Bedside Ultrasound Versus Chest Radiography for Detection of Pulmonary Edema: A Prospective Cohort Study.

OBJECTIVES: Chest radiography has been the preferred imaging study to assess pulmonary congestion. However, chest radiography interpretation is influenced by the level of expertise and high interobserver variability. Lung ultrasound (US) may produce more objective findings through evaluation of vertical comet tail artifacts known as B-lines, which are created by a decrease in the ratio of alveolar air to fluid pulmonary content. Few studies have directly compared chest radiography to bedside US against a reference standard for the diagnosis of pulmonary edema. This study compared the sensitivity and specificity of bedside US and chest radiography in diagnosing pulmonary edema. METHODS: This prospective observational cohort study involved adult patients presenting to the emergency department of an urban tertiary hospital with dyspnea. The primary outcome was the presence or absence of pulmonary edema, as indicated by B-lines on a bedside lung US examination or radiologist-interpreted chest radiography. Patients underwent a US examination within about 1 hour of chest radiography. The final diagnosis from the discharge summary served as the reference standard. RESULTS: Ninety-nine patients were enrolled; 32.3% had congestive heart failure, and 40.4% had chronic obstructive pulmonary disease. Bedside US showed significantly higher sensitivity (96%) compared to chest radiography (65%; P < .001). Of 18 patients with negative radiographic findings and a discharge diagnosis of pulmonary edema, 16 (89%) had positive US findings (P < .001). CONCLUSIONS: Bedside US has the potential to identify pulmonary edema more accurately than chest radiography. As current practice within the United States uses chest radiography, reflecting American College of Cardiology Foundation/American Heart Association guidelines for management of heart failure, the results of this study warrant further evaluation.

Patient Satisfaction With Propofol for Outpatient Colonoscopy: A Prospective, Randomized, Double-Blind Study.

BACKGROUND: Previous literature has shown that propofol has ideal anesthetic properties for patients undergoing colonoscopy, a common procedure at outpatient surgery centers. However, there is a paucity of information regarding patient satisfaction with propofol. OBJECTIVE: The aim of this study was to evaluate patient satisfaction with propofol compared with nonpropofol (fentanyl/midazolam) anesthesia for outpatient colonoscopies. Safety and complications were secondary end points. DESIGN: This study was a double-blind, randomized, parallel-group controlled clinical trial (NCT 02937506). SETTING: This study was conducted at a single ambulatory surgery center at an urban teaching community health system. PATIENTS: Patients were scheduled for outpatient colonoscopy. Those with high-risk cardiac or pulmonary disease were excluded. INTERVENTIONS: Anesthesia personnel administered either fentanyl/midazolam (n = 300) or propofol (n = 300) for sedation during outpatient colonoscopy. A single, highly experienced endoscopist performed all colonoscopies. MAIN OUTCOME MEASURES: The primary outcomes measured were patient satisfaction (5-point Likert scale) and procedure complications. Data were collected on the day of endoscopy by the nursing staff of the postanesthesia care unit. A subinvestigator blinded to the randomization called patients 24 to 72 hours after discharge to obtain data on postprocedure problems and status of resumption of normal activities. Analysis was intention-to-treat. RESULTS: Fewer patients who received propofol remembered being awake during the procedure (2% vs 17% for fentanyl, p < 0.0001) and were more likely to rate the amount of anesthesia received as being "just right" (98.7% vs 91.3% for fentanyl, p = 0.0002) and state that they were "very satisfied" with their anesthesia (86.3% vs 74% for fentanyl, p = 0.0005). Twenty-six percent of fentanyl procedures were rated "difficult" compared with 4.3% for propofol (p < 0.0001), and complications were fewer in the propofol group (2.7% vs 11.7%, p < 0.0001). LIMITATIONS: The endoscopist could not be completely blinded to the anesthetic administered. CONCLUSIONS: Patients prefer propofol over a combination of fentanyl/midazolam as their anesthetic for outpatient colonoscopies. From a patient and provider perspective, propofol appears to be superior to fentanyl/midazolam for outpatient colonoscopy. See Video Abstract at http://links.lww.com/DCR/A445.

Orthostatic hypotension in patients with dementia: clinical features and response to treatment.

OBJECTIVE: To evaluate orthostatic hypotension (OH) prevalence, risk factors, signs and symptoms, and treatment response in patients with dementia. BACKGROUND: No previous studies had systematically delineated the clinical features of OH in patients with dementia and determined the effects of treatment. Diagnosing this treatable disorder may prevent the severe consequences of falls, syncope, confusion, ischemic brain injury, and death; mortality risk rises with worsening OH. Lesser consequences include skin injuries, sprains, fractures, and subdural hematomas. METHODS: We reviewed the charts of 188 patients with dementia who had been treated by author D.F., a solo neurologist/neurobehaviorist. About half of the patients had been diagnosed with OH. D.F. had treated the OH until the patients had much improved blood pressure and symptoms, were asymptomatic, or no longer met OH diagnostic criteria. We collected data on diagnoses, blood pressures, and clinical features before and after treatment. RESULTS: Our patients' most frequent OH signs and symptoms were mental fluctuations (65.6% of patients), excessive sleeping in chairs (29.2%), slow falls without losing consciousness (20.8%), lethargy or fatigue (15.6%), and dizziness (13.5%). All 5 of these signs and symptoms improved significantly with treatment. CONCLUSIONS: Patients with dementia were less likely to have traditional OH symptoms like dizziness than to have mental fluctuations and confusion, drowsiness, and slow falls. Blaming these problems on worsening dementia and neglecting OH as a potential cause may delay diagnosis and specific treatments that can improve patients' safety, daily function, and quality of life.

Weight and body fat changes in postpartum depot-medroxyprogesterone acetate users.

BACKGROUND: Although postpartum depot-medroxyprogesterone acetate (DMPA) recipients often cite weight gain as the reason for discontinuing DMPA, little is known about body composition changes in postpartum DMPA recipients. STUDY DESIGN: Women who used DMPA during the postpartum year were measured on several anthropometric dimensions of body composition and compared with women who elected surgical sterilization with bilateral partial salpingectomy (BPS). RESULTS: After 1 year, DMPA recipients did not differ from the BPS group in weight or percent body fat changes. Almost half the women using DMPA returned to pregravid weight; nearly half gained weight. Higher pre-pregnancy body mass index was associated with weight gain among DMPA recipients. CONCLUSIONS: DMPA recipients who were overweight or obese before pregnancy may have greater risk for weight gain in the first year postpartum. However, when counseling women, the risk for DMPA-related weight gain should be balanced against the potential for increased weight from subsequent pregnancies.

Implementation and early outcomes of a peer-led traffic safety initiative for high school students.

Compared with other age groups, teenagers have the lowest rate of safety belt use. We sought to determine whether an ongoing, student-led initiative would be effective in increasing safety belt use among high school students compared with another school in which the intervention did not take place. At the intervention school, there was a statistically significant increase of 15% in observed safety belt use and evidence of increased knowledge regarding proper safety belt use. High schools can be effective in changing the traffic safety behaviors of its students.

Frequency and characteristics of coagulopathy in trauma patients treated with a low- or high-plasma-content massive transfusion protocol.

A massive transfusion protocol (MTP) in which most non-RBC transfusions were laboratory result-driven was updated to a 1:1:1 RBC/plasma/platelet formula-driven protocol. Platelet count, fibrinogen level, and prothrombin time (PT) were monitored. In the patients who survived the first 12 hours, the results of coagulation tests were analyzed. Irrespective of the MTP or transfused RBC/plasma ratio, a majority of patients became coagulopathic, usually within the first 2 hours, and a fibrinogen deficiency (fibrinogen level, <100 mg/dL [2.9 µmol/L]) was almost always the initial abnormality. The laboratory value trends under each MTP were indistinguishable: PTs were prolonged and platelet counts and fibrinogen levels fell during the first 100 minutes and then corrected back toward baseline. More than 80% of patients in each group were noncoagulopathic at 12 hours. A 1:1:1 formula-driven MTP did not affect the frequency, nature, or duration of coagulopathy according to laboratory test results.

Vaginal-perianal compared with vaginal-rectal cultures for detecting group B streptococci during pregnancy.

OBJECTIVE: To estimate whether vaginal-perianal cultures could be an alternative to the recommended vaginal-rectal screening cultures for the detection of group B streptococci (GBS) during pregnancy, and to compare patient pain and discomfort between the two collection methods. METHODS: Patients included were aged 18 or older and at 35-37 weeks of gestation. After consent, each patient underwent collection of a vaginal-perianal followed by a vaginal-rectal culture. Patients rated their pain on a 0-to-10 scale for each collection method and indicated whether one method had more discomfort than the other. The primary outcome of the study was the proportion of patients whose vaginal-perianal and vaginal-rectal culture results agreed with one another. RESULTS: Data were collected from 193 patients. The overall agreement rate between the vaginal-perianal and vaginal-rectal cultures was 186 out of 193 (96.4%; lower 95% confidence bound was 93.4%), yielding a 91.1% sensitivity and 98.5% specificity. There were two false positives and five false negatives. The GBS detection rates were similar between the two collection methods (P = .257). On average, pain was 3.4 points for the vaginal-rectal method and 1.2 points for the vaginal-perianal method (P<.001). More than two-thirds of the patients stated that the vaginal-perianal collection method had less discomfort than the vaginal-rectal method. CONCLUSION: Agreement was high between the recommended vaginal-rectal and the studied vaginal-perianal collection methods. Patients indicated less pain and discomfort with the vaginal-perianal collection method. Therefore, vaginal-perianal cultures may be reasonable, patient-preferred alternatives for the recommended vaginal-rectal cultures for detection of GBS during pregnancy. LEVEL OF EVIDENCE: II.

Temporal artery scanning falls short as a secondary, noninvasive thermometry method for trauma patients.

Oral and mandibular trauma pose barriers to oral thermometry. We sought to determine whether temporal artery (TA) scanning thermometry could be an accurate, noninvasive back up method of thermometry in patients with these types of traumatic injury. We compared 3 techniques of TA scanning, axillary thermometry, and oral thermometry in critical care patients. Our results indicate that TA scanning methods were, at best, comparable with axillary measurements. In addition, the performance of the TA scanners varied with body mass index, whereas axillary readings did not.

Incidental findings in the cervical spine at CT for trauma evaluation.

OBJECTIVE: CT is the standard of care for assessment of traumatic injuries. Because of the detail depicted with this technique, findings incidental to the injury are easily detected. We sought to determine the frequency and types of incidental findings in the cervical spines of trauma patients undergoing CT. MATERIALS AND METHODS: The trauma registry was accessed to identify the cases of patients evaluated with cervical spine CT at a level 1 trauma center from January to July 2007. Trauma registry data, including age, sex, injury severity score, mechanism of injury, length of stay, and diagnosis were recorded, and all CT scans of the cervical spine were reviewed for incidental findings. Clinically significant incidental findings were classified according to bodily location, and the association between various patient characteristics and the likelihood of an incidental finding was assessed. RESULTS: We identified incidental CT findings in 230 of 1,256 patients (18.3%) who underwent CT of the cervical spine during an initial trauma evaluation. We stratified the incidental findings as trauma-related and not trauma-related. The likelihood of non-trauma-related incidental findings was associated with age (p < 0.0001). The likelihood of trauma-related incidental findings was associated with injury severity score (p < 0.0001). CONCLUSION: Incidental findings in the cervical spine were associated with age, injury severity score, and mechanism of injury. Awareness of the prevalence of incidental findings is important to assuring that both traumatic and nontraumatic pathologic findings are detected and appropriately managed.

Perceived value of trauma autopsy among trauma medical directors and coroners.

INTRODUCTION: Although autopsy is acknowledged as essential for improving quality of medical care of trauma patients and accuracy of injury surveillance systems, the autopsy rate has remained well below 100% for certain categories of trauma. We obtained recent documentation of the frequency of autopsy among trauma-related deaths in Ohio, and surveyed coroners and trauma program medical directors (TMDs) about the perceived benefits and challenges of performing autopsy. MATERIALS AND METHODS: Copies of death certificates were obtained for the years 1996-2001. Death and autopsy rates were calculated and examined for trends over time. Surveys covering the topics of mechanisms of injury prompting autopsy, uses and users of autopsy data, and barriers to performing autopsy were sent to Ohio's coroners, coroners from nearby states, and Ohio TMDs. The chi(2)-test for trend analysed autopsy rates over time, while responses among groups were compared using the chi(2)-test. RESULTS: The autopsy rate for injury related deaths increased from 50% in 1996 to 66.5% in 2001 (p=.0018). During the study period the volume of autopsies rose by 18%, from 2990 to 3546. There was no review by the coroner in almost 10% of trauma deaths. TMDs more often indicated that autopsies advance medical knowledge than did Ohio and non-Ohio coroners (62.9% versus 33.4% and 47.6%, respectively, p=.016). TMDs more frequently reported themselves as users of autopsy information than did Ohio and non-Ohio coroners (91.4% versus 14.6% and 20%, respectively, p<.0001). All groups reported inadequate funds and personnel as the two most common barriers to performing autopsies, although TMDs were more likely to identify these as barriers than coroners (p<.0001). Almost 27% of Ohio coroners agreed with the statement, "I do not feel that trauma-related autopsies are necessary". CONCLUSION: Significant barriers exist to improving autopsy rates among trauma patients who die. These include not only more well-recognised impediments such as inadequate funds and personnel, but less commonly reported issues concerning differing points of view on the role of trauma-related autopsy among coroners and TMDs. To improve trauma-related autopsy rates, each of these issues requires attention and cooperation among all parties.

Randomized trial comparing 3 methods of postoperative analgesia in gynecology patients: patient-controlled intravenous, scheduled intravenous, and scheduled subcutaneous.

OBJECTIVE: The objective of the study was to determine whether any of 3 routes of opioid administration (patient-controlled analgesia [PCA], scheduled intermittent intravenous [i.v.], or scheduled intermittent subcutaneous [s.q.]) provides superior pain relief and satisfaction among patients undergoing abdominal gynecologic surgery. STUDY DESIGN: Patients were randomized to intravenous hydromorphone by PCA, i.v. hydromorphone via scheduled nurse-administered doses, or s.q. hydromorphone via scheduled nurse-administered doses. Self-reported pain and satisfaction were recorded over 48 hours following arrival at the nursing unit. Linear mixed effects modeling was used to compare outcomes among the groups. RESULTS: Neither pain scores nor satisfaction differed by group. PCA patients had higher total opioid use (P < .0001) and a higher rate of pruritus (P = .04). CONCLUSION: Given these findings as well as those in previous literature, no specific method of postoperative analgesia appears to be superior.

Effect of a community-based weight management program on weight loss and cardiovascular disease risk factors.

OBJECTIVE: The purpose of our retrospective database analysis was to describe and evaluate the outcomes of a weight loss intervention in a community medical wellness center. RESEARCH METHODS AND PROCEDURES: Four hundred eighteen overweight and obese adults entered the program between 2001 and 2004. Forty-seven percent completed the 6-month program designed using standards and recommendations established by the NIH, the American Dietetic Association, and the American Academy of Sports Medicine. Data analysis was limited to 198 participants (142 women, 56 men) completing the program. RESULTS: Individuals completing the 6-month program averaged a weight loss of 7.3% in men and 4.7% in women. Fasting lipids and blood glucose improved in both genders regardless of age. Outcomes including BMI and lipids improved in women regardless of menopausal status or hormone replacement therapy. There was a significant correlation between percentage weight loss and number of weekly counseling sessions attended and number of visits to the wellness center for exercise. DISCUSSION: Participants who complete a structured community-based weight management program can achieve significant weight loss and improvement in cardiovascular risk factors regardless of age, gender, or menopausal status. Our analysis suggests that national treatment guidelines/recommendations for weight management can be effectively implemented in a community medical wellness center. The relatively high drop-out rate associated with this program suggests the need to identify strategies and techniques to enhance adherence and completion of programs.

Randomized, double-blind, placebo-controlled trial of vaginal misoprostol for management of early pregnancy failures.

OBJECTIVE: To determine whether misoprostol medical management of early pregnancy failures is more effective than expectant management. STUDY DESIGN: Patients diagnosed with early pregnancy failures, closed cervix, and minimal vaginal bleeding were randomized to 800 microg of misoprostol or placebo placed vaginally. Patients were evaluated by ultrasound imaging 24 hours and 48 hours after study drug administration, with repeat administration if 24-hour imaging showed a persistent gestational sac. Treatment success was defined as expulsion of uterine contents within 48 hours. Patient follow-up occurred 2 weeks after expulsion of uterine contents. RESULTS: Treatment success occurred in 15 of 18 (83%) misoprostol patients and 2 of 16 (13%) placebo patients (P < .0001). Side effects were similar between groups except for vaginal bleeding, which was more common in the misoprostol group (P = .001). Patient satisfaction and pain perception were similar between groups. CONCLUSION: Misoprostol appears to be highly effective for treating early pregnancy failures, with few side effects and high patient satisfaction.