Palliative care patient emergency department visits at tertiary university-based emergency department in Ireland.

INTRODUCTION: Palliative care patients often present to the emergency department (ED) for various reasons e.g., acute illness, pain, altered mental status, and complications of therapy. Many visits involve less severe etiologies e.g., dyspnea, constipation, fear as patients approach the end of life, which may be more effectively and efficiently managed outside of the ED. The objective of this study is to identify and assess the frequency of presenting complaints, primary diagnosis, triage acuity, need for admission, in an Irish setting. METHODS: A single-center retrospective, observational study of palliative care patients presenting to a tertiary-care university hospital emergency department in Dublin, Ireland. Study subjects were identified using the palliative care database and cross-referencing with the ED electronic patient record system database. The primary objective to identify potential areas to minimize ED visits and improve patient care and quality of life by elucidating reasons for visits. Outcome measures include presenting complaint, primary diagnosis, triage severity score, admission, discharge, death in hospital. Statistical analysis presented as descriptive statistics. RESULTS: Four-hundred-ninety-nine ED visits, 245 (49%) were male, and 254 (51%) were female with a mean age of 69.3 years-of-age. Most patients, 285 (57.1%) self-referred to the emergency department, with general practitioners and skilled nursing facility referrals 72 (14.4%) and 39 (7.8%), respectively. Primary diagnoses were various cancers, chronic obstructive pulmonary disease, congestive heart failure, and dementia. Major reasons for visits were dyspnea, pain, falls, trauma, fever, and altered mental status. Two-hundred-eighty-nine patients (58%) had an emergency severity index (ESI) score of 1 or 2 demonstrating a higher level of acuity. Three-hundred-fifty-eight (71.7%) were admitted, 141 (28.3%) discharged to home, 64 (12.8%) admitted patients died during their hospital admission. CONCLUSIONS: Palliative care patients utilize ED services not uncommonly. Though many of these patients presented with higher acuity triage scores, 42% had lower ESI scores and may be effectively managed outside of the ED. These data suggest developing mechanisms for these patients to be urgently evaluated in their homes or facilities obviating the need for an ED evaluation.

Developing Miller's Pyramid to Support Students' Assessment Literacy.

Assessment literacy is increasingly recognized as an important concept to consider when developing assessment strategies for courses and programs. Assessment literacy approaches support students in their understanding of assessment expectations and help them both understand and optimize their performance in assessment. In this teaching tip, a model for assessment literacy that builds on the well-known Miller's Pyramid model for assessment in clinical disciplines is proposed and contextualized. The model progresses thinking from assessment methods themselves to consideration of the activities that need to be built into curricula to ensure that assessment literacy is addressed at each level of the pyramid. The teaching tip provides specific examples at each of the levels. Finally, the relevance of this work to overall curriculum design is emphasized.

Origin of the direct and reflected head of the rectus femoris: an anatomic study.

PURPOSE: This study aimed to define the footprint of the direct and reflected heads of the rectus femoris and the relation of the anterior inferior iliac spine (AIIS) to adjacent neurovascular (lateral circumflex femoral artery and femoral nerve), bony (anterior superior iliac spine [ASIS]), and tendinous structures (iliopsoas). METHODS: Twelve fresh-frozen cadaveric hip joints from 6 cadavers, average age of 44.5 (±9.9) years, were carefully dissected of skin and fascia to expose the muscular, capsular, and bony structures of the anterior hip and pelvis. Using digital calipers, measurements were taken of the footprint of the rectus femoris on the AIIS, superior-lateral acetabulum and hip capsule, and adjacent anatomic structures. RESULTS: The average dimensions of the footprint of the direct head of the rectus femoris were 13.4 mm (±1.7) × 26.0 mm (±4.1), whereas the dimensions of the reflected head footprint were 47.7 mm (±4.4) × 16.8 mm (±2.2). Important anatomic structures, including the femoral nerve, psoas tendon, and lateral circumflex femoral artery, were noted in proximity to the AIIS. The neurovascular structure closest to the AIIS was the femoral nerve (20.8 ± 3.4 mm). CONCLUSIONS: The rectus femoris direct and reflected heads originate over a broad area of the anterolateral pelvis and are in close proximity to critical neurovascular structures, and care must be taken to avoid them during hip arthroscopy. CLINICAL RELEVANCE: A thorough knowledge of the anatomy of the proximal rectus femoris is valuable for any surgical exposure of the anterior hip joint, particularly arthroscopic subspine decompression and open femoroacetabular impingement (FAI) surgery.

Histological and molecular characterisation of feline humeral condylar osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a clinically important and common disease of older cats. The pathological changes and molecular mechanisms which underpin the disease have yet to be described. In this study we evaluated selected histological and transcriptomic measures in the articular cartilage and subchondral bone (SCB) of the humeral condyle of cats with or without OA. RESULTS: The histomorphometric changes in humeral condyle were concentrated in the medial aspect of the condyle. Cats with OA had a reduction in articular chondrocyte density, an increase in the histopathological score of the articular cartilage and a decrease in the SCB porosity of the medial part of the humeral condyle. An increase in LUM gene expression was observed in OA cartilage from the medial part of the humeral condyle. CONCLUSIONS: Histopathological changes identified in OA of the feline humeral condyle appear to primarily affect the medial aspect of the joint. Histological changes suggest that SCB is involved in the OA process in cats. Differentiating which changes represent OA rather than the aging process, or the effects of obesity and or bodyweight requires further investigation.

Patient-specific factors, but neither regional anesthesia nor hip-specific cryotherapy, predict postoperative opioid requirements after hip arthroscopy for femoroacetabular impingement (FAI) syndrome.

Background: We sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy. Methods: 104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length. Results: The average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed. Conclusion: Patient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system. Level of evidence: III, retrospective cohort study.

Effects of negative pressure wound therapy on healing of open wounds in dogs.

OBJECTIVE: To compare the effect of negative pressure wound therapy (NPWT) with standard-of-care management on healing of acute open wounds in dogs. STUDY DESIGN: Prospective, controlled, experimental study. ANIMALS: Adult dogs (n=10). METHODS: Full-thickness 4 m × 2 m wounds were surgically created on each antebrachium and in each dog were randomized to receive either NPWT or standard wound dressings (CON) for 21 days. Dressing changes and wound evaluations were made at 8 time points. First appearance of granulation tissue, smoothness of granulation tissue, exuberance, percent epithelialization, and percent contraction were compared. Biopsies for histopathology were taken, and histologic scores determined, at 5 time points, and aerobic bacterial wound cultures performed at 2 time points. RESULTS: Granulation tissue appeared significantly earlier, and was smoother and less exuberant in NPWT wounds compared with CON wounds. Percent contraction in NPWT wounds was less than CON wounds after Day 7. Percent epithelialization in NPWT wounds was less than CON wounds on Days 11, 16, 18, and 21. Histologic scores for acute inflammation were higher in NPWT on Day 3, and lower on Day 7, than CON wounds. Bacterial load was higher in NPWT on Day 7. CONCLUSION: NPWT accelerated appearance of smooth, nonexuberant granulation tissue; however, prolonged use of NPWT impaired wound contraction and epithelialization.

Relationship between vitamin D status and clinical outcomes in dogs with a cranial cruciate ligament rupture.

Cranial cruciate ligament rupture (CCLR) is one of the most common orthopaedic disorders diagnosed in dogs yet the factors which influence postoperative clinical outcomes are poorly understood. Low vitamin D status has been linked to poorer clinical outcomes in human patients undergoing elective orthopaedic surgery. The aim of this study was to examine the relationship between pre-operative vitamin D status, as defined by serum 25 hydroxyvitamin D (25(OH)D) concentrations, and initial disease severity and clinical outcomes in dogs undergoing surgical treatment for a CCLR. Serum 25(OH)D concentrations were measured in 44 dogs with a CCLR on the day before surgery. C-reactive protein concentrations were measured at a median time of 1 day post-surgery and the patient's clinical and radiographic response to CCLR surgical treatment was assessed at a median timepoint of 60 days post-surgery. Serum 25(OH)D concentrations in dogs with a CCLR was not significantly different to a population of healthy dogs (median 74.1 nmol/L and 88.40 nmol/L, respectively). There was no significant correlation between pre-operative serum 25(OH)D concentrations and length of pre-diagnosis clinical signs, pre-operative lameness scores or day 1 post-operative CRP concentrations. Thirty nine of the 44 dogs were re-examined at a median 60 days post-surgery. There was no relationship between the day 60 lameness scores and pre-operative serum 25(OH)D concentrations. In summary, we discovered that the vitamin D status of dogs with a CCLR was not significantly lower than healthy dogs and pre-operative serum 25(OH)D concentrations were not correlated to either pre-surgical disease severity or post-operative clinical outcomes.

Effects of surgery on free and total 25 hydroxyvitamin D concentrations in dogs.

BACKGROUND: It is unclear whether a low total 25(OH)D concentration is a cause or consequence of illnesses. To address this knowledge gap, studies measuring free and total 25(OH)D during the evolution and resolution of an inflammatory process are required. OBJECTIVES: Serum total and free 25(OH)D concentrations would transiently decline after cruciate surgery in dogs. ANIMALS: Seventeen client-owned dogs with a spontaneous cranial cruciate ligament rupture (CCLR). METHODS: A longitudinal cohort study involving the measurement of serum concentrations of total and free 25(OH)D, total calcium, creatinine, albumin, phosphate, C-reactive protein and plasma ionized calcium, at 1 day before and a median time of 1 and 60 days after surgical treatment of CCLR. RESULTS: Median serum concentrations of total 25(OH)D before surgery (80.3 nmoL/L [range, 43.5-137.3]) significantly declined immediately after surgery; (64.8 nmoL/L [range, 36.3-116.5] 1 day after surgery, P < .005) before increasing to become nonsignificantly different from concentrations before surgery at day 60 after surgery (median 78.0 nmoL/L [range, 24.2-115.8], P = .14). In contrast, median free 25(OH)D concentrations before surgery (7.6 pg/mL [range, 3.8-12.2]) significantly increased immediately after surgery (9.2 pg/mL [range, 5.2-15.7], P < .05) before declining to become nonsignificantly different from before surgery concentrations at day 60 after surgery (median 6.2 pg/mL [range, 4.0-15.8], P = .37). CONCLUSION AND CLINICAL IMPORTANCE: This study reveals the difficulties of assessing vitamin D status in dogs following elective surgery.

Brain lactate responses during visual stimulation in fasting and hyperglycemic subjects: a proton magnetic resonance spectroscopy study at 1.5 Tesla.

Proton magnetic resonance spectroscopy ((1)H-MRS) studies showing increased lactate during neural activation support a broader role for lactate in brain energy metabolism than was traditionally recognized. Proton MRS measures of brain lactate responses have been used to study regional brain metabolism in clinical populations. This study examined whether variations in blood glucose influence the lactate response to visual stimulation in the visual cortex. Six subjects were scanned twice, receiving either saline or 21% glucose intravenously. Using (1)H-MRS at 1.5 Tesla with a long echo time (TE=288 ms), the lactate doublet was visible at 1.32 ppm in the visual cortex of all subjects. Lactate increased significantly from resting to visual stimulation. Hyperglycemia had no effect on this increase. The order of the slice-selective gradients for defining the spectroscopy voxel had a pronounced effect on the extent of contamination by signal originating outside the voxel. The results of this preliminary study demonstrate a method for observing a consistent activity-stimulated increase in brain lactate at 1.5 T and show that variations in blood glucose across the normal range have little effect on this response.

Cortical, medullary, and pelvocaliceal MR renography with and without diuretic modification.

RATIONALE AND OBJECTIVES: This study was conducted to define and characterize magnetic resonance (MR) contrast medium enhancement of the renal cortex, medulla, and pelvocaliceal system in normal and hydronephrotic kidneys with and without furosemide administration. MATERIALS AND METHODS: In 30 subjects known or suspected to have unilateral hydronephrosis and normal serum creatinine levels, multiple timed sets of coronal fast spoiled gradient-echo images were acquired before and after contrast medium administration. MR renograms were derived from changes in the signal intensity (SI) of the cortex, medulla, and pelvocaliceal system. Ten subjects received 40 mg of intravenous furosemide approximately 10 minutes before contrast medium administration. RESULTS: The following values were significantly different between subjects who were given furosemide and those who were not: the peak cortical, medullary, and pelvocaliceal system SIs measured in the normal kidneys during the 4 1/2 minutes following contrast medium administration (163.2 +/- 17.7 [mean arbitrary units plus or minus standard error] vs 120.5 +/- 10.2 [P = .033], 155.5 +/- 18.8 vs 111.5 +/- 9.4 [P = .025], and 332.5 +/- 27.2 vs 229.3 +/- 31.9 [P = .026], respectively); the crossover time between the SI curves of the pelvocaliceal system and the medulla in the normal kidney (2.45 minutes +/- 0.2 vs 3.27 minutes +/- 0.25 [P = .02]); and the peak SIs of the cortex, medulla, and pelvocaliceal system in the unilateral obstructive hydronephrotic kidneys throughout the first 4 1/2 minutes after contrast medium administration (174.6 +/- 16.4 vs 90.6 +/- 13.7 [P = .003], 117.6 +/- 14.1 vs 86.7 +/- 11.8 [P = .015], and 337.2 +/- 41.4 vs 143.1 +/- 74.4 [P = .034], respectively). CONCLUSION: MR renography can be used to depict three separate components of renal enhancement: cortical, medullary, and pelvocaliceal. Furosemide-induced diuresis increases renal parenchymal and pelvocaliceal SI and urinary flow rates.

Initial results of the effects of diuresis on gadolinium enhancement in MR imaging of the abdomen.

RATIONALE AND OBJECTIVES: The authors performed this study to assess the effects of furosemide-induced diuresis on paramagnetic contrast material enhancement at magnetic resonance (MR) imaging of the kidney, liver, spleen, and psoas muscle. MATERIALS AND METHODS: Twenty-five patients (average age, 44.9 years; age range, 23-74 years; 13 men, 12 women) who were suspected of having unilateral renal hydronephrosis received 0.1 mmol/kg contrast material with a standardized injection and imaging protocol to assess organ signal intensity at 0-5 minutes after injection. All patients had a normal serum creatinine level. Imaging was performed with a 1.5-T magnet by using a fat-suppressed fast spoiled gradient-echo pulse sequence and a 70 degrees flip angle. Eight patients received 40 mg of furosemide 10 minutes before contrast material injection. RESULTS: The areas of the renal cortical and medullary signal intensity curves minus baseline in the unilateral normal kidneys were significantly greater in the group who received furosemide (P = .026 and P = .037, respectively). The areas of the renal cortical and medullary signal intensity minus baseline in the unilateral hydronephrotic kidneys were also significantly greater in the group that received furosemide (P = .036 and P = .026, respectively). There was a statistically significant increase in splenic enhancement (P = .02) and a tendency for increased liver (P = .09) and psoas muscle (P = .08) enhancement. CONCLUSION: Furosemide-induced diuresis appears to potentiate the cortical and medullary MR renogram, as well as the MR splenogram. A rapid shift in water compartmentalization from the intracellular to the extracellular space and increased renal water content with diuresis are possible explanations.

Gadolinium-enhanced T1-weighted renal and abdominal MR imaging: quantitative discrepancy between clinical and in vitro findings.

RATIONALE AND OBJECTIVES: This study was conducted to compare the magnetic resonance (MR) contrast medium enhancement of abdominal organs in vivo with the signal intensity (SI) values of known in vitro gadolinium solutions. MATERIALS AND METHODS: A phantom was imaged with the MR contrast medium gadodiamide (Omniscan; Nycomed, Princeton, NJ) of solutions at full-strength (0.5 mmol/mL), one-third, 1/10, and 1/100 concentrations. A fat-suppressed fast spoiled gradient-echo pulse sequence with flip angles ranging from 10 degrees to 170 degrees (at 20 degrees increments) was performed with a 1.5-T magnet. In 12 subjects, the SIs of abdominal organs were determined with identical imaging parameters, before and after administration of gadodiamide injection at 0.1 mmol/kg. RESULTS: As anticipated, the plot of SI in relation to gadodiamide concentration is nonlinear, with a decrease in SI due to T2 effects at concentrations above 0.05 mmol/mL. The kidney showed the highest SI after gadodiamide enhancement (125.2 +/- 11.6 [standard error] at 2.5 minutes), followed by the liver (76.5 +/- 11.5 at 1 minute) and spleen (57.26 +/- 9.35 at 30 seconds). The SI of the renal medulla (114.2 +/- 9.8 at 4.5 minutes) was approximately one-third that in phantom observations. CONCLUSION: The authors observed a marked discrepancy between empirical contrast medium performance in abdominal organs and SI values for comparable gadodiamide concentrations in vitro. One possible reason is the intracellular compartmentalization of water molecules in vivo. These results suggest a need for a better understanding of MR contrast medium performance in vivo.

Treating pain in the emergency department.

The objective of this audit was to evaluate the impact of brief educational intervention on prompt recognition and treatment of pain in the emergency department. The audit was performed on all patients in the emergency department with pain presenting over a 24-h period on three occasions: preintervention, 1-week postintervention and at 4 months. In 151 patients, pain severity scores were mild (24%), moderate (42%), severe (16%) and unknown (18%). Pain score documentation at triage improved from 72 to 94% during the audit (P = 0.01). There was no significant difference in the number of patients treated within 20 min for severe pain (P = 0.076) and within 60 min for moderate pain (P = 0.796) between audits. The likelihood of receiving analgesia within 20 min increased with the patients' pain category (relative risk: 1.8 95% confidence interval: 1.4-2.3). Documentation of pain assessment and the use of pain scores at triage improved after a brief educational intervention but there was no measurable impact on treatment times.