Regionalization of post-cardiac arrest care: implementation of a cardiac resuscitation center.

BACKGROUND: Guidelines recommend standardized treatment of post-cardiac arrest patients to improve outcomes. However, the infrastructure, resources, and personnel required to meet the complex needs of cardiac arrest victims remain a barrier to care. Given that regionalization of time-dependent high-acuity illness is an emerging paradigm, the aim of the present study was to develop and implement a regionalized approach to post-cardiac arrest care. METHODS: We performed a prospective observational study on all patients treated in a regionalized clinical pathway from November 2007 through June 2011. All patients were enrolled after admission to an urban academic medical center. Clinical data including arrest and treatment variables, complications, and outcome were collected on consecutive patients with the use of a preformatted standard data collection tool using Utstein criteria. RESULTS: A total of 220 patients were enrolled; 127 (58%) patients were local direct admissions from our community, and 93 (42%) were transferred from 1 of 24 outlying referral hospitals. One hundred six (48%, 95% CI 38%-53%) patients survived to hospital discharge. The primary outcome of hospital survival with good neurologic function was observed in 94 (43%, 95% CI 32%-48%). There was no difference in survival with good neurologic outcome among local and referred patients. Overall 1-year survival was 44% (95% CI 38%-51%). Among patients discharged from the hospital with good neurologic function, 93% (95% CI 85%-97%) remained alive at 1 year. CONCLUSION: Development of a regionalized approach to post-cardiac arrest care using previously established referral relationships is feasible, and implementation of such an approach was clinically effective in our region.

Predictors of the complication of postintubation hypotension during emergency airway management.

OBJECTIVE: Arterial hypotension is a recognized complication of emergency intubation that is independently associated with increased morbidity and mortality. Our aim was to identify factors associated with postintubation hypotension after emergency intubation. METHODS: Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements below 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with postintubation hypotension (PIH), defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. Multiple logistic regression modeling was used to define predictors of PIH. RESULTS: A total 465 patients underwent emergency intubation during the study period, and 300 met inclusion criteria for this study. Postintubation hypotension occurred in 66 (22%) of 300 patients, and these patients experienced significantly higher in-hospital mortality (35% vs 20%; odds ratio [OR] 2.1; 95% confidence interval [CI], 1.2-3.9). Multiple logistic regression analysis demonstrated that preintubation shock index (SI), chronic renal disease, intubation for acute respiratory failure, and age were independently associated with PIH. Of these, SI was the most strongly associated factor (OR, 55; 95% CI, 13-232). Receiver operating characteristic plot showed optimized SI 0.8 or higher predicting PIH with 67% sensitivity and 80% specificity. Rapid sequence intubation paralysis was associated with a lower incidence of PIH (OR, 0.04; 95% CI, 0.003-0.4). CONCLUSIONS: Preintubation and peri-intubation factors predict the complication of PIH. Elevated SI strongly and independently forewarned of cardiovascular deterioration after emergency intubation with pre-RSI SI 0.8 or higher as the optimal threshold to identify patients at risk.

Antenatal sexually transmitted infection screening in private and indigent clinics in a community hospital system.

OBJECTIVE: To determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics. STUDY DESIGN: One hundred eighty-three women were divided into cohorts based on whether they received prenatal care at a private or indigent clinic. Timing of required antenatal sexually transmitted infection screening was collected for 8 tests and compliance scores were calculated. Primary outcome was average compliance score compared between clinic types. Secondary outcomes included disease-specific compliance and percent of perfect compliance at different office types. RESULTS: Compliance was found to be different between clinic types (P = .023). Indigent clinics had the same median with slightly higher inner-quartile range than private clinics (7 [7-8], 7 [7-7]). Indigent clinics had higher mean compliance scores (7.1 vs 6.9) and a greater percentage of patients demonstrating perfect compliance (42% vs 14%, P < .001). CONCLUSION: Clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.

A retrospective, cohort study of the prevalence and risk factors of oral burning in patients with dry mouth.

OBJECTIVES: The aims of this study were to evaluate the prevalence of oral burning in a dry mouth cohort of patients and to determine associated factors. STUDY DESIGN: A retrospective cohort study was conducted by reviewing the charts of 170 patients who presented to Carolinas Medical Center's Department of Oral Medicine from January 2004 to June 2009. Information collected from their charts was extensive. RESULTS: Forty percent (68 of 170) of dry mouth patients had a concomitant complaint of oral burning. Sixty-four were female and 4 were male. The mean age was 61.1 years (range 25-89). Cofactors associated with oral burning included age (OR 1.03, CI 1.00-1.05, P = .028) and use of herbal medications (OR .26, CI .10-.67, P = .005). CONCLUSIONS: Oral burning is often concomitant with oral dryness. Targeting factors associated with oral dryness may help alleviate an oral burning complaint in select populations.

Molecular methodology to assess the impact of cancer chemotherapy on the oral bacterial flora: a pilot study.

OBJECTIVE: This pilot study determined the profile of the oral bacterial flora in an outpatient cancer population before and after chemotherapy using molecular techniques. STUDY DESIGN: We recruited 9 newly diagnosed breast cancer patients scheduled for induction chemotherapy. All were seen immediately before chemotherapy, and 7 to 14 days later. At both visits, we performed oral evaluations and obtained mucositis grading (with the World Health Organization [WHO] scale), absolute neutrophil counts (ANC), and bacterial samples from the buccal mucosa. Bacterial DNA was isolated, and 16S ribosomal RNA gene clonal libraries were constructed. Sequences of genes in the library were used to determine species identity by comparison to known sequences. RESULTS: After chemotherapy, WHO scores of 0 and 1 were in 3 and 6 patients, respectively, and mean ANC (+/-SD) dropped from 3326 +/- 463 to 1091 +/- 1082 cells/mm(3). From pre- and post-chemotherapy samples, 41 species were detected, with a predominance of Gemella haemolysans and Streptococcus mitis. More than 85% of species have not been previously identified in chemotherapy patients. Seven species appeared exclusively before chemotherapy and 25 after chemotherapy. After chemotherapy, the number of species per patient increased by a mean of 2.6 (SD = 4.7, P = .052). CONCLUSION: We identified species not previously identified in chemotherapy patients. Our results suggest a shift to a more complex oral bacterial profile in patients undergoing cancer chemotherapy.

Closed versus open reduction of mandibular condylar fractures in adults: a meta-analysis.

PURPOSE: A review of the literature shows a difference of opinion regarding whether open or closed reduction of condylar fractures produces the best results. It would be beneficial, therefore, to critically analyze past studies that have directly compared the 2 methods in an attempt to answer this question. MATERIALS AND METHODS: A Medline search for articles using the key words "mandibular condyle fractures" and "mandibular condyle fracture surgery" was performed. Articles that compared open and closed reduction were selected for further evaluation. Additional articles were obtained from reference lists in the Medline-selected articles. Of the 32 articles identified, 13 met the final selection criteria. These contained data on at least one of the following: postoperative maximum mouth opening, deviation on opening, lateral excursion, protrusion, asymmetry, and joint or muscle pain. RESULTS: Numerous problems were found with the information presented in the various articles. These included lack of patient randomization, failure to classify the type of condylar fracture, variability within the surgical protocols, and inconsistencies in choice of variables and how they were reported. However, the results from the meta-analyses were explored in a general sense. CONCLUSIONS: Because of the great variation in the manner in which the various study parameters were reported, it was not possible to perform a reliable meta-analysis. There is a need for better standardization of data collection as well as randomization of the patients treated in future studies to accurately compare the 2 methods.