Population-based cohort study of hospital delivery volume, geographic accessibility, and obstetric outcomes.

OBJECTIVE: To determine associations between geographic accessibility, delivery volume, and obstetric outcomes. METHODS: Population-based cohort study of linked hospital administrative, census, and geospatial data (2006-2009) from all Canadian jurisdictions except Quebec. Perinatal mortality and major maternal morbidity/mortality were compared across categories of road distance and hospital delivery volume. RESULTS: Among 820 761 mothers delivering 827 504 neonates, travel distance had minimal effect on perinatal mortality. Compared with mothers travelling 0-9 km, the odds of adverse maternal outcomes was decreased for women travelling modest distances (20-49 km, odds ratio, 0.80 [95% confidence interval, 0.75-0.86]), and increased thereafter (50-99 km, 0.99 [0.89-1.10]; 200-299 km, 1.44 [1.10-1.87]; >400 km, 2.22 [1.06-4.63]). Relative to high-volume hospitals (>2500 deliveries/year), adverse maternal outcomes were less likely for hospitals with 1000-2499 (0.90 [0.86-0.95]), and roughly equivalent for hospitals with 200-499 (1.34 [1.22-1.48]) and 500-999 (1.27 [1.17-1.39]) deliveries/year. Odds of perinatal mortality ranged from 1.04 (0.73-1.49; 100-199 deliveries/year) to 1.50 (1.04-2.16; 50-99 deliveries/year); the pattern did not suggest causality. CONCLUSION: Maternal outcomes worsen when travel distance is greater than 200 km, and improve when delivery volume exceeds 1000 deliveries per year.

Utility of computed tomography and derivation and validation of a score to identify an emergent outcome in 2,315 patients with suspected urinary tract stone.

OBJECTIVE: Because a majority of urinary tract stones (UTSs) pass spontaneously and clinically significant alternative pathology is rare, we hypothesize that many computed tomographic (CT) scans to diagnose them are likely unnecessary. We sought to measure the impact of renal CT scans on resource use and to justify a prospective study to derive a score that predicts an emergent diagnosis in patients with suspected UTS by doing so in our retrospective series. METHODS: We conducted a retrospective study of ED patients who had noncontrast CT of the abdomen for suspected UTS. A split-sample was used to derive and validate a score to predict the presence of an emergent diagnosis on CT. RESULTS: Of the 2,315 patients (50.8% female, mean age 45 years), 49 (2.1%) had an emergent outcome observed on CT. An additional 12 (0.5%) patients had an urgent outcome and 239 (10.6%) had a urologic procedure within 8 weeks of the CT. Serum white blood cell count, highest temperature, urine red blood cell count, and the presence of abdominal pain were significant predictors of the primary outcome. A score derived using these predictors had a potential range of -2 (0.26% predicted risk, 0.5% actual risk of the outcome) to 6 (52% predicted risk). The score was moderately discriminatory with c-statistics of 0.752 (derivation) and 0.668 (validation) and accurate with Hosmer-Lemeshow statistics of 10.553 (p  =  0.228, derivation) and 9.70 (p  =  0.286, validation). CONCLUSIONS: A sensible, relevant score derived and validated on all patients presenting with symptoms suggestive of renal colic could be useful in reducing abdominal CT scan ordering.

613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review.

BACKGROUND: Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion. METHODS: Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011. RESULTS: We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy. CONCLUSIONS: Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture.

Trivial trauma and delayed rupture of a normal spleen: a case report.

INTRODUCTION: Although a majority of splenic ruptures present acutely with a known mechanism of injury, a minority of patients present days to weeks following trauma with a delayed rupture. Also uncommon is the atraumatic rupture, the vast majority of which occur in patients with underlying splenic pathology. A handful of cases of apparently spontaneous rupture of a normal spleen are reported; however, there is debate about whether these actually represent delayed ruptures following a history of trauma that is not elicited. Although a few cases of delayed rupture of the spleen following trivial trauma have been reported, the majority of these present evidence of an underlying disease process. We found only two such cases that documented a normal spleen and three cases where underlying splenic pathology was not reported. We review the literature and discuss the phenomenon of delayed rupture of the normal spleen following trivial trauma. CASE PRESENTATION: A 27-year-old Caucasian man with no underlying splenic pathology presented with splenic rupture one week after playfully wrestling with his partner. The patient did not present at the time of the injury and only recalled it upon repeated questioning after computed tomography diagnosis. CONCLUSIONS: This case lends support to the theory that the normal spleen can rupture some time after trivial trauma, which seems like a more plausible explanation than rupture without cause. However, given the dearth of similar reports in the literature, the possibility remains that the association we have observed is not causational.

Post-traumatic stress disorder in physicians from an underserviced area.

BACKGROUND: Studies suggest a high prevalence of mental illness in physicians. The rate of post-traumatic stress disorder (PTSD) has been examined in physicians exposed to traumatic circumstances and physicians in training but never in physicians in regular practice. OBJECTIVE: To estimate the prevalence of PTSD in physicians practicing in a predominantly rural and remote and medically underserviced region of Canada. METHODS: The PTSD Checklist-Civilian Version (PCL-C) was mailed to all 331 physicians in Northwestern Ontario, Canada. A PCL-C score of >or=50 was used to define 'probable' PTSD and >or=30 defined 'possible' PTSD. Additional comments and demographic information were also requested. RESULTS: Completed questionnaires were received from 159 physicians (48%). The prevalence of probable PTSD was 4.4%. No differences between demographic groups were observed for probable PTSD, but possible PTSD was more frequent in males than females (47.3% versus 20.4%, chi-square = 10.59, P = 0.001). Mean scores were also higher for males than for females (30.4 versus 25.4, 95% confidence interval for the difference: 1.4-8.5, P = 0.006). Respondents identified overwork, insufficient resources and relationships with colleagues and patients as common stressors. CONCLUSIONS: Results suggest a high rate of PTSD in Northwestern Ontario physicians. The prevalence of possible PTSD and mean PCL-C scores are higher in men than in women in this region, which may relate to differences in practice characteristics and the opportunity for exposure to traumatic events.