Various Clinical Scenarios in Secondary Malignant Lymphedema.

Diagnosing malignant lymphedema is a challenge in daily clinical practice. Clinically, patients may show clear signs of malignancy, but this is not always the case, and at times the diagnosis is not straightforward. In some patients, pain, hardness of the tissues, joint stiffness, proximal involvement, collateral circulation, or an acute onset will provide the clue to determining malignancy. Our aim is to describe several diverse scenarios of Secondary Malignant Lymphedema (SML) with the etiopathogenesis. One possible cause is lymphatic obstruction due to extrinsic compression of lymphatic vessels and/or nodes by either the primary tumor or metastatic masses. Lymphatic obstruction can also be caused by tumoral infiltration. This infiltration can affect both deep and regional nodes as well as cutaneous and subcutaneous vessels and is commonly known as lymphangitis carcinomatosa. Malignant lymphedema can also be secondary to obstruction of the venous flow due to tumoral venous thromboembolism or to extrinsic compression of the veins by tumors or adenopathic masses. Nevertheless, the most frequent cause of this illness is a mixed mechanism of compression of the lymphatic and venous systems. Frequently, SML is the first manifestation of relapse. When lymphedema appears abruptly, is progressive, with intense pain, associated with collateral circulation, or with hard and infiltrated skin or joint stiffness, SML must be ruled out with an urgent referral to the oncologist and an imaging evaluation.

Respiratory tract infections during the 2011 Mycoplasma pneumoniae epidemic.

In 2011, Norway experienced a surge in community acquired Mycoplasma pneumoniae infections. Norway also has one of the highest rates of reported Bordetella pertussis infections, despite high vaccine coverage. We aimed to determine the prevalence of upper respiratory tract pathogens in patients attending primary care physicians for respiratory illness during the 2011 M. pneumoniae epidemic period. A retrospective analysis of data from 26,039 patients that have had nasopharyngeal swabs analysed by nucleic acid amplification testing (NAAT) for M. pneumoniae, C. pneumoniae and B. pertussis was performed. Subsets of samples were tested for additional pathogenic bacteria, including B. parapertussis and B. holmesii, as well as influenza virus. M. pneumoniae, C. pneumoniae and B. pertussis were detected in 2,484 (9.5 %), 261 (1.0 %) and 821 (3.2 %) patients, respectively. Co-infection of M. pneumoniae and B. pertussis was found in 50 (0.19 %) patients, C. pneumoniae and B. pertussis in 4 (0.02 %). Influenza virus was found in 899 (24.5 %) of 3,661 nasopharyngeal swabs. Co-infection of influenza virus and bacterial pathogens was common, although influenza virus co-infection with B. pertussis occurred significantly more often than with C. pneumoniae and M. pneumoniae (20.4 % versus 2.9 % and 9.1 %, respectively; p<0.005). Testing for Bordetella species genes IS1001, IS1002 and recA showed that B. holmesii was most likely misdiagnosed as B. pertussis in 5.8 % of cases. The most prevalent respiratory tract pathogen in the general population in 2011 was M. pneumoniae. B. pertussis was also found frequently as was B. pertussis and influenza virus co-infections.

Translating addictions research into evidence-based practice: the Polaris CD outcomes management system.

Converting the findings from addictions studies into information actionable by (non-research) treatment programs is important to improving program outcomes. This paper describes the translation of the findings of studies on Patient-Services matching, prediction of patient response to treatment (Expected Treatment Response) and prediction of dropout to provide evidence-based decision support in routine treatment. The findings of the studies and their application to the development of an outcomes management system are described. Implementation issues in a network of addictions treatment programs are discussed. The work illustrates how outcomes management systems can play an important role in translating research into practice.

Pulmonary alterations associated with inhalation of occupational and environmental irritants.

Many gases, vapors, or particles found in occupational and/or environmental settings can act as irritants. In the present study, sensory irritants are characterized by the stimulation of neuropeptide release from sensory nerves in the nasal mucosa, while pulmonary irritants are characterized by recruitment of PMN into bronchoalveolar airspaces, elevation of breathing frequency, and neuropeptide release from sensory fibers innervating the epithelium of the conducting airways. A review of data from our laboratory as well as results from others indicate that asphalt fume is a sensory irritant; toluene diisocyanate (TDI), methyl isocyanate, and machining fluid act as both sensory and pulmonary irritants; while cotton dust, agricultural dusts, microbial products, leather conditioner, and ozone exhibit responses characteristic of pulmonary irritants.

Milestones in medical management of trauma.

Trauma care appears to be a relatively young science because of the major strides made after World War II. A historical foundation of today's practice is provided, with interesting anecdotes concerning some of the pioneers, their motivations, and the reactions of their medical peers. A chronology of trauma care highlights the growth of multiple fields of science that eventually blended to become the basis for modern care.

Easing pain in children.

The assessment and management of pain in children has been essentially ignored until recently. Thankfully, these "dark ages of pain" are ending. The trauma nurse is an integral part of the pain management team and can have a positive impact on outcome by using a combination of relatively simple strategies. These include using multiple types of assessment to measure the severity of pain; providing adequate pain relief with a combination of pharmacologic and nonpharmacologic interventions; and carefully monitoring and documenting the efficacy of all pain management approaches.

Evaluation of a model for improving emergency medical and trauma services for children in rural areas.

STUDY OBJECTIVE: To evaluate the effectiveness of a rural emergency medical and trauma services project in increasing the knowledge and confidence of emergency care personnel in the management of acutely ill and injured children. METHODS: This prospective, quasi-experimental study used an untreated control group design with pretest and posttest of pre-hospital and hospital-based emergency care personnel in two rural counties in central Ohio. Project evaluation compared 50 emergency care providers from the intervention county with 43 emergency care providers from the control county. Changes in knowledge and confidence of these personnel in the assessment and management of pediatric emergencies were compared. RESULTS: Providers in the intervention county demonstrated a significantly greater increase in test scores regarding knowledge of pediatric emergencies than did providers in the control county (P = .001). Significantly greater improvement was also seen when comparisons of test scores were made for field (P = .02) and hospital (P = .03) emergency care personnel separately. Self-reports on a visual analog scale indicated that providers in the project intervention county had a significantly greater decrease in anxiety than did control subjects when presented a scenario of a child experiencing a respiratory arrest (P = .01). On the basis of scores from a five-point Likert scale, emergency personnel in the intervention county had a greater increase in confidence regarding management of the pediatric airway (P = .0003) and a greater increase in the belief that they had adequate pediatric training (P = .000001) after participating in the project than emergency personnel in the control county. CONCLUSION: The rural pediatric emergency medical and trauma services project was effective in increasing the knowledge and confidence of emergency care personnel in the management of acutely ill and injured children. This project offers a model that can be replicated in other rural areas nationally.

Essentials of airway management for the injured child.

The anatomy of a child's airway presents multiple challenges for health care providers who must maintain adequate ventilation and oxygenation. The care giver must be knowledgeable about the anatomic differences between children and adults and skilled in the use of pediatric airway adjuncts to provide safe, effective airway management.