (54%) patients, with a mean age of 34.2 years. Three (23%) patients had subarachnoid hemorrhage, and three (23%) had intracerebral hemorrhage. Three patients from other institutions were included in the analysis, for a total of 16 patients, (eight with cerebral ischemia, four with subarachnoid hemorrhage, and four with intracerebral hemorrhage). Of the six patients with head computed tomographic findings of cerebral infarction, five had subcortical infarcts. Two of the four patients who presented with a subarachnoid hemorrhage had a congenital intracranial aneurysm. One of the four patients with an intracerebral hemorrhage had an underlying arteriovenous malformation. The mechanism through which these complications occur is not completely understood. Factors that may play a role include the acute hypertensive response that occurs with cocaine use as well as disordered neurovascular control.