Colonic wall thickening on computed tomography scan and clinical correlation. Does it suggest the presence of an underlying neoplasia?

The widespread use of computed tomography (CT) scanning technology frequently leads to the incidental discovery of thickened bowel wall. The clinical significance of such a CT scan finding is largely under-investigated. The purpose of our study was to determine the incidence of significant clinical pathology and, particularly, neoplasia in patients with abnormally thickened bowel on CT scan examination. This is a single institution retrospective analysis of patients that underwent CT scanning of their abdomen. The radiological picture was correlated with colonoscopic findings. A total of 40 consecutive patients with thickened bowel on CT scan that also underwent colonoscopy were identified and their records were reviewed. Thirty-five patients had no history of previous gastrointestinal disorder and form our study group. The median age of the patients was 69 years (range, 24-97 years). There were 26 female and 9 male patients. The incidental CT finding of bowel wall thickening was the only reason for the colonoscopy in 14 (35%) out of the 40 patients. Eight (23%) patients with thick bowel had colonic neoplasia based on pathology. Five (14%) patients had invasive adenocarcinoma of the colon. Four (11%) of the 5 patients with colon adenocarcinoma did not have any associated gastrointestinal symptoms or signs. One (3%) patient had lymphoma of the colon and two (6%) had benign polyps. Colonoscopy was unremarkable in 10 (28%) patients. The incidental finding of colonic thickening on CT imaging could be associated with underlying colonic malignancy and, more importantly, represent the initial disease presentation. Therefore, we propose that these patients should undergo colonoscopy.

Bilateral sclerosing stromal tumor of the ovaries in a premenarchal girl.

BACKGROUND: Sclerosing stromal tumor of the ovary is a rare benign neoplasm that is usually unilateral in menstruating women with a mean age of 27. CASE: An 11-year-old girl presented with asymptomatic bilateral sclerosing stromal tumor of the ovaries prior to menarche. We describe the clinical, radiologic and histologic findings with reference to other reported cases. CONCLUSION: We herein report a unique case of bilateral sclerosing stromal tumor of the ovaries arising in a premenarchal girl.

A comparison among the abilities of various injury severity measures to predict mortality with and without accompanying physiologic information.

BACKGROUND: A few recent studies have compared the abilities of different injury severity measures to predict inpatient mortality. This study extended previous studies in that it used a registry with noncenters as well as centers, and examined the relative marginal abilities of competing severity measures to predict mortality when physiologic data also are available. METHODS: Several methods for assessing injury severity of trauma patients were compared in terms of their ability to predict mortality with and without the addition of additional demographic and physiologic information using logistic regression models. Separate determinations also were made for all patients and for three groups of patients with blunt trauma resulting from motor vehicle crashes, low falls, and other blunt injuries. Statistical models were compared using measures of discrimination and calibration. RESULTS: The International Classification of Disease-Based Severity Score (ICISS) had the best discrimination for each of the eight models examined, and it was significantly better than all the other measures in relation to the models for all patients and for victims of motor vehicle crashes. The ICISS also had the best calibration in half of the models with and half without demographic and physiologic information. The New Injury Severity Score had the best calibration in relation to two of the remaining four models. Physiologic data add substantially to the ability to predict mortality regardless of the anatomic injury severity measure used. CONCLUSIONS: On the average, the ICISS had the best discrimination of all of the measures, as well as a slight edge with respect to calibration in predicting trauma mortality with or without the aid of demographic or physiologic measures.

Establishing the scope and methodological approach to out-of-hospital outcomes and effectiveness research.

Outcomes research offers out-of-hospital medicine a valuable methodology for studying the effectiveness of services provided in the out-of hospital setting. A clear understanding of the history and constructs of outcomes research is necessary for its integration into emergency medical services research. This report describes the conceptual framework of outcomes research and key methodological considerations for the successful implementation of out-of-hospital outcomes research. Illustrations of the specific applications of outcomes research and implications to existing methodologies are given, as well as suggestions for improved interdisciplinary research.

Risk adjustment and outcome measures for out-of-hospital respiratory distress.

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. In prior work, this group delineated the priority conditions, described conceptual models, suggested core and risk adjustment measures potentially useful to emergency medical services research, and summarized out-of-hospital pain measurement. In this fifth article in the EMSOP series, the authors recommend specific risk-adjustment measures and outcome measures for use in out-of-hospital research on patients presenting with respiratory distress. The methodology included systematic literature searches and a structured review by an expert panel. The EMSOP group recommends use of pulse oximetry, peak expiratory flow rate, and the visual analog dyspnea scale as potential risk-adjustment measures and outcome measures for out-of-hospital research in patients with respiratory distress. Furthermore, using mortality as an outcome measure is also recommended. Future research is needed to alleviate the paucity of validated tools for out-of-hospital outcomes research.

Hemodynamic monitoring in the elderly undergoing elective colon resection for cancer.

Controversy surrounds the use of pulmonary artery catheters (PACs). We evaluated the influence of preoperative hemodynamic monitoring and optimization on the outcome in elderly patients undergoing elective resection for colon cancer. We performed a retrospective analysis of all elderly patients (age > 65 years) who had undergone elective colon resection during 1985 to 1995. Sixty patients had preoperative insertion of PAC; 217 patients were managed without PAC. Charts were reviewed for Goldman's cardiac risk index (CRI), preoperative risk factors, and hospital mortality. On the basis of CRI the patients were divided into two groups (< 10 and > or = 10). There was no significant difference between PAC or no-PAC patients for age, previous myocardial infarction, congestive heart failure, hypertension, chronic obstructive pulmonary disease, renal insufficiency, hemoglobin, and albumin. There were 12 deaths (4.3%). CRI, which was a significant predictor of mortality in the no-PAC group (2.2% mortality for CRI < 10 vs 15.8% for CRI > or = 10; P < 0.001), was insignificant in the PAC group (2.5% mortality for CRI < 10 vs 5% for CRI > or = 10, P = not significant). Although preoperative optimization using PAC was not beneficial in the low-CRI group it resulted in a threefold reduction in mortality (5% vs 15.8%) in the high-CRI group. We conclude that preoperative optimization of cardiovascular function using a PAC is only beneficial in reducing mortality in high-risk (CRI > or = 10) elderly patients undergoing elective colon resection.

Emergency Medical Services Outcomes Project (EMSOP) IV: pain measurement in out-of-hospital outcomes research.

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. In prior work (EMSOP I), discomfort had the highest weighted score among outcome categories for the top 3 adult conditions (ie, minor trauma, respiratory distress, chest pain) and the first and third highest rankings for children's conditions (ie, minor trauma, respiratory distress). In this fourth article in the EMSOP series, we discuss issues relevant to the measurement of pain in the out-of-hospital setting, recommended pain measures that require evaluation, and implications for outcomes research focusing on pain. For adults, adolescents, and older children, 2 verbal pain-rating scales are recommended for out-of-hospital evaluation: (1) the Adjective Response Scale, which includes the responses "none," "slight," "moderate," "severe," and "agonizing," and (2) the Numeric Response Scale, which includes responses from 0 (no pain) to 100 (worst pain imaginable). The Oucher Scale, combining a visual analog scale with pictures, seems most promising for out-of-hospital use among younger children. Future research in out-of-hospital care should be conducted to determine the utility and feasibility of these measures, as well as the effectiveness of interventions for pain relief.

Emergency Medical Services Outcomes Project III (EMSOP III): the role of risk adjustment in out-of-hospital outcomes research.

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. Fundamental to that purpose is the identification of priority conditions, risk-adjustment measures (RAMs), and outcome measures. In this third EMSOP article, we examine the topic of risk adjustment, discuss the relevance of risk adjustment for out-of-hospital outcomes research, and recommend RAMs that should be evaluated for potential use in emergency medical services (EMS) research. Risk adjustment allows better judgment about the effectiveness and quality of alternative therapies; it fosters a better comparison of potentially dissimilar groups of patients. By measuring RAMs, researchers account for an important source of variation in their studies. Core RAMs are those measures that might be necessary for out-of-hospital outcomes research involving any EMS condition. Potential core RAMs that should be evaluated for their feasibility, validity, and utility in out-of-hospital research include patient age and sex, race and ethnicity, vital signs, level of responsiveness, Glasgow Coma Scale, standardized time intervals, and EMS provider impression of the presenting condition. Potential core RAMs that could be obtained through linkage to other data sources and that should be evaluated for their feasibility, validity, and utility include principal diagnosis and patient comorbidity. We recommend that these potential core RAMs be systematically evaluated for use in risk adjustment of out-of-hospital patient groups that might be used for outcomes research

Paramedic versus nurse crews in the helicopter transport of trauma patients.

INTRODUCTION: A wide variety of opinions exist about using paramedics on flight teams, most of which have not been substantiated by research findings. This study was conducted to explore the outcomes of patients transported by helicopter crews that consisted of either two nurses or a nurse and a paramedic. METHODS: Using data from the New York State Trauma Registry and prehospital care reports, a retrospective comparison was made between the outcomes of 1193 air medical patients transported either by crews consisting of two nurses (N/N) or a nurse and a paramedic (N/P). The sample included blunt and penetrating trauma patients with an Injury Severity Score greater than or equal to 9 and who were older than 16 years. RESULTS: The findings indicate the percentages of patients who lived, died, or were discharged home or to rehabilitation were similar for N/P and N/N groups. Using TRISS methodology and the Z statistic, no statistically significant difference was found in observed versus predicted mortality for both groups (P <.05). CONCLUSION: No significant difference existed in patient outcomes between N/P and N/N crews.