The prevention and management of hospital admissions for urinary tract infection in patients with multiple sclerosis.

INTRODUCTION: Urinary tract infections (UTIs) are one of the commonest reasons for patients with multiple sclerosis (PwMS) presenting to hospital. Management of recurrent UTIs in PwMS can be challenging and characteristics of such patients are not well described. AIMS: To describe the neurological and urological features of PwMS presenting to hospital for UTIs and identify areas of management that could be improved to reduce UTI frequency. METHODS: Health episode statistics data were used to identify PwMS presenting to a tertiary hospital with UTI over a 5-year period. Medical records were reviewed for demographic, MS and urological history. The seven PwMS with the highest numbers of encounters were seen in a multidisciplinary clinic to enable detailed assessments. RESULTS: 52 PwMS (25 female, 27 male) with mean age of 60 had 112 emergency department presentations and 102 inpatient admissions for UTI. 24 presented multiple times and were more likely to be older and male with progressive MS. Almost two-thirds were using a urinary catheter. Less than half were under current urological and neurological follow-up. Escherichia coli and Pseudomonas spp were the commonest organisms cultured. Resistance to antibiotics was more frequent in patients with multiple presentations. CONCLUSIONS: PwMS presenting to hospital for UTIs are more often male, older, with progressive MS and high levels of disability. A small group of PwMS accounted for a large number of encounters. Preventative and management strategies can be applied in primary and secondary care settings, with an emphasis on bladder, catheter and general physical care.

Screening for urinary tract colonisation prior to corticosteroid administration in acute multiple sclerosis relapses: Validation of an updated algorithm.

INTRODUCTION: To evaluate an updated algorithm in the detection of urinary tract infection (UTI) prior to high-dose corticosteroid treatment in acute relapses in multiple sclerosis (MS). This updated algorithm aimed to decrease the unnecessary use of antibiotics, whilst maintaining accuracy and safety. METHODS: Prospective cohort study of 471 consecutive patients with MS relapses in a hospital-based outpatient acute relapse clinic. 172 patients met exclusion criteria, leaving 299 patients for analysis. Patients underwent urine dipstick and were treated for UTI if 2 or more of: nitrites, leukocyte esterase and cloudy urine were positive. Patients with confirmed acute MS relapse were treated with high dose intravenous or oral methylprednisolone. RESULTS: Significant bacteriuria (>105 colony forming units/mL) was present in 33 (11%, 95% CI 8-15) patients. The algorithm sensitivity and specificity was 24% and 94% respectively; the negative predictive value was 91%. The overall accuracy of the algorithm was 87%. No adverse sequelae were identified in 25 patients who received high dose methylprednisolone in the presence of an untreated UTI. CONCLUSION: With an improved specificity, this updated algorithm addresses previous issues concerning the unnecessary prescription of antibiotics, whilst improving accuracy and maintaining safety.

Open label feasibility study evaluating D-mannose combined with home-based monitoring of suspected urinary tract infections in patients with multiple sclerosis.

OBJECTIVE: To assess the feasibility of using D-mannose, a natural food supplement, in patients with multiple sclerosis (MS) reporting recurrent urinary tract infections (UTIs) as a preventative. METHODS: A single-center, open-label, feasibility study enrolled patients with MS, using and not using urinary catheters, experiencing recurrent UTIs (≥3/year or ≥2/6 months). Participants were given D-mannose powder 1.5 grams twice daily for 16-weeks and were instructed to monitor suspected UTIs at home using urine dipsticks. Diaries were used to record compliance, number of prescriptions of antibiotics received for UTIs, results of urine dipsticks and cultures. RESULTS: Overall, 22 patients with MS, median age 50 years (46-59) were enrolled: 10 were not using catheters and 12 were using catheters. The compliance rates for using D-mannose and dipsticks for testing suspected UTIs were 100% and 90.2%, respectively. Sixty-one episodes of suspected UTIs were recorded, 19/61 (31.1%) were confirmed UTIs and 29/61 (47.5%) prescriptions of antibiotics were made. The number of monthly proven UTIs decreased both in catheter users and non-users (P < 0.01). No adverse effects were reported. CONCLUSION: Using D-mannose in patients with MS experiencing recurrent UTIs and self-monitoring for infections is feasible and safe. Further studies are required to establish efficacy. CinicalTrials.gov (identifier NCT02490046).

Research Professionals' Perspectives, Barriers, and Recommendations Regarding Minority Participation in Clinical Trials.

OBJECTIVE: This study aims to investigate research professionals' perspectives regarding minority participation in clinical trials. METHODS: A web-based survey of research professionals at US institutions receiving NIH and/or AHRQ funding to conduct clinical research in 2013. Descriptive statistics, mean, standard deviation (SD), and the Wilcoxon rank-sum test were utilized for analysis. RESULTS: Distributed were 13,041 surveys with 967 (7.4%) responses. Overall and race-stratified analyses included 633 and 521 surveys, respectively. A majority agreed that patients' race (mean, 3.4; SD = 1.0) and primary language (mean, 4.0; SD = 0.9) have an effect on enrollment. They had more success in enrolling those whose primary language was the same as their own (mean, 3.8; SD = 1.0), and that a language barrier and time spent arranging for interpreters had prevented them from offering a study to potential candidates (mean, 3.2; SD = 1.2). Non-Caucasian respondents were more likely to agree that "fear of unknown side effects" was a deterrent for minorities (p < 0.01), "minorities are more likely to be unavailable for follow-up phone calls" (p = 0.07), and "the unavailability of translated material discourages non-English speakers from participation" (p = 0.08). They also were more likely to be neutral or agree with being discouraged from enrolling minorities because of the possibility of their withdrawal or being less likely to be available for phone follow-ups and follow-up visits (all p < 0.01). CONCLUSION: Despite a few subtle racial differences in research professionals' perspectives, a majority expressed no hesitation in enrolling minorities. Patients' race and primary language appeared to influence enrollment. A language barrier appeared to be the strongest barrier for research professionals.

Perceived Fall Risk and Functional Decline: Gender Differences in Patient's Willingness to Discuss Fall Risk, Fall History, or to Have a Home Safety Evaluation.

The CDC reports that among older adults, falls are the leading cause of injury-related death and rates of fall-related fractures among older women are twice those of men. We set out to 1) determine patient perceptions (analyzed by gender) about their perceived fall risk compared to their actual risk for functional decline and death and 2) to report their comfort level in discussing their fall history or a home safety plan with their provider. Elders who presented to the Emergency Department (ED†) were surveyed. The survey included demographics, the Falls Efficacy Scale (FES) and the Vulnerable Elders Survey (VES); both validated surveys measuring fall concern and functional decline. Females had higher FES scores (mean 12.3, SD 5.9) than males (mean 9.7, SD 5.9 p = .007) in the 146 surveys analyzed. Females were more likely to report an increased fear of falling, and almost three times more likely to have a VES score of 3 or greater than males (OR = 2.86, 95% CI: 1.17-7.00, p = .02). A strong correlation was observed between FES and VES scores (r = 0.80, p < .001). No difference in correlation was observed between males and females, p = .26. Participants (77 percent) reported they would be comfortable discussing their fall risk with a provider; there was no difference between genders (p = .57). In this study, irrespective of gender, there appears to be a high association between subjects' perceived fall risk and risk for functional decline and death. The majority of patients are likely willing to discuss their fall risk with their provider. These findings may suggest a meaningful opportunity for fall risk mitigation in this setting.

A Cross-Sectional Study of Medical Student Knowledge of Evidence-Based Medicine as Measured by the Fresno Test of Evidence-Based Medicine.

BACKGROUND: Evidence-based medicine (EBM) has been included in the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Emergency Medicine (ABEM) milestones project as a required component during emergency medicine (EM) residency training. Milestone Level One states that graduating medical students must be able to "describe basic principles of EBM." OBJECTIVE: We sought to identify the EBM skills of third- and fourth-year medical students. METHODS: Our institution, a network with 17 different residencies, hosts U.S. osteopathic and allopathic medical students. As a part of orientation, students are required to complete an entry Fresno Test of EBM (FTEBM). Retrospectively, medical student FTEBM scores from 2011 were assessed using descriptive statistics. RESULTS: Four hundred seventeen FTEBM scores were analyzed. Participants represented 40 medical schools, including 17 allopathic (MD) and 23 osteopathic (DO) schools. Fifty percent of participants (n = 210) were female, and 51.6% (n = 215) were from a DO medical school. Overall mean performance for the FTEBM was 47.2%. Exploring the results by individual question were (individual EBM question topics are in parentheses): 1A (study question), 62.0%; 1B (study question), 64.4%: 2 (sources of evidence), 67.6%; 3 (study design), 57.1%; 4 (search strategies), 53.2%; 5 (relevance), 41.2%; 6 (internal validity), 43.6%; 7 (magnitude), 37.8%; 8 (two-by-two grids), 30.0%; 9 (number needed to treat), 16.9%; 10 (confidence intervals), 34.3%; 11 (diagnosis), 5.0%; and 12 (prognosis), 43.4%. CONCLUSIONS: As measured by the FTEBM, senior medical students demonstrate understanding of about half of EBM. EM residencies can anticipate the need to instruct their residents in EBM concepts in order to meet ACGME/ABEM milestone requirements.

Urinary tract infections in multiple sclerosis.

BACKGROUND: Urinary tract infections (UTIs) are commonly reported by people with multiple sclerosis (PwMS) and significantly impact quality of life. OBJECTIVE: To provide an overview of the problem of UTIs in PwMS and offer a practical approach for the diagnosis and management. METHODS: A review of the literature through a Pubmed search up to October 2015 was performed using the following keywords: multiple sclerosis, neurogenic bladder, urinary tract infections, relapse, dipsticks, culture, recurrent and prevention. RESULTS: Noteworthy topics include the definition of a confirmed symptomatic UTI as a positive urine culture defined by >10(5) colony-forming units (CFU)/mL or >10(4) CFU/mL if a urethral catheter urine sample is taken, or any count of bacteria in a suprapubic bladder puncture specimen, both in addition to symptoms including fever, pain, changes in lower urinary tract symptoms or neurological status. Urinalysis is useful to exclude a UTI; however, on its own is insufficient to confirm a UTI, for which urine culture is required. Experts advise asymptomatic UTIs should not be treated except in the context of an acute relapse. From international guidelines, there is no validated strategy to prevent recurrent UTIs in PwMS. CONCLUSION: This review provides an overview of the diagnosis, treatment and prevention of UTIs in the setting of multiple sclerosis (MS).

Comparison of airway intubation devices when using a biohazard suit: a feasibility study.

OBJECTIVES: We set out to compare emergency medicine residents' intubating times and success rates for direct laryngoscopy (DL), GlideScope-assisted intubation (GS), and the Supraglottic Airway Laryngopharyngeal Tube (SALT) airway with and without biohazard gear. METHODS: Each resident passed through 2 sets of 3 testing stations (DL, GS, SALT) in succession, intubating Laerdal mannequin heads with the 3 modalities after randomization to start with or without biohazard gear. RESULTS: Thirty-seven residents participated, and 27 were male (73%); 14 (37.8%) had prior experience intubating in biohazard suits. There was a statistically significant difference in those who had prior intubation experience between DL (37, 100%), GS (32, 86.5%), and SALT (12, 32.4%) (P < .001) and in median time to intubation (48 seconds, no suit; 57 seconds, with suits) (P = .03). There was no statistically significant difference between the overall times to intubate for the 3 devices. First-pass success was highest for DL (91.2%, no suit; 83.7%, suit) followed by GS (89%, no suit; 78.3%, suit) and SALT (51%, no suit; 67.6%, suit). CONCLUSION: A minority of participants had prior experience intubating in biohazard suits. Use of biohazard suits extends time to successful intubation. There was no difference in time to intubation for the 3 devices, but first-pass success was highest for DL (with or without biohazard gear).

A predictive model for corticosteroid response in individual patients with MS relapses.

OBJECTIVES: To derive a simple predictive model to guide the use of corticosteroids in patients with relapsing remitting MS suffering an acute relapse. MATERIALS AND METHODS: We analysed individual patient randomised controlled trial data (n=98) using a binary logistic regression model based on age, gender, baseline disability scores [physician-observed: expanded disability status scale (EDSS) and patient reported: multiple sclerosis impact scale 29 (MSIS-29)], and the time intervals between symptom onset or referral and treatment. RESULTS: Based on two a priori selected cut-off points (improvement in EDSS ≥ 0.5 and ≥ 1.0), we found that variables which predicted better response to corticosteroids after 6 weeks were younger age and lower MSIS-29 physical score at the time of relapse (model fit 71.2% - 73.1%). CONCLUSIONS: This pilot study suggests two clinical variables which may predict the majority of the response to corticosteroid treatment in patients undergoing an MS relapse. The study is limited in being able to clearly distinguish factors associated with treatment response or spontaneous recovery and needs to be replicated in a larger prospective study.

Mechanical falls: are patients willing to discuss their risk with a health care provider?

BACKGROUND: Falls in the elderly cause serious injury. OBJECTIVE: We aimed to determine subjects' comfort in discussing fall risk and home safety evaluations. METHODS: This prospective study surveyed a convenience sample of subjects (≥50 years old) in an emergency department (ED), health fair (HF), and family practice (FP). The survey included the Falls Efficacy Scale and Vulnerable Elders Survey-validated surveys measuring fall concern and functional decline. Other data-environmental living conditions, participant behaviors, fall frequency-were collected. The associations between perceived fall risk and participant characteristics were assessed using descriptive statistics and random-effects logistic regression. RESULTS: Participants (n = 416, 38% males, 62% females) had a mean age of 67.6 years; 35% were high fall risk. Previous year falls (p = 0.002), use of assistive device (p < 0.001), having at least one alcoholic drink/week (p = 0.043), and poor or fair perceived health status (p < 0.001) were associated with perceived fall risk. HF respondents were more willing than FP respondents to discuss falls (84.9% vs. 73.1%, p = 0.025). The difference was not significant between the HF and ED respondents (84.9% vs. 76.9, p = 0.11). HF subjects were more willing than FP to have a home safety inspection (68.9% vs. 45.9%, p < 0.001). The difference was not significant between the HF and ED respondents (68.9% vs 58.5, p = 0.09). CONCLUSIONS: Perceived and actual fall risks are highly associated. Most participants are willing to discuss their fall risk and a home safety evaluation. HF subjects were most willing to have these discussions; ED subjects were less willing than HF, but not significantly different from health fair participants. FP participants were significantly less willing to have these discussions than HF participants. This may suggest a meaningful opportunity for fall risk prevention in outpatient settings such as health fairs and the ED.

Effect of triage-based use of the Ottawa foot and ankle rules on the number of orders for radiographic imaging.

CONTEXT: Reducing unnecessary testing lessens the cost burden of medical care, but decreasing use depends on consistently following evidence-based clinical decision rules. The Ottawa foot and ankle rules (OFARs) are validated, longstanding evidence-based guidelines to predict fractures. Frequently, radiography is automatically ordered for acute ankle injuries despite findings from OFARs suggesting no fracture. OBJECTIVES: First, to determine whether implementation of protocol-driven use of the OFARs at triage would decrease the number of radiography orders and length of stay (LOS) in the emergency department. Second, to quantify the incidence of OFARs use at triage and to assess patient expectations of radiography use and patient satisfaction as rated by both patients and clinicians. METHODS: In this prospective, 2-stage sequential pilot study, patients with acute ankle and foot injuries were screened in the emergency department between January 2013 and October 2013. In the first stage, clinicians (physician assistants, residents, and attending physicians) performed their usual practice habits for radiography use in the control group. For the second stage, they were educated to appropriately apply the OFARs before ordering radiography. For patients who were suspected of having a fracture at triage, nursing staff ordered radiography. For patients who were not suspected of having a fracture at triage, a clinician reassessed them using the OFARs after their triage assessment. Radiography was then ordered at the discretion of the clinician. Results gathered after training in the OFARs comprised the intervention group. After discharge, patients were surveyed regarding their expectations and satisfaction, and clinicians were surveyed on their perceptions of patient satisfaction. RESULTS: A total of 131 patients were screened, 62 patients were enrolled in the study after consent was obtained, and 2 patients withdrew from the study prematurely, leaving 30 patients in each group. Fifty-eight of the 60 patients (97%) underwent radiography. Emergency department LOS decreased from 103 minutes to 96.5 minutes (P=.297) after the OFARs were applied. There was also a decrease in LOS in patients with a fracture (137 minutes vs 103 minutes [P=.112]). Radiography was expected to be ordered by 27 of 30 patients in the control group (90%) and 24 of 30 in the intervention group (80%) (P=.472). Patients were equally satisfied among the groups (54 of 60 [90%]) (with no difference between groups), and 27 of 30 (90%) vs 30 of 30 (100%) clinicians in the control and intervention groups, respectively, perceived that patients were satisfied with their treatment. CONCLUSION: There was no statistical evidence that application of the OFARs decreases the number of imaging orders or decreases LOS. This observation suggests that even when clinicians are being observed and instructed to use clinical decision rules, their evaluation bias tends toward recommendations for testing.

Sex differences in cardiac arrest survivors who receive therapeutic hypothermia.

OBJECTIVE: Sex differences have not been well defined for patients undergoing therapeutic hypothermia (TH). We aimed to determine sex differences in mortality and Cerebral Performance Category (CPC) scores at discharge among those receiving TH. METHODS: This retrospective cohort study used data abstracted from an "ICE alert" database, an institutional protocol expediting mild TH for postarrest patients. Quality assurance variables (such as age, time to TH, CPC scores, and mortality) were reviewed and compared by sex. χ2 Test and Wilcoxon rank sum test were used. Stepwise logistic regression was used to assess the association between mortality and sex, while controlling for patient characteristics and clinical presentation of cardiac arrest. RESULTS: Three hundred thirty subjects were analyzed, 198 males and 132 females. Subjects' mean age (SD) was 61.7 years (15.0); there was no significant sex difference in age. There were no statistically significant sex differences in history of coronary artery disease, congestive heart failure, arrhythmia, hypertension, chronic obstructive pulmonary disease, renal disease, type 1 and/or type 2 diabetes mellitus, or those previously healthy. Obesity (body mass index>35 kg/m2) was more likely in females (37, 28.0%) than males (35, 17.7%); P=.03. Females (64, 49.6%) were more likely than males (71, 36.8%) to have shock; P=.02. There was no difference in arrest to initiating hypothermia, but there was a significant difference in time to target temperature (in median minutes, interquartile range): male (440, 270) vs female (310, 270), P=.003. There was no statistical difference in CPC at discharge. Crude mortality was not different between sexes: male, 67.7%; female, 70.5%; P=.594. However, after controlling for differences in age, obesity, shock, and other variables, females were less likely to die (odds ratio, 0.46; 95% confidence interval, 0.23-0.92; P=.03) than males. CONCLUSION: There is no statistically significant difference in CPC or crude mortality outcomes between sexes. After adjusting for confounders, females were 54% less likely to die than males.

I can't move my face! a case of bilateral facial palsy.

The authors present a case of bilateral facial palsy in a 52-year-old man. The patient presented to an emergency department in Pennsylvania, describing left-sided neck pain and headache from "sleeping wrong," symptoms which eventually progressed to facial diplegia by his fourth visit in 2 weeks. His admitting diagnosis was Bell palsy; he was ultimately tested for and found to have Lyme disease. Delay in treatment of patients with Lyme disease may lead to bilateral facial paralysis and disease progression. Thorough history taking, physical examination, and scrutiny of prior records are important elements of identifying and treating patients such as these (ie, whose vague symptoms progress to facial diplegia) appropriately.

A tool to measure the attributes of receiving IV therapy in a home versus hospital setting: the Multiple Sclerosis Relapse Management Scale (MSRMS).

BACKGROUND: Intravenous steroids are routinely used to treat disabling relapses in multiple sclerosis (MS). Theoretically, the infusion could take place at home, rather than in hospital. Findings from other patient populations suggest that patients may find the experiences of home relapse management more desirable. However, formal comparison of these two settings, from the patients' point of view, was prevented by the lack of a clinical scale. We report the development of a rating scale to measure patient's experiences of relapse management that allowed this question to be answered confidently. METHODS: Scale development had three stages. First, in-depth interviews of 21 MS patients generated a conceptual model and pool of potential scale items. Second, these items were administered to 160 people with relapsing-remitting MS. Standard psychometric techniques were used to develop a scale. Third, the psychometric properties of the scale were evaluated in a randomised controlled trial of 138 patients whose relapses were managed either at home or hospital. RESULTS: A preliminary conceptual model with eight dimensions, and a pool of 154 items was generated. From this we developed the MS Relapse Management Scale (MSRMS), a 42-item with four subscales: access to care (6 items), coordination of care (11 items), information (7 items), interpersonal care (18 items). The MSRMS subscales satisfied most psychometric criteria but had notable floor effects. CONCLUSIONS: The MSRMS is a reliable and valid measure of patients' experiences of MS relapse management. The high floor effects suggest most respondents had positive care experiences. Results demonstrate that patients' experiences of relapse management can be measured, and that the MSRMS is a powerful tool for determining which services to develop, support and ultimately commission.

Establishing a comprehensive networkwide pressure ulcer identification process.

BACKGROUND: Pressure ulcers (PUs) are a critical concern, endangering patients and requiring significant resources for treatment in Stage II/IV. The Centers for Medicare & Medicaid Services (CMS) denies reimbursement in cases where a more complex diagnosis-related group (DRG) is assigned as a result of hospital-acquired conditions such as a PU that could have been reasonably prevented. IMPLEMENTATION: An interdisciplinary PU present-on-admission (POA) team developed an algorithm to support the early identification of PUs for units participating in the process. This approach standardized work, resulting in consistent (1) skin assessment, (2) physician notification, (3) reporting of findings in the patient safety reporting system, and (4) communication to receiving units. Computer-entry tools were developed and completed for six months by the patient care services unit-based process improvement councils; these councils made possible immediate "loop closure" for either positive feedback or needed reeducation with the nursing staff. RESULTS: The total number of PUs recognized and reported after implementation of the process improvement initiative--from April 1, 2008, to March 31, 2009--increased to 1,103--an increase of 36.3% in PU reporting when compared with the same period the year before. This initiative has yielded 100% effectiveness in identifying Stage III/IV PUs POA and in preventing hospital-acquired Stage III/IV PUs. The success of the project has helped to ensure high-quality patient care and protection of precious fiscal resources. CONCLUSIONS: The data suggest that the identification of all PUs that are present at time of admission is clinically feasible.