Implementation of a Postpartum Note Reminder and Factors Associated with Postpartum Glucose Tolerance Screening.

OBJECTIVES: Although reminder systems are used to increase provider adherence, we are not aware of any real-time reminder systems for provider adherence to postpartum glucose tolerance testing. We studied whether a reminder in the electronic medical records affects provider ordering of a postpartum glucose tolerance test. We also studied whether any demographic, medical history, prenatal, or delivery variables are associated with patient attendance to a postpartum visit and patient completion of the postpartum glucose tolerance test when ordered. METHODS: This was a retrospective study of 246 women diagnosed as having gestational diabetes mellitus who completed prenatal care and delivered at a suburban public safety-net hospital. RESULTS: Implementation of the real-time postpartum note reminder system significantly improved provider adherence to postpartum glucose screening recommendations from 58.1% to 75.0% (P = 0.01). Delivery complications were significantly associated with increased odds for postpartum visit attendance (odds ratio [OR] 3.80, 95% confidence interval [CI] 1.63-8.86, P < 0.01). Increased gestational age at first prenatal visit was significantly associated with decreased odds for postpartum visit attendance (OR 0.93, 95% CI 0.87-0.99, P < 0.05). Speaking Spanish was associated with an increased odds for completion of the postpartum glucose tolerance test when ordered (OR 2.88, 95% CI 1.24-6.70, P = 0.01). CONCLUSIONS: We recommend that hospital managers include a reminder system in the electronic medical record. Providers should focus counseling on the potential future risks to the mother, in addition to encouraging continued adherence to postpartum care. Providers also should counsel those who present later to prenatal care about the importance of obtaining postpartum glucose tolerance tests.

Evaluation of a liquid dressing for minor nonbleeding abrasions and class I and II skin tears in the emergency department.

BACKGROUND: Minor abrasions and skin tears are usually treated with gauze dressings and topical antibiotics requiring frequent and messy dressing changes. OBJECTIVE: We describe our experience with a low-cost, cyanoacrylate-based liquid dressing applied only once for minor abrasions and skin tears. METHODS: We conducted a single-center, prospective, noncomparative study in adult emergency department (ED) patients with minor nonbleeding skin abrasions and class I and II skin tears. After cleaning the wound and achieving hemostasis, the wounds were covered with a single layer of a cyanoacrylate liquid dressing. Patients were followed every 1-2 days until healing. RESULTS: We enrolled 40 patients with 50 wounds including 39 abrasions and 11 skin tears. Mean (standard deviation) age was 54.5 (21.9) years and 57.5% were male. Wounds were located on the face (n = 16), hands (n = 14), legs (n = 11), and arms (n = 9). Pain scores (0 to 10 from none to worst) after application of the liquid dressing were 0 in 62% and 1-3 in the remaining patients. Follow-up was available on 36 patients and 46 wounds. No wounds re-bled and there were no wound infections. Only one wound required an additional dressing. Median (interquartile range [IQR]) time to complete sloughing of the adhesive was 7 (5.5-8) days. Median (IQR) time to complete healing and sloughing of the overlying scab was 10 (7.4-14) days. CONCLUSIONS: Our study suggests that a single application of a low-cost cyanoacrylate-based liquid adhesive is a safe and effective treatment for superficial nonbleeding abrasions and class I and II skin tears that eliminates the need for topical antibiotics and dressings.

Ibuprofen vs acetaminophen vs their combination in the relief of musculoskeletal pain in the ED: a randomized, controlled trial.

Non-opioid analgesics are often administered to emergency department (ED) patients with musculoskeletal pain but if inadequate, opioids are given with associated potential adverse events. We tested the hypothesis that the reduction in pain scores with the combination of ibuprofen and acetaminophen would be at least 15 mm greater than with either of the agents alone. We conducted a double-blind, randomized, controlled trial of adult ED patients with acute musculoskeletal pain. Patients were randomized to oral ibuprofen 800 mg, acetaminophen 1 g, or their combination. Pain scores across the groups were compared with repeated measures analysis of variance at 20, 40, and 60 minutes. A sample of 30 patients in each group had 80% power to detect a 15 mm difference in pain scores across the groups (α = .05). Thirty patients were randomized to each study group. Mean (SD) age was 36 (15), 54% were male, 73% were white, and 13% were Hispanic. Groups were well balanced in baseline characteristics including initial pain scores (59, 61, and 62 for ibuprofen, acetaminophen, and their combination). Pain decreased over the one hour study period for all groups (P < .001) with mean (SD) scores about 20 mm lower on the Visual Analogue Scale than the mean initial score. However, there was no significant difference among treatments (P = .59). The need for rescue analgesics was similar across groups. We conclude that the combination of ibuprofen and acetaminophen did not reduce pain scores or the need for rescue analgesics compared with either agent alone in ED patients with pain secondary to acute musculoskeletal injuries.

The Wong-Baker pain FACES scale measures pain, not fear.

OBJECTIVE: The Wong-Baker FACES pain rating scale (WBS) is preferred by parents and patients for reporting pain severity. However, it is speculated that the "no hurt" and "hurts worst" anchors confound pain measurement with nonnociceptive states. The objective of our study was to determine if fear confounds reporting of pain severity on the WBS. We hypothesized that the WBS would correlate with a psychometrically different pain severity scale (the visual analog scale [VAS]) and not correlate with a fear measure, the Child Medical Fear Scale (CMFS). METHODS: This was a prospective observational study of children 7 to 12 years presenting to a university-based suburban pediatric ED with acute pain. Patients rated pain severity on the WBS ordinal scale and a 100-mm unhatched VAS with marked end points of "no pain" and "worse pain ever." Patients also completed a 26-item CMFS. Correlations between the WBS and VAS with the CMFS total score were assessed with Spearman correlation and exploratory factor analysis. RESULTS: All 3 scales were completed in 197 children. Correlation between the severity scales (WBS-VAS) was moderate: 0.63 (95% confidence interval [CI], 0.54-0.71). However, correlations between the WBS-CMFS and VAS-CMFS were poor: -0.02 (95% CI, -0.16 to -0.12) and 0.01 (95% CI, -0.13 to 0.15), respectively. Correlations did not differ by sex, grade, pain location, or cause of pain (traumatic vs atraumatic). Exploratory factor analysis demonstrated excellent loadings within 2 factors: pain and fear. CONCLUSIONS: The WBS demonstrates moderate correlation with another measure of pain (VAS) and is not mistaken for fear among school-aged patients presenting to the ED with pain.

Utilization of coronary computed tomography angiography for exclusion of coronary artery disease in ED patients with low- to intermediate-risk chest pain: a 1-year experience.

OBJECTIVE: We describe our preliminary experience with coronary computed tomography angiography (CCTA) in emergency department (ED) patients with low- to intermediate-risk chest pain. METHODS: A convenience cohort of patients with low- to intermediate-risk acute chest pain presenting to a suburban ED in 2009 were prospectively enrolled if the attending physician ordered a CCTA for possible coronary artery disease. Demographic and clinician data were entered into structured data collection sheets required before any imaging. The results of CCTA were classified as normal, nonobstructive (1%-50% stenosis), and obstructive (>50% stenosis). Outcomes included hospital admission and death within a 6-month follow-up period. RESULTS: In 2009, 507 patients with ED chest pain had a CCTA while in the ED. The median (interquartile range) age was 54 (47-62) years; 51.5% were female. Thrombolysis in myocardial infarction risk scores were 0 (42.6%), 1 (42.2%), 2 (11.8%), 3 (2.4%), and 4 (1.0%). The results of CCTA were normal (n = 363), nonobstructive (n = 123), and obstructive (n = 21). Admission rates by CCTA results were obstructive (90.5%), nonobstructive (4.9%), and normal (3.0%). None of the patients with normal or nonobstructive CCTA died within the 6-month follow-up period (0%; 95% confidence interval, 0-0.9%). CONCLUSIONS: Many ED patients with low- to intermediate-risk chest pain have a normal or nonobstructive CCTA and may be safely discharged from the ED without any associated mortality within the following 6 months.

Increased individual glucose tolerance test values in women with gestational diabetes.

BACKGROUND: Individual oral glucose tolerance test (OGTT) values may be of interest to clinicians. We evaluate factors associated with these values. METHODS: This retrospective study included 225 pregnant women diagnosed with gestational diabetes by abnormal 100-gram oral GTT. Predictor variables were maternal age, race/ethnicity, gravida, parity, pre-pregnancy Body Mass Index (BMI), weight gain in current pregnancy, family history of diabetes, personal history of gestational diabetes, and neonate gender. Outcome variables were continuous OGTT and categorical elevated OGTT for fasting, 1-hour postprandial, 2-hour postprandial, and 3-hour postprandial. RESULTS: Obese BMI was associated with increased odds for higher fasting level in the continuous OGTT and elevated categorical OGTT; for 1-hour postprandial this significant obese association only occurred for the continuous OGTT. Higher weight gain in pregnancy was associated with a higher fasting level continuous OGTT and elevated categorical OGTT. Higher maternal age at time of delivery was associated with higher 2-hour continuous OGTT and an elevated 1-hour categorical OGTT. Female neonate gender was associated with decreased odds for elevated 2-hour categorical OGTT. Hispanic and Black race/ethnicities were each associated with higher 3-hour continuous OGTT. CONCLUSIONS: These findings can help clinicians identify the women potentially at risk for having abnormal GTT values diagnostic of GDM to provide preemptive early intervention. Clinicians have the goals to identify these women early so that women can be properly educated and counseled in terms of their nutrition status and as to what negative clinical outcomes may occur should their glucose levels remain poorly controlled in the pregnancy.

Pathologist Experience and Concordance in the Diagnosis of Dysplasia in Long-standing Inflammatory Bowel Disease.

Surveillance colonoscopies focused to detect dysplasia are recommended to prevent colorectal cancer in patients with long-standing colonic inflammatory bowel disease (IBD). To date, histologic diagnosis and gradation of IBD-related dysplasia has been challenged by a high variability among pathologists. We aimed to analyze the observer characteristics that are correlated with concordance deviations in this diagnosis. Eight pathologists evaluated a set of 125 endoscopic biopsy samples with a representative distribution of nondysplastic and dysplastic lesions from long-standing IBD patients. Two rounds of diagnosis were carried out during a period of 18 months. The κ test was applied to analyze concordance. Pathologists were grouped on the basis of their experience. A subanalysis was performed by eliminating the highly prevalent nondysplastic samples, as well as an analysis after observers' grouping. Overall interobserver agreement was good (κ=0.73), with an even higher pairwise value (κ=0.86) as well as the intraobserver agreement values (best κ=0.85). After eliminating the highly prevalent nondysplastic samples, the interobserver agreement was still moderate to good (best overall κ=0.50; best paired κ=0.72). Notable differences were seen between the pathologists with a high-volume and low-volume practice (best overall κ=0.61 and 0.41, respectively). The agreement in the diagnosis of dysplasia in IBD endoscopic biopsies may have been undervalued over time. This is the first study evaluating pathologists' diagnostic robustness in this field. The results suggest that examining a large volume of samples is the key factor to increase the consistency in the diagnosis and gradation of IBD-related dysplasia.

Internal fixation of proximal humerus fractures using the T2-proximal humeral nail.

INTRODUCTION: Surgical management of proximal humerus fractures remains controversial and there is an increasing interest in intramedullary nailing. Created to improve previous designs, the T2-proximal humeral nail (PHN) (Stryker) has been recently released, and the English literature lacks a series evaluating its results. We present a clinical prospective study evaluating this implant for proximal humeral fractures. METHOD: We evaluated the functional and radiological results and possible complications. Twenty-nine patients with displaced fractures of the proximal humerus were treated with this nail. One patient was lost right after surgery and excluded from the assessment. Eighteen patients were older than 70 years. RESULTS: There were 21 fractures of the proximal part of the humerus and 7 fractures that also involved the shaft; 15 of the fractures were two-part fractures (surgical neck), 5 were three-part fractures, and 1 was a four-part fracture. All fractures healed in a mean period of 2.7 months. There was one delayed union that healed in 4 months. One case of avascular necrosis of the humeral head was observed (a four-part fracture), but remained asymptomatic and did not require further treatment. In one case a back-out of one proximal screw was observed. A final evaluation with a minimum 1 year follow-up was performed by an independent observer; in 18 patients, the mean Constant score was 65.7 or 76.1% with the adjustment of age and gender; in 19 patients, the mean Oxford Shoulder Score was 21.7. The results obtained with the T2-PHN nail indicate that it represents a safe and reliable method in the treatment of two- and three-part fractures of the proximal humerus. The proximal fixation mechanism diminishes the rate of back-out of the screws, a frequent complication described in the literature. Better functional results were obtained from the patients younger than 70 years, but these were not statistically significant.

Bone contamination and blood culture in tissue donors.

INTRODUCTION: Swab cultures are the most usual method to detect graft contamination; nevertheless it has been confirmed his limited sensibility. We have studied the relationship between blood cultures, swab surface cultures and cultures of entirely samples of cancellous bone. MATERIAL AND METHODS: We have evaluated 5 donors with positive blood culture, from 70 multiorganic donors during 2002. Blood samples were obtained prior the heart arrest. The bone procurement was done just after the organ recovery under aseptic conditions, and surface cultures were performed of each bone. After storage at -80 degrees C, cancellous samples were obtained by trephine and were completely cultured. RESULTS: In one case, the same microorganism grown in blood culture, in 2 of 9 surface cultures, and in 15 of 26 samples of cancellous bone. CONCLUSION: We conclude that to guarantee allograft's safety it is recommended to add donor's blood culture to the habitual surface swab culture if secondary sterilisation is not performed.

Diagnostic characteristics of a clinical screening tool in combination with measuring bedside lactate level in emergency department patients with suspected sepsis.

BACKGROUND: Early identification of sepsis and initiation of aggressive treatment saves lives. However, the diagnosis of sepsis may be delayed in patients without overt deterioration. Clinical screening tools and lactate levels may help identify sepsis patients at risk for adverse outcomes. OBJECTIVES: The objective was to determine the diagnostic characteristics of a clinical screening tool in combination with measuring early bedside point-of-care (POC) lactate levels in emergency department (ED) patients with suspected sepsis. METHODS: This was a prospective, observational study set at a suburban academic ED with an annual census of 90,000. A convenience sample of adult ED patients with suspected infection were screened with a sepsis screening tool for the presence of at least one of the following: temperature greater than 38°C or less than 36°C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min, or altered mental status. Patients meeting criteria had bedside POC lactate testing following triage, which was immediately reported to the treating physician if ≥2.0 mmol/L. Demographic and clinical information, including lactate levels, ED interventions, and final diagnosis, were recorded. Outcomes included presence or absence of sepsis using the American College of Chest Physicians/Society of Critical Care Medicine consensus conference definitions and intensive care unit (ICU) admissions, use of vasopressors, and mortality. Diagnostic test characteristics were calculated using 2-by-2 tables with their 95% confidence intervals (CIs). The association between bedside lactate and ICU admissions, use of vasopressors, and mortality was determined using logistic regression. RESULTS: A total of 258 patients were screened for sepsis. Their mean (± standard deviation [SD]) age was 64 (±19) years; 46% were female, and 82% were white. Lactate levels were 2.0 mmol/L or greater in 80 (31%) patients. Patients were confirmed to meet sepsis criteria in 208 patients (81%). The diagnostic characteristics for sepsis of the combined clinical screening tool and bedside lactates were sensitivity 34% (95% CI = 28% to 41%), specificity 82% (95% CI = 69% to 90%), positive predictive value 89% (95% CI = 80% to 94%), and negative predictive value 23% (95% CI = 17% to 30%). Bedside lactate levels were associated with sepsis severity (p < 0.001), ICU admission (odds ratio [OR] = 2.01; 95% CI = 1.53 to 2.63), and need for vasopressors (OR = 1.54; 95% CI = 1.13 to 2.12). CONCLUSIONS: Use of a clinical screening tool in combination with early bedside POC lactates has moderate to good specificity but low sensitivity in adult ED patients with suspected sepsis. Elevated bedside lactate levels are associated with poor outcomes.

Anterior Dislocation of the Hip Associated with an Actebular Fracture: Case Report.

Anterior hip joint dislocation is less common than posterior dislocation. Although fractures of the acetabulum can occur in anterior hip dislocations, they are infrequently. In this article, we report an uncommon lesion in a woman who sustained an anterior dislocation of the hip associated with a fracture of the acetabular wall. Close reduction was performed immediately the initial injury. The patient underwent open reduction and internal fixation since the hip joint was result unstable and the CT scan showed the presence of a bone fragment of the anterior acetabular wall. At 2-year follow-up, the clinical and radiological results are excellent.

Elbow tuberculosis: an unusual location and diagnostic problem.

Tuberculous arthritis of the elbow joint is not commonly seen by orthopaedic physicians. In the past 20 years, with the pandemic of the human immunodeficiency virus and the increase in immunocompromised people, we have observed a resurgence of tuberculosis. Osteoarticular involvement has increased, too. Spinal and monoarthritis of weight-bearing joints such as the hip or knee are most frequently involved. The elbow joint is an uncommon location of osteoarticular tuberculosis. The aim of this case report is to describe a case of tuberculous arthritis of the elbow and the diagnostic problems that may arise and lead to a delay in treatment.