Changes in the Management of Common Bile Duct Stones: 1980 to Date.

OBJECTIVE: To compare the results of treating patients with common bile duct (CBD) stones by endoscopic sphincterotomy (ES), surgical exploration, or a combination of ES and surgical CBD exploration (the rendezvous technique). METHODS: A narrative review of the literature. SUMMARY OF DATA: Before 1990, 17 cohort studies indicated that ES cleared CBD stones in 92.0% of patients, with a mortality rate of 1.5%. Surgery removed CBD stones in 90.2% of patients, with a 2.1% mortality rate. A single randomized controlled trial in 1987 showed that ES removed CBD stones in 91% of 55 patients, with a 3.6% mortality rate and a 27% complication rate, whereas surgical CBD exploration removed CBD stones in 92%, with a 1.8% mortality rate and a 22% complication rate. Since 1991, 26 randomized controlled trials have shown that laparoscopic-ES rendezvous is as effective as ES alone and laparoscopic surgery alone but is associated with fewer complications, a reduced need for additional procedures, and a shorter hospital stay. CONCLUSIONS: A laparoscopic-ES rendezvous appears to be the optimal approach to the treatment of CBD stones in younger and fit patients. The choice between ES alone and laparoscopic-ES rendezvous in older or high-risk patients remains uncertain.

Meaningful shared decision-making: complex process demanding cognitive and emotional skills.

BACKGROUND: Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences. METHODS: The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM. RESULTS: We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills. CONCLUSIONS: We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

Human Factors and Quality Improvement in the Emergency Department: Reducing Potential Errors in Blood Collection.

OBJECTIVES: Adverse events in blood collection procedures such as mismatched or unlabeled samples may have critical implications on patient safety (such as wrong diagnosis and treatments). The current study examined blood collection procedures in an emergency department before and after the application of a human factors approach for improving performance quality and preventing adverse events. METHODS: In the emergency department of a community care hospital, 190 blood collection events were observed in 2 phases: preintervention and postintervention. Two quality measures were tested as follows: quality measure 1, performing all 7 stages in the procedure of blood collection according to protocol, and quality measure 2, performing the stages of the procedure in the correct sequence according to the protocol. In addition, medical staff anonymously answered questionnaires about their procedure for collecting blood. RESULTS: Analyses of data collected before the intervention revealed only 2 events in which all 7 stages in the protocol of the procedure were performed and only 1 event in which the 7 stages of the procedure were performed in the correct sequence. In 91% of the events, the patient was not fully identified. Based on these findings, we developed an intervention using a human factors approach to improve the quality of performance. Analyses of data collected after the intervention revealed significant differences (t188 = -14.9, ρ < 0.01) in quality measure 1 before (mean [SD], 4.8 [0.6]) and after (mean [SD], 6.4 [0.8]) the intervention was initiated, which implies improvement on efficiency subsequent to the implementation of the intervention. Improvement also appeared in quality measure 2. CONCLUSIONS: This study illustrates the nature of potential errors in blood collection performance, offering a proactive approach to improve the rate of proper performance.

Organizational factors affecting length of stay in the emergency department: initial observational study.

BACKGROUND: Length of stay (LOS) is considered a key measure of emergency department throughput, and from the perspective of the patient, it is perceived as a measure of healthcare service quality. Prolonged LOS can be caused by various internal and external factors. This study examined LOS in the emergency department and explored the main factors that influence LOS and cause delay in patient care. METHODS: Observations of 105 patients were performed over a 3-month period at the emergency room of a community urban hospital. Observers monitored patients from the moment of entrance to the department until discharge or admission to another hospital ward. RESULTS: Analysis revealed a general average total emergency department LOS of 438 min. Significant differences in average LOS were found between admitted patients (Mean = 544 min, SD = 323 min) and discharged patients (Mean = 291 min, SD = 286 min). In addition, nurse and physician change of shifts and admissions to hospital wards were found to be significant factors associated with LOS. Using an Ishikawa causal diagram, we explored various latent organizational factors that may prolong this time. CONCLUSIONS: The study identified several factors that are associated with high average emergency department LOS. High LOS may lead to increases in expenditures and may have implications for patient safety, whereas certain organizational changes, communication improvement, and time management may have a positive effect on it. Interdisciplinary methods can be used to explore factors causing prolonged emergency department LOS and contribute to a better understanding of them.

Renal infarction in the ED: 10-year experience and review of the literature.

OBJECTIVE: We aimed to describe clinical and radiologic features of acute renal infarction (RI). METHODS: Clinical, computed tomography (CT), and laboratory findings were retrospectively reviewed for patients diagnosed from 1999 to 2009 with CT proof of acute RI. Possible etiology of infarction was recorded. All available published series of RI were reviewed. RESULTS: Thirty-eight patients with acute RI met inclusion criteria; 127 cases of RI from 7 previous series were pooled for analysis. The most common symptoms were abdominal pain, flank pain, nausea, and vomiting. Leukocytosis (>10 × 10(9)/L) and elevated lactate dehydrogenase levels (>620 IU/L) were the most prominent laboratory findings. Computed tomography features included wedge-shaped hypodensities in the renal parenchyma in 35 (92%) and global renal ischemia in 3 (8%) patients; 13 patients (34%) had concomitant splenic infarction. The most common etiology was atrial fibrillation. Computed tomography determined the specific cause for RI in 5 patients (13%) and a possible etiology in 17 (45%). Exact correlation with previous series was limited by methodological diversity. CONCLUSION: Renal infarction should be considered in the differential diagnosis of a patient presented to the emergency department with abdominal or flank pain. Laboratory workup should include lactate dehydrogenase levels. After ruling out stone disease, contrast-enhanced CT examination is essential for the diagnosis.

Hypersensitivity reaction to a mosquito bite in a patient with chronic myeloid leukemia.

A twenty-one-year-old male patient with an exaggerated hypersensitivity reaction to a mosquito bite presented to the department of emergency medicine for further evaluation. He was noted on physical examination to have splenomegaly. The hematological blood tests that were performed were compatible with chronic myeloid leukemia (CML). In this case, the mosquito bite heralded the diagnosis of CML.

Need for emergency department observation after scorpion sting: prospective study and review of the literature in the Middle East.

OBJECTIVE: To question the existing practice to observe the victims of scorpion sting in the emergency department at least for 6 h. METHODS: Prospective study of all adult patients presenting to emergency department after scorpion sting during 3 years, and review of existing literature from Middle East countries. CONCLUSION: Serious toxicity after scorpion sting in Israel and some of neighboring countries is rare, and always presents within 1 h from the sting. Thus, prolonged observation can be reserved for a high-risk population and patients with serious toxicity on admission.

Splenic infarction: 10 years of experience.

OBJECTIVE: The aim of this study was to study the clinical presentation of splenic infarction. METHODS: A retrospective examination of files during a 10-year period was conducted. Only computed tomography-proven diagnoses of splenic infarction were included. Signs, symptoms, medical history, and results of investigation were recorded. RESULTS: We found 49 episodes of acute splenic infarction. Abdominal or left flank pain was the most common symptoms (80%), and left upper quadrant tenderness was the most common sign (35%). Splenic infarction was the presenting symptom of underlying disease in 16.6% of the patients. Based on the computed tomography results, ultrasound was diagnostic only in 18% of patients. There was no in-hospital mortality or serious complications. DISCUSSION: We present, to the best of our knowledge, the largest series of patients with splenic infarction diagnosed on clinical and radiological grounds. Awareness of the diagnostic possibility of splenic infarction in a patient with unexplained abdominal pain is important because it can be the presenting symptom of potentially fatal diseases.

[Practice of toxicology screening in an emergency department].

UNLABELLED: The present study examines standards of toxicology screening in the Emergency Department. METHODS: A retrospective analysis was performed on 583 patients for whom 713 different toxicology assays were conducted. RESULTS: The most commonly used test was the urine toxicology assay which was found positive in 10% of the subjects. Most of the patients in this group were treated with respective antidotes before the results of the tests became available. One out of 13 subjects who denied acetaminophen ingestion showed toxic blood levels. High carboxyhemoglobin saturation was found only in subjects with symptoms of intoxication. CONCLUSIONS: The medical utility of urine toxicology assay is not clear, as patients reviewed were treated according to their clinical conditions. Acetaminophen blood levels should be examined more frequently, as symptoms are vague and appropriate treatment is very effective. Carboxyhemoglobin saturation should be examined whenever exposure is suspected and symptoms and or signs are compatible with intoxication.

Nicotine gum withdrawal and migraine headaches.

Some abstinent smokers develop withdrawal symptoms when they stop using nicotine gum or when placebo is substituted. The present report describes a patient who suffered from severe migraine headaches after sudden discontinuation of nicotine gum. It has been suggested that physical dependence may be a cause of behavioral dependence on nicotine gum. Physicians should emphasize the need for gradual reduction of nicotine gum.

Undertreatment of acute pain in the emergency department: a challenge.

OBJECTIVE: Evaluation and improvement of pain management in our emergency department (ED). DESIGN: This was a "before-after" study. For each subject, the nurse, the physician, and the patient were asked to rate the initial intensity of the pain on a Visual Analogue Score (VAS). The timing and the type of analgesics administered were then recorded and follow-up VAS was performed. SETTING: A teaching, community-based, 400-bed hospital. STUDY PARTICIPANTS: 140 patients admitted for acute pain related to orthopedic injuries. MAIN OUTCOME MEASURES: The gap between the VAS expressed by the patient and estimated by the staff, the proportion of patients receiving analgesics, and the length of time delays between admission and analgesic administration. INTERVENTION: The intervention included education of medical and nursing staffs, insertion of a VAS template in the patient's chart, initiation of routine VAS assessment and re-assessment, and implementation of a protocol for pain management with standing orders for nurses. RESULTS: The VAS gap between the patient and the nurse decreased significantly from 1.91 2.04 to 1.03 1.97 after the intervention (P = 0.01). The percentage of patients receiving analgesics rose from 70 to 82% following the intervention. Time from admission to analgesia decreased from 80 +/- 68 min (mean +/- SD) before the intervention, to 58 +/- 37 min after the intervention (P = 0.05). CONCLUSION: Inadequate pain management in the ED appears related to poor staff assessment of pain and may be improved by routine VAS recording and by a nurse-based pain protocol.

Aphrodisiac drug-induced hemolysis.

Volatile alkyl nitrites have been used during the past decades for "recreational purposes," and for intensifying sexual experience. Their use has been associated with methemoglobinemia and hemolysis. We report three patients who presented over the past year with acute hemolysis after inhalation of butyl nitrite, two of them had glucose-6-phosphate dehydrogenase (G6PD) deficiency.

The significance of routine serum magnesium determination in the ED.

To determine the significance of routine serum magnesium determination in the ED, a retrospective analysis was done on 253 patients in whom serum magnesium levels were examined in the department of EM. Mild, moderate, and severe hypomagnesemia was found in 19.5%, 9.1%, and 2.5% of the study population, respectively. Univariate analysis showed that pregnancy and pregnancy-related conditions, diabetes mellitus, gender, renal function, infectious diseases, and the presence of ischemic heart disease were associated with low serum magnesium levels. In multivariate analysis, only pregnancy and pregnancy-related conditions (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.2-15.3) and diabetes mellitus (OR, 9.04, 95% CI, 3.3-24.75) were significantly associated with low serum magnesium levels. The number of patients admitted to the hospital and the number of patients who died was not statistically significantly different between the groups of patients with normal serum magnesium levels as compared with those with low serum magnesium levels. Although hypomagnesemia was found in 31% of the study population, its clinical significance is not clear given the absence of hypomagnesemia-related complications and death.

Acute psychosocial stress and cardiovascular events.

Stressful life events can trigger acute myocardial infarction and sudden cardiac death. Victims of natural disasters, such as earthquakes and other conditions of extreme stress should be evaluated for physical injuries as well as for cardiac disease.