Risk prediction tools for keratinocyte carcinoma after solid organ transplantation: a review of the literature.

Long-term iatrogenic immunosuppression increases the risk of cutaneous malignancies in organ transplant recipients (OTRs), particularly the keratinocyte cancers basal cell carcinoma and cutaneous squamous cell carcinoma (cSCC). cSCC is the most common malignancy in OTRs, with the risk increased to over 65-fold in transplanted patients relative to the general population. There have been very few risk prediction tools developed for accurate determination of the risk of developing keratinocyte cancers in the OTR population. This review summarizes the prediction tools developed to date, and outlines future directions for developing more accurate prediction models that are clinically useful for the transplant physician and dermatologist.

Genetic structure of Aedes aegypti in Australia and Vietnam revealed by microsatellite and exon primed intron crossing markers suggests feasibility of local control options.

The distribution of Aedes aegypti (L.) in Australia is currently restricted to northern Queensland, but it has been more extensive in the past. In this study, we evaluate the genetic structure of Ae. aegypti populations in Australia and Vietnam and consider genetic differentiation between mosquitoes from these areas and those from a population in Thailand. Six microsatellites and two exon primed intron crossing markers were used to assess isolation by distance across all populations and also within the Australian sample. Investigations of founder effects, amount of molecular variation between and within regions and comparison of F(ST) values among Australian and Vietnamese populations were made to assess the scale of movement ofAe. aegypti. Genetic control methods are under development for mosquito vector populations including the dengue vector Ae. aegypti. The success of these control methods will depend on the population structure of the target species including population size and rates of movement among populations. Releases of modified mosquitoes could target local populations that show a high degree of isolation from surrounding populations, potentially allowing new variants to become established in one region with eventual dispersal to other regions.

The role of alcohol in new-onset atrial fibrillation.

Forty cases of new-onset atrial fibrillation (AF) were reviewed to establish the frequency of various causes. Alcohol intoxication caused or contributed to 14 cases (35%). Coronary artery disease (22.5%) and pulmonary disease (22.5%) were also common causes of acute AF. Among patients less than 65 years old, alcohol caused or contributed to approximately two thirds (63%) of the cases of AF. Thyrotoxicosis was uncommon (one case in 40); no patient had a diagnosis of mitral stenosis, pulmonary embolism, or pericarditis. There were no complications of AF in alcoholic patients; the majority (88.9%) converted spontaneously to a normal sinus rhythm within 24 hours. Alcohol intoxication should be considered early in the differential diagnosis of new-onset AF in young patients. Many patients may not require admission to an intensive care unit or a costly battery of diagnostic tests.

Safety belt nonuse by internal medicine patients: a missed opportunity in clinical preventive medicine.

BACKGROUND: The United States Preventive Services Task Force recommends that physicians routinely counsel all patients to wear safety belts. We undertook this study to determine the prevalence of the nonuse of safety belts among internal medicine patients, to measure the association of nonuse with other health risk factors, and to ascertain the safety belt counseling practices of physicians. PATIENTS AND METHODS: A total of 492 consecutive patients attending a university-based general medicine clinic were given a validated, self-administered questionnaire, and 94% responded. A medical chart review was performed in a blinded fashion on 94% of the eligible charts. RESULTS: Of the 454 patients who provided safety belt information, 243 (54%) did not wear safety belts. Nonusers were more likely to be problem drinkers, inactive, obese, and to have a low income (adjusted odds ratios 1.8 to 2.0). Of patients with all four of these characteristics, 91% did not use safety belts. The leading reasons for safety belt nonuse were discomfort (35%), short driving distances (24%), and forgetfulness (13%). Obese patients were more likely to report discomfort as their reason for nonuse (odds ratio 2.4; 95% confidence limit 1.4 to 4.3). Eighteen patients (3.9%) reported that a physician had ever counseled them about safety belt use. Only two of 314 medical records (0.6%) noted physician questioning or counseling about safety belt use. CONCLUSIONS: The majority of patients attending an internal medicine clinic do not wear safety belts. Nonusers are more likely to be problem drinkers, inactive, obese, and to have a low income. Patients with multiple health risk factors are at significant risk of nonuse. The most common reason for nonuse is physical discomfort, especially among obese patients. Finally, physicians rarely counsel patients to use safety belts.

Granulomatous tenosynovitis and carpal tunnel syndrome caused by Sporothrix schenckii.

Although the usual form of sporotrichosis is a lymphocutaneous lesion, Sporothrix schenckii can cause articular disease that is difficult to diagnose. We describe two patients with sporotrichosis who presented with tenosynovitis and the carpal tunnel syndrome. A tissue specimen is required for a precise diagnosis; granulomatous tenosynovitis suggests an infectious cause. Unless appropriate cultures for bacteria, mycobacteria and fungi are obtained, the diagnosis may be missed or delayed. Mouse inoculations may be required to isolate S. schenckii from tissue, which rarely shows the delicate fungus in histologic sections. Our patients were cured by a combination of synovectomy and the intravenous administration of amphotericin B. Sporotrichosis should be considered in the differential diagnosis of the carpal tunnel syndrome, particularly when surgical exploration discloses a granulomatous tenosynovitis.

Benefits of training physicians in advanced cardiac life support.

Unexpected cardiopulmonary arrests occur commonly both in the prehospital setting and in the course of hospital care. Survival after prehospital arrest is improved if bystanders and paramedics are trained in basic and advanced cardiac life support. However, within the hospital, the bystanders are the physicians; it is not known if life support training of these hospital-based physician bystanders leads to improved survival. Therefore, we reviewed the outcome of resuscitation attempts in a teaching hospital during two matching six-month periods, before (period 1) and after (period 2) institution of a mandatory course in Advanced Cardiac Life Support (ACLS) for medical houseofficers. It was concluded that survival after inhospital cardiopulmonary arrest is significantly increased if house officers who staff the Code teams are trained in ACLS.

Predictive validity of a screen for partner violence against women.

BACKGROUND: While public health leaders recommend screening for partner violence, the predictive value of this practice is unknown. The purpose of this study was to test the ability of a brief three-question violence screen to predict violence against women in the ensuing months. METHODS: We conducted a prospective cohort study of adult women participating in the Colorado Behavioral Risk Factor Surveillance System (BRFSS), a population-based, random-digit-dialing telephone survey. During 8 monthly cohorts, 695 women participated in the BRFSS; 409 women participated in follow-up telephone interviews approximately 4 months later. Violent events during the follow-up period, measured using a modified 28-item Conflict Tactics Scale, were compared between women who initially screened positive and those who screened negative. RESULTS: Among BRFSS respondents, 8.4% (95% confidence interval [CI]=6.3%-10.5%) had an initial positive screen. During the follow-up period, women who screened positive were 46.5 times (5.4-405) more likely to experience severe physical violence, 11.7 times (5.0- 27.3) more likely to experience physical violence, 3.6 (2.4-5.2) times more likely to experience verbal aggression, and 2.5 times (1.2-5.1) more likely to experience sexual coercion. In a multivariate model, separation from one's spouse and a positive screen were significant independent predictors of physical violence. CONCLUSIONS: A brief violence screen identifies a subset of women at high risk for verbal, physical, and sexual partner abuse over the following 4 months. Women with a positive screen who are separated from their spouse are at highest risk.

A research paradigm for severity for illness: issues for the diagnosis-related group system.

The new Medicare Prospective Payment System has been challenged with regard to its fairness in reimbursing hospitals adequately, given the true resource needs in caring for patients. Most of these criticisms are now labelled as issues about adjustments for severity of illness. Critics point to the large amount of unexplained variation in charges and length of stay within the existing DRG's as indirect support for their contentions about inadequate adjustments. A paradigm is presented which argues that the key questions on the types of severity of illness measures to be utilized in future refinements of DRG's revolve around the extent and type of data which can feasibly be included in any workable reimbursement approach. A paradigm is presented on how these questions about information define a series of research options in the severity of illness arena.

Smoking habits of emergency department patients: an opportunity for disease prevention.

OBJECTIVE: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients. METHODS: A questionnaire was administered prospectively to all noncritical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients. RESULTS: The study patients were mostly young (mean age = 35 +/- 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36-0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46-0.64) of these patients were current smokers. CONCLUSIONS: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.

Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.

OBJECTIVES: To determine: 1) the extent of emergency physicians' (EPs') training in smoking cessation counseling; 2) their understanding of counseling and pharmacologic treatment techniques; 3) their current practices in screening, counseling, and referring patients who smoke; and 4) perceived barriers to routine smoking cessation counseling in emergency medical practice. METHODS: A 26-item questionnaire addressing the above issues was mailed to all 256 members of the Colorado Chapter of the American College of Emergency Physicians. RESULTS: Completed questionnaires were returned by 196 physicians (77% response rate). The majority of respondents were men (80%), practiced in urban settings (87%), and were board-certified in emergency medicine (82%). Most EPs lacked formal smoking cessation training (55%) and felt poorly prepared to counsel patients about smoking cessation (65%). A minority (27%) of the physicians reported routinely asking patients to quit smoking. The physicians with formal smoking cessation training were more likely to counsel and refer patients routinely (34% vs 20%, p = 0.03). The physicians cited the following barriers to routine smoking cessation counseling: a lack of time; a perception that patients are not interested; a belief that the ED setting is inappropriate for counseling; and a sense that counseling is ineffective. Lack of reimbursement was cited by only 13% of the respondents. The physicians who had formal smoking cessation training perceived fewer barriers to ED-based counseling. CONCLUSIONS: Emergency physicians have received little training in smoking cessation and perceive many barriers to ED-based smoking cessation interventions. Not surprisingly, they infrequently take action to encourage or assist their patients to quit smoking.

Behavioral risk factors in emergency department patients: a multisite survey.

BACKGROUND: Many people rely on EDs for routine health care. Often, however, screening and counseling for health risks are not provided. OBJECTIVE: To determine prevalence rates of chronic disease and injury risk factors and access to routine health care in a random sample of ED patients in 3 cities. METHODS: A prospective survey was conducted at 3 hospital EDs in Akron, OH, Boston, MA, and Denver, CO. A modified version of the national Behavioral Risk Factor Surveillance Survey was administered by trained researchers to a convenience sample of non-critically ill patients during randomly selected shifts. RESULTS: Of 1,143 eligible patients, 923 (81%) agreed to participate. Their mean age was 39 (range = 17-96) years. Most were female (58%), white (60%), and unmarried (68%). Thirty-eight percent had no access to primary care. Injury-prone behaviors were prevalent: 53% of the respondents did not wear seat belts regularly; 15% had no working smoke detector; 3% kept loaded, unlocked handguns in their homes; 11% had attempted suicide; 23% had a positive CAGE screen for alcoholism; 3% had operated a motor vehicle in the preceding month while alcohol-intoxicated; and 11% had ridden in an automobile with an intoxicated driver. Cancer and chronic disease risks were also common: 48% smoked; 16% had not received a blood pressure check in the preceding year; and 4% reported unsafe sexual practices. Among women aged > 50 years, 42% had not received a Pap test in the prior 2 years and 14% had never had mammography. Many prevalence rates and access to care varied among the 3 sites. However, for most risk factors, prevalence rates did not differ in patients with and without access to primary health care. CONCLUSIONS: ED patients have high rates of injury and chronic disease risks, and many have no other source of routine health care. Research is needed to determine whether ED-based programs, designed to reduce injury and chronic disease risks, are feasible and cost-effective.

Coping with the suicidal elderly: a physician's guide.

Advancing age is associated with a markedly increased risk of suicide. In the United States, one fourth of all suicides are carried out by citizens age 60 or older. The majority of American elders who commit suicide use a firearm to do so. Most suicidal elders look to their primary care physician for help, although they may not directly express their plan. Therefore, physicians must be alert to clues. By far the principal risk factor for suicide is major depression. The risk is heightened by recent losses, alcohol or drug abuse, psychosis, cognitive decline, and chronic disease. Hopelessness, anhedonia, self-reproach, guilt, and a formed lethal plan are signs of a life-threatening suicidal crisis which requires urgent intervention. Physicians must act decisively in recognition of the fact that suicidality is a transient, treatable condition.

A wide, complex look at cardiac dysrhythmias.

The diagnosis and treatment of cardiac dysrhythmias answers the following four questions: Is the patient stable? Is the rate fast or slow? Are the ventricular complexes wide or narrow? Is the rhythm regular or irregular? The most common narrow complex regular tachycardias are sinus tachycardia, atrial flutter, atrial tachycardia that blocks, and paroxysmal supraventricular tachycardia. Carotid sinus massage is useful in differentiation. Irregular narrow-complex tachycardias are usually atrial fibrillation. An ultra-rapid wide-complex or polymorphous irregular tachycardia is likely to be atrial fibrillation with ventricular preexcitation. Wide-complex regular tachycardias present a special challenge, since wide beats may result from supraventricular or ventricular impulse formation. Ventricular tachycardia is more likely than supraventricular tachycardia in the presence of underlying ischemic heart disease, atrioventricular dissociation, fusion or capture beats, or a very broad (greater than .14 seconds) QRS complex. Still, misdiagnosis is common; the most costly mistake is over-diagnosis of SVT. In emergencies, where vital organ hypoperfusion is present, the origin of the impulse and the name of the dysrhythmia are unimportant. With the exception of sinus tachycardia, all life-threatening, rapid tachycardias should be terminated by electrical cardioversion.

Measuring the accuracy of the infrared tympanic thermometer: correlation does not signify agreement.

This prospective study assessed the accuracy of the infrared tympanic thermometer (ITT) compared to the rectal thermometer (RT) using statistical measures of agreement. In a convenience sample of 100 adult emergency department patients, ear examinations to assess for cerumen or otitis were followed by temperature measurements using the First Temp 2000A thermometer in both ears and the IVAC 2000 rectally. Left and right ITT temperatures showed high correlation and agreement; therefore, only right ITT results are reported. Both the ITT and RT recorded similar mean temperatures, standard deviations, and ranges. The correlation of the ITT and RT and agreement were below the 0.8 level, indicating excellent agreement. The mean temperature difference (RT-ITT) between the two devices was 0.1 +/- 0.7 degrees C; in 10% of patients, the temperature difference was > or = 1 degree C. Among 10 patients identified as febrile by RT (RT > or = 38.5 degrees C), 6 were febrile by ITT. Significant differences occurred between the temperature measurements using the ITT and RT; these devices do not demonstrate excellent agreement.

Recognition and treatment of multifocal atrial tachycardia: a critical review.

Multifocal atrial tachycardia (MAT) is an uncommon but clinically important tachydysrhythmia that is usually seen in the setting of severe cardiopulmonary illness. Diagnostic criteria include the presence of at least three different, nonsinus P waves in the same lead; an atrial rate greater than 100 beats per minute; and an isoelectric baseline between P waves. MAT is often difficult to differentiate from atrial fibrillation. The pathogenesis of MAT is unknown; however, it is probably incited by "triggered" electrical activity, a form of abnormal automaticity. This electrophysiologic model has led to several small, uncontrolled clinical trials using calcium channel and beta-adrenergic blocking agents, specifically verapamil and metropolol. None of these trials meets rigorous methodologic standards, and all exclude unstable patients who are at greatest risk for hemodynamic compromise from the tachycardia. Treatment of MAT should first be directed at potential predisposing factors, such as hypoxia, congestive heart failure, and theophylline toxicity. Pharmacologic treatment includes intravenous metoprolol or verapamil; in published reports both agents have been well tolerated and have controlled the heart rate in a majority of patients.

The electrocardiogram in chronic obstructive pulmonary disease.

The electrocardiogram is often abnormal in patients who have chronic obstructive pulmonary disease. The most frequent abnormalities are a rightward P-wave axis (greater than or equal to 70 degrees) and a rightward QRS axis (greater than or equal to 90 degrees). In addition, low voltage in the limb leads, an S1S2S3 pattern, poor R-wave progression, a posterior-superior terminal QRS vector or other changes may be present. Transient atrial and ventricular dysrhythmias are common. Knowledge of the usual electrocardiographic manifestations of chronic obstructive pulmonary disease enables the clinician to recognize uncharacteristic abnormalities, which often represent the effects of superimposed illnesses or drug toxicity.

Paroxysmal supraventricular tachycardias.

Paroxysmal supraventricular tachycardia (PSVT) is a distinct clinical syndrome. Most patients present with the abrupt onset of palpitations, dizziness, dyspnea, or chest pain. The electrocardiogram (ECG) demonstrates a fast heart rate (150-250 beats per min), a regular rhythm, and most often, a narrow QRS complex. The P wave is usually hidden within the QRS complex. PSVT is caused by reentry, and the tachycardias are classified, electrophysiologically, according to the anatomic location of the reentry circuit. Atrioventricular nodal reentry is the most common form of PSVT. In A-V nodal reentry, there are two conducting pathways (alpha and beta) that have different conduction times and refractory periods; both pathways are confined to the A-V nodal and perinodal atrial tissue. The other common form of PSVT, termed atrioventricular reciprocating tachycardia, depends on an anatomically distinct, or "accessory," pathway that may conduct impulses between the atria and the ventricles, while bypassing the AV node. The two forms of PSVT may be distinguished in many cases by examining the 12-lead electrocardiogram. In the majority of cases of A-V nodal reentry, the atria and ventricles are depolarized simultaneously, and the P waves are hidden in the QRS complex. If the reentry circuit includes an accessory pathway, the P wave always follows the QRS, and usually the R-P interval exceeds 70 msec. Several principles should guide the management of PSVT: (a) Unstable patients require emergent electrical cardioversion; (b) A 12-lead ECG should be obtained immediately to confirm that the tachycardia has a narrow complex (ventricular tachycardia may masquerade as PSVT if only a single lead is examined); (c) Vagal maneuvers may be attempted (the Valsalva maneuver is safer and more efficacious, especially in the elderly); and (4) In most patients, adenosine is the first-line agent to treat PSVT. Contraindications to adenosine and drug interactions are noted in this article. In addition, the use of adenosine in wide complex tachycardias and the indications for admission and referral for electrophysiologic evaluation are discussed.

Second-degree atrioventricular block: Mobitz type II.

Acute atrioventricular (AV) block occurs frequently in patients with myocardial infarction. Atrioventricular block is also a common manifestation of sclerodegenerative conduction system disease. Occasionally, heart block results from drug toxicity, hyperkalemia, cardiac valvular calcification, myocarditis, or infiltrative cardiomyopathy. Second-degree AV block is a form of "incomplete" heart block, in which some, but not all, atrial beats are blocked before reaching the ventricles. Mobitz type II second-degree block is an old term, which refers to periodic atrioventricular block with constant PR intervals in the conducted beats. The distinction between type II and type I block is descriptive; of greater importance to the clinician is the anatomic site of the block and the prognosis. In Mobitz type II block the site is almost always below the AV node; in Mobitz type I block the site is usually within the AV node. Type II AV block is more likely to progress to complete heart block and Stokes-Adams arrest. In most cases of second-degree heart block, including cases of 2:1 conduction, it is possible to determine the site of the AV block (intranodal or infranodal) using information about the age of the patient, the clinical setting, and the width of the QRS complex on the surface electrocardiogram. Second-degree atrioventricular block must be distinguished from other "causes of pauses." Nonconducted premature atrial contractions and atrial tachycardia with block are common conditions, which may mimic second-degree AV block.

What determines whether patients are willing to participate in resuscitation studies requiring exception from informed consent?

OBJECTIVES: To examine the willingness of patients to participate in a resuscitation study that requires exception from informed consent and to determine if willingness to participate is associated with demographic and other characteristics. METHODS: Adult patients in an emergency department and in a geriatric outpatient clinic were surveyed. Patients were asked to imagine that they presented to an emergency department with cardiac arrest and asked about their willingness to (1) receive a new drug outside of a study, (2) receive a new drug as part of a study and (3) participate in a randomised controlled trial (RCT) for a new drug. Patients were also asked about participation in studies of invasive procedures. RESULTS: 213 patients from a geriatric clinic and 207 from an emergency department were surveyed. Two thirds of patients from the geriatric clinic and 83% from the emergency department were willing to receive an experimental drug outside of a study. Patients were less willing to participate in a study of the new drug and even less likely to participate in an RCT for the new drug (chi(2) test for trend, p<0.001 for both settings). Patients were less likely to participate in a study of thoracotomy than in a study that required placement of a femoral catheter (p = 0.008 for the geriatric clinic, p = 0.01 for the emergency department). Willingness to participate was not associated with trust in the doctors. CONCLUSIONS: Study design and invasiveness of the intervention were associated with the willingness of patients to participate in resuscitation studies that require exception from informed consent.