Correction: Clinical Predictors of Survival for Patients with Stage IV Cancer Referred to Radiation Oncology.

[This corrects the article DOI: 10.1371/journal.pone.0124329.].

Clinical Predictors of Survival for Patients with Stage IV Cancer Referred to Radiation Oncology.

BACKGROUND: There is an urgent need for a robust, clinically useful predictive model for survival in a heterogeneous group of patients with metastatic cancer referred to radiation oncology. METHODS: From May 2012 to August 2013, 143 consecutive patients with stage IV cancer were prospectively evaluated by a single radiation oncologist. We retrospectively analyzed the effect of 29 patient, laboratory and tumor-related prognostic factors on overall survival using univariate analysis. Variables that were statistically significant on univariate analysis were entered into a multivariable Cox regression to identify independent predictors of overall survival. RESULTS: The median overall survival was 5.5 months. Four prognostic factors significantly predicted survival on multivariable analysis including ECOG performance status (0-1 vs. 2 vs. 3-4), number of active tumors (1 to 5 vs. ≥ 6), albumin levels (≥ 3.4 vs. 2.4 to 3.3 vs. < 2.4 and primary tumor site (Breast, Kidney or Prostate vs. Other). Risk group stratification was performed by assigning points for adverse prognostic factors resulting in very low, low, intermediate and high risk groups. The median survival was > 31.4 months for very low risk patients compared to 14.5 months for low risk, 4.1 months for intermediate risk and 1.2 months for high risk (p < 0.001). CONCLUSIONS: These data suggest that a model that considers performance status, extent of disease, primary tumor site and serum albumin represents a simple model to accurately predict survival for patients with stage IV cancer who are potential candidates for radiation therapy.

Descriptive study of prescriptions for opioids from a suburban academic emergency department before New York's I-STOP Act.

INTRODUCTION: Controlled prescription opioid use is perceived as a national problem attributed to all specialties. Our objective was to provide a descriptive analysis of prescriptions written for controlled opioids from a database of emergency department (ED) visits prior to the enactment of the I-STOP law, which requires New York prescribers to consult the Prescription Monitoring Program (PMP) prior to prescribing Schedule II, III, and IV controlled substances for prescriptions of greater than five days duration. METHODS: We conducted a retrospective medical record review of patients 21 years of age and older, who presented to the ED between July 1, 2011 - June 30, 2012 and were given a prescription for a controlled opioid. Our primary purpose was to characterize each prescription as to the type of controlled substance, the quantity dispensed, and the duration of the prescription. We also looked at outliers, those patients who received prescriptions for longer than five days. RESULTS: A total of 9,502 prescriptions were written for opioids out of a total 63,143 prescriptions for 69,500 adult patients. Twenty-six (0.27%) of the prescriptions for controlled opioids were written for greater than five days. Most prescriptions were for five days or less (99.7%, 95% CI [99.6 to 99.8%]). CONCLUSION: The vast majority of opioid prescriptions in our ED prior to the I-STOP legislature were limited to a five-day or less supply. These new regulations were meant to reduce the ED's contribution to the rise of opioid related morbidity. This study suggests that the emergency physicians' usual prescribing practices were negligibly limited by the new restrictive regulations. The ED may not be primarily contributing to the increase in opioid-related overdoses and death. The effect of the I-STOP regulation on future prescribing patterns in the ED remains to be determined.

A research primer, Part 2: Guidelines for developing a research project.

In this article, the second in a series on the basic concepts of research, the authors review aspects of research design including participant considerations, randomization, reliability and validity of measurements, and data collection and management. The authors also discuss considerations for research using questionnaires and tests. The goal of this article is to assist the novice researcher in identifying potential problems that must be addressed during the design of a research project.

Is fever treated more promptly than pain in the pediatric emergency department?

BACKGROUND: Fever can be treated with a higher priority than pain in the pediatric emergency department (ED) population. OBJECTIVE: The primary objective was to assess whether patients with a fever are treated with acetaminophen or ibuprofen more promptly than they are treated for pain. METHODS: A retrospective descriptive study was performed on all patients between the ages of 3 and 19 years who received acetaminophen or ibuprofen in the pediatric ED from February 1, 2010 to January 31, 2011. The time interval from arrival to treatment with acetaminophen or ibuprofen was compared for those patients with a fever (≥100.4°F) and those without a fever and had reported pain. Other measurable points (time of vital signs, bed assignment, and medication order) on the medical record were compared to further describe any differences. RESULTS: Pediatric patients with fever (n = 1097) received ibuprofen or acetaminophen a median of 54.0 min (interquartile range [IQR], 35.4-89.3 min) after arrival. The corresponding median time for afebrile patients (n = 1861) that received the same medications was 83.2 min (IQR, 52.7-136.1). The difference between medians was 24.6 min (95% confidence interval 21.3-27.9 min). CONCLUSIONS: Fever is treated more promptly than pain in the pediatric ED. This difference is associated with prevailing and largely unfounded concerns about fever and the undertreatment of pain (oligoanalgesia).

A research primer: basic guidelines for the novice researcher.

Research can achieve many objectives, primarily by establishing a supportable, verifiable basis for clinical decisions. An evidence-based practice can streamline patient care, improving safety through consistency of care and making health care more affordable for patients. By cultivating research skills, osteopathic physicians and trainees can begin to forge a reciprocal relationship with medical literature and current findings, approaching research as active contributors as well as consumers. Many challenges, however, potentially hinder osteopathic physicians, residents, or medical students who wish to develop research skills. In the present article, the authors summarize research concepts and terminology that will enable novice researchers to interact effectively with more experienced researchers, statisticians, and methodologists.

Medical reconciliation in patients discharged from the emergency department.

BACKGROUND: Medication errors are considered to be a significant cause of morbidity and mortality. For each patient, emergency departments (EDs) are expected to compile a list of medications, reconcile them, and pass them along to the next provider. The electronic medical record provides a method to automatically capture and propagate what may be incorrect information. OBJECTIVES: The aim of this study was to compare the medication information that patients ultimately discharged from the ED provide to the ED staff vs. the medication information the patients provide at follow-up, and to classify and quantify the types of discrepancies between the two. METHODS: We conducted a retrospective descriptive study of a convenience sample of 36 patients who were discharged from the ED and who reported taking five or more medications. Discrepancies were identified by comparing information collected at the time of the index ED visit with that gleaned from follow-up contact within 7 days of discharge. RESULTS: Of the 36 charts analyzed, 286 medications were provided by patients at the time of their ED visit. Subsequent determination of actual medication use on follow-up found 120 discrepancies, for a discrepancy rate of 42.0% (95% confidence interval [CI] 36.4-47.8%). One or more discrepancies were found on 86.1% of charts (95% CI 74.8-97.4%). CONCLUSIONS: Frequent discrepancies are found in the medication information that patients provide in the ED. Requiring the ED to reconcile medication information and to pass it on to the next provider can be a source of treatment errors in the outpatient setting.

Blue 470-nm light kills methicillin-resistant Staphylococcus aureus (MRSA) in vitro.

BACKGROUND DATA: In a previous study, we showed that 405-nm light photo-destroys methicillin-resistant Staphylococcus aureus (MRSA). The 390-420 nm spectral width of the 405-nm superluminous diode (SLD) source may raise safety concerns in clinical practice, because of the trace of ultraviolet (UV) light within the spectrum. OBJECTIVE: Here we report the effect of a different wavelength of blue light, one that has no trace of UV, on two strains of MRSA--the US-300 strain of CA-MRSA and the IS-853 strain of HA-MRSA--in vitro. MATERIALS AND METHODS: We cultured and plated each strain, and then irradiated each plate with 0, 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 25, 30, 35, 40, 45, 50, 55, or 60 J/cm2 of energy a single time, using a 470-nm SLD phototherapy device. The irradiated specimens were then incubated at 35 degrees C for 24 h. Subsequently, digital images were made and quantified to obtain colony counts and the aggregate area occupied by bacteria. RESULTS: Photo-irradiation produced a statistically significant dose-dependent reduction in both the number and the aggregate area of colonies formed by each strain (p < 0.001). The higher the dose the more bacteria were killed, but the effect was not linear, and was more impressive at lower doses than at higher doses. Nearly 30% of both strains was killed with as little as 3 J/cm2 of energy. As much as 90.4% of the US-300 and the IS-853 colonies, respectively, were killed with an energy density of 55 J/cm2. This same dose eradicated 91.7% and 94.8% of the aggregate area of the US-300 and the IS-853 strains, respectively. CONCLUSION: At practical dose ranges, 470-nm blue light kills HA-MRSA and CA-MRSA in vitro, suggesting that a similar bactericidal effect may be attained in human cases of cutaneous and subcutaneous MRSA infections.

Visible 405 nm SLD light photo-destroys methicillin-resistant Staphylococcus aureus (MRSA) in vitro.

BACKGROUND: Infections with MRSA remain a growing public health concern, prompting the need to explore alternative treatments instead of the on-going effort to develop stronger drug-based therapies. We studied the effect of 405 nm blue light on two strains of MRSA-US-300 strain of CA-MRSA and the IS853 strain of HA-MRSA-in vitro. METHODS: We cultured and plated each strain, following which bacteria colonies were irradiated with 0, 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 25, 30, 35, 40, 45, 50, 55, or 60 J cm(-2) energy densities-just once-using a Solaris superluminous diode (SLD) device. Specimens were incubated at 35 degrees C for 24 hours. Then, digital images obtained were quantified to obtain colony counts and the aggregate area occupied by bacteria colonies. RESULTS: Blue light irradiation produced a statistically significant dose-dependent reduction in both the number and the aggregate area of colonies formed by each bacteria strain (P<0.001). Maximum eradication of the US-300 (92.1%) and the IS-853 colonies (93.5%) was achieved within 9.2 and 8.4 minutes of exposure, respectively. The longer the irradiation the more bacteria were eradicated. However, the effect was non-linear as increases of energy densities between 1.0 and 15 J cm(-2) resulted in more bacteria death than similar increases between 15 and 60 J cm(-2). CONCLUSION: At low doses, blue light photo-destroys HA-MRSA and CA-MRSA in vitro; raising the prospect that phototherapy may be an effective clinical tool in the on-going effort to stem MRSA infections.

Prediction of left main coronary artery obstruction by 12-lead electrocardiography: ST segment deviation in lead V6 greater than or equal to ST segment deviation in lead V1.

BACKGROUND: Acute coronary syndrome (ACS) resulting from culprit lesion in left main coronary artery (LMCA) can cause rapid hemodynamic deterioration. It is important to identify these patients early to facilitate timely revascularization. ST segment elevation in aVR greater than or equal to V(1) (aVR-V(1)>or= 0) has been suggested as a sensitive predictor of LMCA disease. As a result of balanced forces, we hypothesized that ST deviation in V(6) greater than or equal to ST deviation in V(1) (V(6)-V(1)>or= 0) might be a good determinant of LMCA disease. METHODS: We compared admission 12-lead ECGs of ACS resulting from culprit LMCA lesion (n = 75, group I) with ACS resulting from culprit left anterior descending lesion (n = 81, group II). Group I was selected over a period of 10 years. We compared V(6)-V(1)>or= 0 to aVR-V(1)>or= 0 in both groups. We also looked at ratios of ST deviations in V(6),V(1) (V(6)/V(1)>or= 1) and aVR,V(1) (aVR/V(1)>or= 1) in patients where ST segment in V(1) was not isoelectric (group I = 54 and group II = 55). RESULTS: ST deviation in V(6) was significantly greater in group I as compared to group II (P < 0.001). The reliabilities of V(6)-V(1)>or= 0, V(6)/V(1)>or= 1, aVR-V(1)>or= 0, and aVR/V(1)>or= 1 in predicting LMCA disease were determined. CONCLUSION: This is the largest series of ECG analysis on ACS resulting from culprit LMCA lesion. V(6)-V(1)>or= 0 and V(6)/V(1)>or= 1 were more sensitive in predicting LMCA as culprit vessel in comparison to previously reported greater ST segment elevation in aVR than V(1).

In hospital cardiac arrest: a role for automatic defibrillation.

INTRODUCTION: Sudden cardiac death (SCD) survival decreases by 10% for each minute of delay in defibrillation, however, survival rates of 98% can be achieved when defibrillation is accomplished within 30s of collapse. Recently, a fully automated external cardioverter-defibrillator (AECD) was approved by the FDA for in-hospital use. The AECD can be programmed to automatically defibrillate when a life threatening ventricular arrhythmia occurs. The purpose of this study was to assess the potential impact of in-hospital AECDs on the critical time to defibrillation in monitored hospital units. METHODS: Mock emergency (n = 18) were conducted using simulated ventricular fibrillation in various monitored units. Observers were stationed to record the time staff responded to the arrhythmia, and the time to shock. These times were compared to an AECD protocol that defibrillates automatically in an average of 38.3 s from onset of arrhythmia (n = 18). RESULTS: Staff versus AECD response time to arrhythmia (s) was 76.3 +/- 113.7 (CI 19.8-132.8) versus 7.6 +/- 0.6 (CI 7.3-7.9). Staff versus AECD time to shock was 169.2 +/- 103.1 (CI 117.9-220.4) versus 38.3 +/- 0.7 (CI 37.9-38.6). P-values are <0.0001 for differences between the groups. CONCLUSION: The use of AECDs on monitored units would significantly reduce the critical time to defibrillation in patients with SCA. We anticipate this would translate to improved survival rates, and better neurologic outcomes.

Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries.

STUDY OBJECTIVE: The purpose of this study was to evaluate the efficacy of osteopathic manipulative treatment (OMT) as administered in the emergency department (ED) for the treatment of patients with acute ankle injuries. METHODS: Patients aged 18 years and older with unilateral ankle sprains were randomly assigned either to an OMT study group or a control group. Independent outcome variables included edema, range of motion (ROM), and pain. Both groups received the current standard of care for ankle sprains and were instructed to return for a follow-up examination. Patients in the OMT study group also received one session of OMT from an osteopathic physician. RESULTS: Patients in the OMT study group had a statistically significant (F = 5.92, P = .02) improvement in edema and pain and a trend toward increased ROM immediately following intervention with OMT. Although at follow-up both study groups demonstrated significant improvement, patients in the OMT study group had a statistically significant improvement in ROM when compared with patients in the control group. CONCLUSIONS: Data clearly demonstrate that a single session of OMT in the ED can have a significant effect in the management of acute ankle injuries.