Systematic review of factors influencing decisions to limit treatment in the emergency department.

BACKGROUND: Emergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment in the Emergency Department (ED) through a systematic search of the available literature. DESIGN: Prospectively registered systematic review of studies employing any methodology to investigate factors influencing decisions to limit treatment in the ED. Medline and EMBASE were searched from their inception until January 2019. Methodological quality was assessed using the Mixed Methods Appraisal Tool, but no studies were excluded based on quality. Findings were summarised by narrative analysis. RESULTS: 10 studies published between 1998 and 2016 were identified for inclusion in this review, including seven cross-sectional studies investigating factors associated with treatment-limiting decisions, two surveys of physicians making treatment-limiting decisions and one qualitative study of physicians making treatment-limiting decisions. There was significant heterogeneity in patient groups, outcome measures, methodology and quality. Only three studies received a methodology-specific rating of 'high quality'. Important limitations of the literature include the use of small single-centre retrospective cohorts often lacking a comparison group, and survey studies with low response rates employing closed-response questionnaires. Factors influencing treatment-limiting decisions were categorised into 'patient and disease factors' (age, chronic disease, functional limitation, patient and family wishes, comorbidity, quality of life, acute presenting disorder type, severity and reversibility), 'hospital factors' (colleague opinion, resource availability) and 'non-patient healthcare factors' (moral, ethical, social and cost factors). CONCLUSIONS: Several factors influence decisions to limit treatment in the ED. Many factors are objective and quantifiable, but some are subjective and open to individual interpretation. This review highlights the complexity of the subject and the need for more robust research in this field.

Experiences of surgical nurses in providing end-of-life care in an acute care setting: a qualitative study.

BACKGROUND: The number of deaths occurring in hospitals is rising, and many occur in settings other than specialist palliative care, oncology or critical care. Nurses working outside these specialist environments report end-of-life (EoL) care as a source of stress. This research aimed to explore these experiences. AIMS AND METHODS: This qualitative study, using semi-structured interviews as a research technique, aimed to investigate the experiences of surgical nurses caring for dying patients. RESULTS: Five themes emerged: understanding of and preference for EoL care; perceived barriers while providing EoL care; robust support from the team as a facilitator while providing EoL care; symptom management; future training and support. CONCLUSION: Participants considered providing EoL care as part of their professional role and reported that they were able to provide appropriate physical care. Participants identified challenges in providing emotional and psychological support to dying patients and their families in an acute surgical setting.

A review of research into the development of radiologic expertise: implications for computer-based training.

RATIONALE AND OBJECTIVES: Studies of radiologic error reveal high levels of variation between radiologists. Although it is known that experts outperform novices, we have only limited knowledge about radiologic expertise and how it is acquired. MATERIALS AND METHODS: This review identifies three areas of research: studies of the impact of experience and related factors on the accuracy of decision-making; studies of the organization of expert knowledge; and studies of radiologists' perceptual processes. RESULTS AND CONCLUSION: Interpreting evidence from these three paradigms in the light of recent research into perceptual learning and studies of the visual pathway has a number of conclusions for the training of radiologists, particularly for the design of computer-based learning programs that are able to illustrate the similarities and differences between diagnoses, to give access to large numbers of cases and to help identify weaknesses in the way trainees build up a global representation from fixated regions.

Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making.

BACKGROUND: Diagnostic error is a significant problem in specialities characterised by diagnostic uncertainty such as primary care, emergency medicine and paediatrics. Despite wide-spread availability, computerised aids have not been shown to significantly improve diagnostic decision-making in a real world environment, mainly due to the need for prolonged system consultation. In this study performed in the clinical environment, we used a Web-based diagnostic reminder system that provided rapid advice with free text data entry to examine its impact on clinicians' decisions in an acute paediatric setting during assessments characterised by diagnostic uncertainty. METHODS: Junior doctors working over a 5-month period at four paediatric ambulatory units consulted the Web-based diagnostic aid when they felt the need for diagnostic assistance. Subjects recorded their clinical decisions for patients (differential diagnosis, test-ordering and treatment) before and after system consultation. An expert panel of four paediatric consultants independently suggested clinically significant decisions indicating an appropriate and 'safe' assessment. The primary outcome measure was change in the proportion of 'unsafe' workups by subjects during patient assessment. A more sensitive evaluation of impact was performed using specific validated quality scores. Adverse effects of consultation on decision-making, as well as the additional time spent on system use were examined. RESULTS: Subjects attempted to access the diagnostic aid on 595 occasions during the study period (8.6% of all medical assessments); subjects examined diagnostic advice only in 177 episodes (30%). Senior House Officers at hospitals with greater number of available computer workstations in the clinical area were most likely to consult the system, especially out of working hours. Diagnostic workups construed as 'unsafe' occurred in 47/104 cases (45.2%); this reduced to 32.7% following system consultation (McNemar test, p < 0.001). Subjects' mean 'unsafe' workups per case decreased from 0.49 to 0.32 (p < 0.001). System advice prompted the clinician to consider the 'correct' diagnosis (established at discharge) during initial assessment in 3/104 patients. Median usage time was 1 min 38 sec (IQR 50 sec-3 min 21 sec). Despite a modest increase in the number of diagnostic possibilities entertained by the clinician, no adverse effects were demonstrable on patient management following system use. Numerous technical barriers prevented subjects from accessing the diagnostic aid in the majority of eligible patients in whom they sought diagnostic assistance. CONCLUSION: We have shown that junior doctors used a Web-based diagnostic reminder system during acute paediatric assessments to significantly improve the quality of their diagnostic workup and reduce diagnostic omission errors. These benefits were achieved without any adverse effects on patient management following a quick consultation.

Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study.

BACKGROUND: Computerized decision support systems (DSS) have mainly focused on improving clinicians' diagnostic accuracy in unusual and challenging cases. However, since diagnostic omission errors may predominantly result from incomplete workup in routine clinical practice, the provision of appropriate patient- and context-specific reminders may result in greater impact on patient safety. In this experimental study, a mix of easy and difficult simulated cases were used to assess the impact of a novel diagnostic reminder system (ISABEL) on the quality of clinical decisions made by various grades of clinicians during acute assessment. METHODS: Subjects of different grades (consultants, registrars, senior house officers and medical students), assessed a balanced set of 24 simulated cases on a trial website. Subjects recorded their clinical decisions for the cases (differential diagnosis, test-ordering and treatment), before and after system consultation. A panel of two pediatric consultants independently provided gold standard responses for each case, against which subjects' quality of decisions was measured. The primary outcome measure was change in the count of diagnostic errors of omission (DEO). A more sensitive assessment of the system's impact was achieved using specific quality scores; additional consultation time resulting from DSS use was also calculated. RESULTS: 76 subjects (18 consultants, 24 registrars, 19 senior house officers and 15 students) completed a total of 751 case episodes. The mean count of DEO fell from 5.5 to 5.0 across all subjects (repeated measures ANOVA, p < 0.001); no significant interaction was seen with subject grade. Mean diagnostic quality score increased after system consultation (0.044; 95% confidence interval 0.032, 0.054). ISABEL reminded subjects to consider at least one clinically important diagnosis in 1 in 8 case episodes, and prompted them to order an important test in 1 in 10 case episodes. Median extra time taken for DSS consultation was 1 min (IQR: 30 sec to 2 min). CONCLUSION: The provision of patient- and context-specific reminders has the potential to reduce diagnostic omissions across all subject grades for a range of cases. This study suggests a promising role for the use of future reminder-based DSS in the reduction of diagnostic error.

Breast cancer cell-derived EMMPRIN stimulates fibroblast MMP2 release through a phospholipase A(2) and 5-lipoxygenase catalyzed pathway.

Metalloproteinases (MMP) produced by both cancer and normal stromal fibroblast cells play a critical role in the metastatic spread of tumours, however little is known of the regulation of their release. In this report we demonstrate that breast cancer cells in culture release apparently full length soluble EMMPRIN that promotes the release of pro-MMP2 from fibroblasts. The generation of MMP2 is mediated by activation of phospholipase A(2) and 5-lipoxygenase. These results suggest that the production of soluble EMMPRIN, phospholipase A(2) and 5-lipoxygenase activities are sites for potential therapeutic intervention.

Madura foot in the U.K.: fungal osteomyelitis after renal transplantation.

We report the case of an ethnic Asian patient who attended the renal transplant follow-up clinic complaining of pain in the right great toe. He had undergone transplantation nine months earlier and was maintained on triple immunosuppression. Initially, a clinical diagnosis of gout was made and the patient treated with analgesia. Two weeks later he remained symptomatic and developed a discharging sinus on his toe. A plain X-ray revealed a lytic lesion with minimal periosteal reaction. Aspiration of his first right metatarsal phalangeal joint was performed and fungal hyphae were observed in the fluid. Subsequently, despite surgical debridement and treatment with Itraconozaole amputation of the toe was required. Microbiological analysis revealed the organism to be Madurella grisea,which was resistant to both Itraconazole and Amphotericin B. He has remained well since amputation. We believe this to be the first case of Madurella infection to be described in a transplant patient.

Measuring the impact of diagnostic decision support on the quality of clinical decision making: development of a reliable and valid composite score.

OBJECTIVE: Few previous studies evaluating the benefits of diagnostic decision support systems have simultaneously measured changes in diagnostic quality and clinical management prompted by use of the system. This report describes a reliable and valid scoring technique to measure the quality of clinical decision plans in an acute medical setting, where diagnostic decision support tools might prove most useful. DESIGN: Sets of differential diagnoses and clinical management plans generated by 71 clinicians for six simulated cases, before and after decision support from a Web-based pediatric differential diagnostic tool (ISABEL), were used. MEASUREMENTS: A composite quality score was calculated separately for each diagnostic and management plan by considering the appropriateness value of each component diagnostic or management suggestion, a weighted sum of individual suggestion ratings, relevance of the entire plan, and its comprehensiveness. The reliability and validity (face, concurrent, construct, and content) of these two final scores were examined. RESULTS: Two hundred fifty-two diagnostic and 350 management suggestions were included in the interrater reliability analysis. There was good agreement between raters (intraclass correlation coefficient, 0.79 for diagnoses, and 0.72 for management). No counterintuitive scores were demonstrated on visual inspection of the sets. Content validity was verified by a consultation process with pediatricians. Both scores discriminated adequately between the plans of consultants and medical students and correlated well with clinicians' subjective opinions of overall plan quality (Spearman rho 0.65, p < 0.01). The diagnostic and management scores for each episode showed moderate correlation (r = 0.51). CONCLUSION: The scores described can be used as key outcome measures in a larger study to fully assess the value of diagnostic decision aids, such as the ISABEL system.

Detection of known and novel genes encoding aromatic ring-hydroxylating dioxygenases in soils and in aromatic hydrocarbon-degrading bacteria.

Primers were designed and successfully used to screen aromatic hydrocarbon-degrading bacteria for the presence of class II aromatic ring-hydroxylating dioxygenase (RHD) genes and to amplify novel RHD genes from DNA extracted from soil using the polymerase chain reaction. Two previously undiscovered groups of genes encoding putative class II RHDs, designated the S and T clusters, were found in RHD different soil samples. Only one of 70 RHD gene fragments amplified from these soil samples could be assigned to a cluster of previously reported RHD genes. These results suggest that distinct and potentially numerically dominant groups of as-yet unrecognized aromatic hydrocarbon-degrading bacteria exist in soils.

Recognizing dying in terminal illness.

Recognizing dying in terminally ill patients is a complex clinical skill. This article outlines the approach to the decision, common difficulties encountered in patients with both malignant and non-malignant disease, and a simple approach to considering the question 'Is this patient dying?'

Haemoptysis in pregnancy caused by a well-differentiated fetal adenocarcinoma: a case report.

INTRODUCTION: Haemoptysis in pregnancy is frequently assumed to be caused by a pulmonary embolism. However, it can also be an indicator of serious pathology. CASE PRESENTATION: We report the case of a 27-year-old Caucasian woman who presented with haemoptysis in pregnancy that was discovered to be caused by a well-differentiated fetal adenocarcinoma of the lung. CONCLUSION: This case demonstrates the importance of establishing an accurate diagnosis when a pregnant woman presents with haemoptysis and that more serious pathology should be considered if the clinical symptoms persist and/or the presumed diagnosis of pulmonary embolism is not confirmed.

A method for assessing the potential for a dermal burn hazard from malfunctioning consumer electronic devices.

We developed an approach to adapt the ASTM C1055-03 Standard to assess the potential for contact burn injury from portable consumer electronic devices. The approach involves measuring the maximum temperature profile during the fault and devising a way to reproduce these temperatures in an exemplar device in a controlled manner for thermesthesiometer measurements. By comparing the results of the thermesthesiometer measurements to the contact burn injury threshold data published in ASTM C1055-03 and various guidelines for unintentional contact times, we were able to predict whether a potential hazard exists and verify result with "finger tests." We applied this method on a number of occasions to assess the likelihood of a contact burn injury resulting from a fault arising inside portable consumer electronic devices.

Variations in the abundance and identity of class II aromatic ring-hydroxylating dioxygenase genes in groundwater at an aromatic hydrocarbon-contaminated site.

The abundance of genes encoding aromatic ring-hydroxylating dioxygenases (RHDs) in the groundwater at an aromatic hydrocarbon-contaminated landfill near Sydney, Australia, was determined by quantitative DNA-DNA hybridization using class II RHD genes as probes. There were marked differences in hybridization signal intensity against DNA extracted from the groundwater at seven different locations across this heterogeneous site. This was interpreted as indicating variation in RHD gene abundance. Clone libraries of polymerase chain reaction (PCR)-amplified RHD gene fragments were constructed from DNA from each of the groundwater samples. The libraries from the samples with greater RHD gene abundance were dominated by a group of bacterial class II RHD genes, designated the S-cluster, that has yet to be found in cultured isolates. These groundwater samples contained no detectable petroleum hydrocarbons. A second group of class II RHD gene sequences, designated the T-cluster, dominated RHD gene clone libraries prepared from groundwater samples that contained detectable levels of total petroleum and aromatic hydrocarbons but lower RHD gene abundance. The hosts and in situ expression of these novel genes, and the substrates of the enzymes they encode, remain unknown. The scarcity of genes from known aromatic hydrocarbon-degrading bacteria and the numerical dominance of the novel genes suggest that the hosts of these novel genes may play an important role in aromatic hydrocarbon degradation at this site.

Osteochondritis Dissecans as a Cause of Posterior Heel Pain.

In brief Osteochondritis dissecans of the calcaneus is a condition that results in a small fragment of bone and cartilage being deposited between the calcaneus and the Achilles tendon and causes pain on the posterior aspect of the calcaneus. This paper discusses how the condition can be differentiated from other causes of posterior heel pain so a proper treatment plan can be started. Two case histories of individuals with different levels of activity are presented to demonstrate this condition.

Image-guided peritoneal access and management of complications in peritoneal dialysis.

The principal complications of continuous ambulatory peritoneal dialysis (CAPD), namely malposition of the dialysis catheter, peritonitis, exit site infection, leakage of dialysis fluid, sclerosing peritonitis, and renal cysts and tumors, are considered in this article. The techniques that are used to reposition displaced dialysis catheters and extend the duration of dialysis are described. The role of imaging in establishing the diagnosis of peritonitis is relatively small. However, both computed tomography (CT) and ultrasound may be used to identify loculation of fluid and localized sites of sepsis, and permit percutaneous drainage. Ultrasonography of the catheter track through the percutaneous tissues allows identification of pericatheter collections in patients with exit-site infection. The technique of CT peritoneography is helpful in establishing sites of dialysis fluid leakage. These commonly occur at the site of entry of the dialysis catheter, through abdominal incisions, or along the patent tunica vaginalis into the scrotum. The appearances on CT of sclerosing peritonitis reflect pathologic changes and are characterized by the presence of peritoneal thickening and calcification. Bowel obstruction, which may develop in sclerosing peritonitis, can be identified on abdominal radiographs or barium studies of the gastrointestinal tract. Acquired renal cystic disease and renal carcinomas occur in a significant proportion of patients undergoing CAPD. Ultrasound is the investigation of first choice in the identification and clarification of the pathology (cystic or solid) of suspected renal masses.

Improved culturability of soil bacteria and isolation in pure culture of novel members of the divisions Acidobacteria, Actinobacteria, Proteobacteria, and Verrucomicrobia.

The culturability of bacteria in the bulk soil of an Australian pasture was investigated by using nutrient broth at 1/100 of its normal concentration (dilute nutrient broth [DNB]) as the growth medium. Three-tube most-probable-number serial dilution culture resulted in a mean viable count that was only 1.4% of the mean microscopically determined total cell count. Plate counts with DNB solidified with agar and with gellan gum resulted in viable counts that were 5.2 and 7.5% of the mean microscopically determined total cell count, respectively. Prior homogenization of the soil sample with an ultrasonic probe increased the viable count obtained by using DNB solidified with gellan gum to 14.1% of the mean microscopically determined cell count. A microscopic examination of the cell aggregates that remained after sonication revealed that the potential CFU count was only 70.4% of the total cell count, due to cells occurring as pairs or in clumps of three or more cells. Staining with SYTO 9 plus propidium iodide indicated that 91.3% of the cells in sonicated soil samples were potentially viable. Together, these findings suggest that the maximum achievable CFU count may be as low as 64.3% of the total cell count. Thirty isolates obtained from plate counting experiments performed with DNB as the growth medium were identified by comparative analysis of partial 16S rRNA gene sequences. A large proportion of these isolates represent the first known isolates of globally distributed groups of soil bacteria belonging to novel lineages within the divisions Actinobacteria, Acidobacteria, Proteobacteria, and Verrucomicrobia.