Perspectives of emergency department clinicians on the challenges of addressing low back pain in the emergency setting: A qualitative study.

OBJECTIVE: To identify and explore ED clinician perspectives on: (i) why patients with low back pain (LBP) present to the ED and are admitted into hospital from ED; (ii) barriers and enablers they face when providing care to patients with LBP; and (iii) strategies to improve the care of patients with LBP, and associated care processes, in the ED. METHODS: We undertook a qualitative exploratory study with ED clinicians (medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia, using focus groups and individual interviews. We used thematic analysis to synthesise participant responses to answer the predefined research questions. RESULTS: Twenty-one clinicians participated (two individual interviews, 19 focus groups). Perceptions about better access to the ED and advanced care within ED were thought to drive presentations to the ED for LBP. Barriers and enablers to optimal patient care included patient-, clinician- and service-level factors. The main strategies to improve care included a department LBP pathway, modernised patient and clinician resources, better follow-up options post-discharge and improved communication between ED and primary care. CONCLUSION: We identified a range of targets to improve LBP management in ED. Clinicians perceived internal and external factors to the ED as influences of ED presentation and hospital admission. Clinicians also reported that patient-, clinician- and service-level barriers and enablers influenced patient management in ED. Strategies suggested by clinicians included improved follow-up options, access to resources and an 'LBP pathway' to support decision making.

Novel Conservative Approach to High Surgical Risk Frail Proximal Femur Fractures.

One of the major impacts following a neck of femur fracture is pain. Most patients (nearly all) undergo an operation. This usually includes the frailest terminal patients and deemed a palliative procedure to reduce ongoing pain. The operation comes with risks and can reduce life expectancy in these patients and result in prolonged hospital admission, delirium, and postoperative complications. This case highlights a novel approach to managing the frailest end-of-life patients that does not require them to undergo a conventional operation. The case resulted in a quick discharge from hospital and for the patient and family to maximise the time out of hospital, with a reduced analgesic burden and a peaceful passing away. We feel that this could be an alternative, more humane option for such patients.

Emergency department after-hours primary contact physiotherapy service reduces analgesia and orthopaedic referrals while improving treatment times.

Objective The aims of this study were to identify: (1) whether an after-hours emergency department (ED) collaborative care service using primary contact physiotherapists (PCPs) improves treatment times for musculoskeletal and simple orthopaedic presentations; and (2) differences in orthopaedic referral rates and analgesia prescription for patients managed by PCPs compared with secondary contact physiotherapists. Methods A prospective observational study was conducted of diagnosed, matched patients seen in a 4-day week after-hours ED primary contact physiotherapy service in a tertiary referral ED. Patients presenting with a musculoskeletal or simple orthopaedic diagnosis reviewed by a physiotherapist as either the primary or secondary physiotherapy contact between 1630 and 2030 hours from Saturday to Tuesday were included in the analysis. Outcome measures collected included ED length of stay, orthopaedic referrals in the ED, follow-up plan on discharge from the ED and analgesia prescriptions. Results There were no adverse events, missed diagnoses or re-presentations for any patients managed by an ED PCP. Mean (±s.d.) treatment time for patients seen by an ED PCP was 130±76min, compared with 240±115min for those seen by a secondary contact physiotherapist (P<0.001). There were significant differences between patients managed by PCP versus secondary contact physiotherapists, with decreases of 20.4% for referrals to orthopaedics in the ED, 21.2% for orthopaedic clinic referrals on discharge and 8.5% in analgesia prescriptions for patients managed by an ED PCP (P<0.001). In addition to these reductions, there was a 17.5% increase in general practitioner referrals on discharge for patients managed by an ED PCP (P<0.001). Conclusion An after-hours ED physiotherapy service is a safe service that reduces ED treatment times, as well as analgesia prescriptions and orthopaedic referrals for patients managed by a PCP. What is known about the topic? PCPs are capable of providing safe and effective care to patients in the ED who present with musculoskeletal complaints. Patients managed by physiotherapists as the primary contact require fewer X-rays and have reduced treatment times. What does this paper add? Compared with previously published articles, this study demonstrates similar reductions in ED treatment times in an after-hours setting for patients managed by an ED PCP. However, this was achieved by physiotherapists who have less reported experience. Furthermore, this study found that management of patients by PCPs resulted in a reduction in the amount of analgesia prescribed and orthopaedic input required for these patients. What are the implications for practitioners? PCPs can be trained to operate in the ED with minor or no prior ED experience while facilitating reductions in the amount of analgesia prescribed, orthopaedic referrals required (in ED and on discharge) and reducing treatment times for patients.

Ureteroscopy Without Fluoroscopy: A Feasibility Study and Comparison with Conventional Ureteroscopy.

INTRODUCTION AND OBJECTIVES: Patients with urolithiasis are exposed to significant amounts of radiation during their initial work-up, surgical treatment, and follow-up. The purpose of this study was to determine the feasibility of performing ureteroscopy without fluoroscopy. In addition, we compared patients treated using a completely fluoroless ureteroscopic technique with a cohort of conventional ureteroscopies performed using fluoroscopy. MATERIALS AND METHODS: A retrospective review of 50 consecutive patients undergoing fluoroless ureteroscopy was performed. These procedures were performed by inserting guidewires and instruments using tactile feedback, direct visualization, and external visual cues to substitute for fluoroscopy. In addition, this cohort was compared with 50 conventional, fluoroscopy-guided ureteroscopies performed in the same time period. RESULTS: Fifty ureteroscopies were performed without image guidance. For this cohort, the mean operative time was 59.2 minutes, overall stone burden was 91.53 mm(2), complication rate was 4%, and repeat procedure rate was 8%. Compared with conventional ureteroscopy the fluoroless ureteroscopy patients had a larger stone burden (p=0.042; 91.53 vs 56.58 mm(2)), but similar age, gender, American Society of Anesthesiologists (ASA) score, body-mass index, operative time, complication rate, and repeat procedure rate. CONCLUSIONS: This study demonstrates the feasibility and efficacy of the completely fluoroless ureteroscopic treatment of calculi throughout the entire upper urinary tract while completely removing radiation exposure to the patients and staff. Although this fluoroless technique may be most applicable in patients at highest risk for radiation exposure, such as pregnant women, children, and recurrent stone formers, it offers an alternative for reduction of radiation in all patients.

Postoperative cystogram findings predict incontinence following robot-assisted radical prostatectomy.

INTRODUCTION: The factors that contribute to continence following robot-assisted radical prostatectomy (RARP) are currently being investigated. The purpose of this study is to determine the relationship of the bladder neck location on postoperative cystogram to subsequent continence rates following RARP. PATIENTS AND METHODS: A retrospective review of 611 consecutive RARP patients identified 215 patients with a postoperative cystogram. A ratio was created by measuring the distance from the superior edge of the pubic symphysis to the bladder neck and dividing it by the total pubic symphysis height, termed the bladder neck to pubic symphysis (BNPS) ratio. Odds ratios with 95% confidence intervals (CI) were calculated for the relationship between incontinence and BNPS tertile categories. RESULTS: At 3-month follow-up, continent patients had a mean BNPS ratio of 0.39 (95% CI 0.35, 0.43), while incontinent patients had a mean BNPS ratio of 0.49 (95% CI 0.42, 0.56; p=0.01). At 12 months, the mean BNPS ratio was 0.40 (95% CI 0.37, 0.44) for continent patients, whereas incontinent patients had a mean BNPS ratio of 0.60 (95% CI 0.43, 0.77; p=0.001). When analyzed as tertile groups, the corresponding incontinence rates at 12 months were 2.8%, 2.8%, and 19.4% for the lowest, middle, and highest BNPS tertiles, respectively. CONCLUSIONS: Postprostatectomy bladder neck location defined by the BNPS ratio on cystogram correlates with continence rates and may predict patients at risk for prolonged incontinence. Efforts designed to preserve support of the bladder neck and sphincteric complex in relation to the pubic symphysis may improve both early and late continence.

Comparing stone attenuation in low- and conventional-dose noncontrast computed tomography.

BACKGROUND AND PURPOSE: Noncontrast computed tomography (NCCT) has high sensitivity, specificity, and is able to predict stone composition using Hounsfield units (HU) but is associated with high radiation exposure. In an attempt to reduce radiation exposure, low-dose stone protocols have been developed that provide excellent detection of stones. It is not known, however, whether these protocols are equally effective in determining HU stone density. The purpose of this study is to compare stone HU attenuation between low- and conventional-dose NCCT. MATERIALS AND METHODS: In this prospective randomized, single blinded study, 7-mm calcium oxalate stones were placed randomly into nine intact urinary systems and scanned in three different cadaveric vehicles. Holding other parameters constant, NCCT was performed at varying mAs levels ranging from 5 to 140. Identical magnified images at each mAs setting were reviewed in a blinded fashion to determine HU attenuation. Statistical analyses were performed using a Kruskal-Wallis test and the Levene test, with P<0.05 considered significant. RESULTS: In 19 different stone configurations with 133 stones, median attenuation levels were 614, 674, 681, 669, 670, 674, and 667 HU at 5, 7.5, 15, 30, 50, 70, and 140 mAs, respectively. The differences in median attenuation levels were not significantly different (P=0.998). An increasing trend of attenuation variability was noticed as the radiation dose decreased; however, this was not significant (P=1.0). CONCLUSION: Low-dose NCCT results in similar HU attenuation compared with conventional-dose NCCT. Although there is a slight increase in variability, low-dose NCCT provides similar information to assist in determining stone composition as conventional-dose NCCT.

Radiation exposure during continuous and pulsed fluoroscopy.

UNLABELLED: Abstract Background and Purpose: Previous studies using pulsed fluoroscopy have shown variable effects on radiation exposure because of the ramp and trail effect in older C-arm systems. This study compares radiation delivered in pulsed and continuous modalities using a modern C-arm system. MATERIALS AND METHODS: Thermoluminescent dosimeters (TLDs) positioned in three body locations directly measured radiation dose during simulated ureteroscopy. Thirty pedal activations were administered using a pulsed or continuous mode to visualize an implanted guidewire and a radiopaque stone. TLD absorbed radiation and image quality were compared between imaging modes. RESULTS: Pulsed fluoroscopy delivered less radiation compared with continuous fluoroscopy at each site: Anterior skin (0.10 vs 0.26 mGy, P<0.001), kidney (0.15 vs 0.40 mGy, P<0.001), and posterior skin (0.92 vs 2.62 mGy, P<0.001). Mean fluoroscopy time differed between continuous and pulsed modes (12.5 vs 3.0 seconds; P<0.001). Fluoroscopy time positively correlated with radiation exposure at all sites: Anterior skin (0.017 mGy/s, R(2)=0.90), left kidney (0.026 mGy/s, R(2)=0.96), and posterior skin (0.18 mGy/sec, R(2)=0.98). When evaluated by blinded urologists, 100% of reviewers felt pulsed images were adequate to identify guidewire position and 90.5% felt pulsed images were adequate for stone localization. CONCLUSION: Pulsed fluoroscopy reduced fluoroscopy time by 76% and radiation dose by 64% compared with continuous fluoroscopy. Pulsed fluoroscopy images were adequate for most tasks of ureteroscopy and should be considered for reduction of radiation during ureteroscopy.

Fluoro-less ureteral stent placement following uncomplicated ureteroscopic stone removal: a feasibility study.

OBJECTIVE: To test the feasibility of ureteral stent placement without image guidance after uncomplicated ureteral stone removal and to compare the outcomes of fluoro-less and conventional ureteral stent placement. METHODS: A technique was devised to allow placement of a ureteral stent without image guidance by substituting fluoroscopy with visual and tactile cues. A retrospective review of 25 patients using fluoro-less stent placement was compared with 25 consecutive patients who underwent conventional stent placement with fluoroscopy. Stent placement was graded on a 6-point scale to assess coil symmetry and location. Comparisons between the fluoro-less stent placements and controls were performed with the Mann-Whitney U test. All hypotheses were 2-sided and conducted at an alpha level of 0.05. RESULTS: All 25 ureteral stent placements were performed successfully without the use of fluoroscopy for image guidance. There was no significant difference in age, gender, body mass index, stone size, or complication rates when fluoro-less and conventional stent placements were compared. In addition, grade 1 placement was achieved in 76% of the fluoro-less group and in 64% of the conventional group. Although placement accuracy was higher in the fluoro-less group this was not statistically significant (P = .13). CONCLUSION: Ureteral stent placement without fluoroscopic guidance is feasible. It maintains comparable efficacy and complication rates with conventional ureteral stent placement. This technique allows reduced radiation exposure in patients requiring ureteral stent placement.

In automated fluoroscopy settings, does shielding affect radiation exposure to surrounding unshielded tissues?

BACKGROUND AND PURPOSE: Automatic brightness control (ABC), a function of modern fluoroscopy machines, adjusts radiation intensity in real time to enhance image quality. While shielding reduces radiation exposure to protected areas, it is unknown how much radiation adjacent unshielded areas receive when using ABC settings. Our purpose was to assess radiation dosage to shielded and unshielded tissue when using fluoroscopic ABC mode compared with fixed exposure settings. MATERIALS AND METHODS: In a simulated ureteroscopy, thermoluminescent dosimeters (TLDs) were placed at three sites in a female human cadaver, including the right renal hilum, right distal ureter adjacent to the uterus, and directly over the uterus. The cadaver received 60 seconds of radiation exposure using a C-arm fluoroscopy system under ABC and fixed settings (1.38 mAs, 66 kVp) with and without uterine shielding. Radiation dosage absorbed by the TLDs was compared using two-way analysis of variance and least-squares confidence intervals. RESULTS: Shielding significantly reduced radiation dose to the uterus by 62% and 82% (P<0.05 for both) in ABC and fixed settings, respectively. Shielding of the uterus in ABC, however, resulted in an approximately twofold increase in radiation dosage to the ureter and ipsilateral kidney (P<0.05 for both) and a decrease in image quality. Using fixed settings, shielding of the uterus did not increase radiation dose to the ipsilateral ureter and kidney. CONCLUSION: There is a significant increase in radiation dosage to surrounding tissues when shielding is used with ABC mode during fluoroscopy. Radiation can be reduced and image quality improved by using fixed settings when shielding is indicated.

Ureteral calculi detection using low dose computerized tomography protocols is compromised in overweight and underweight patients.

PURPOSE: Low dose computerized tomography protocols have demonstrated a reduction in radiation exposure while maintaining excellent sensitivity and specificity in the detection of stones in patients of average size. Low dose computerized tomography protocols have not yet been evaluated in subjects in the extremes of weight. We evaluated the effect of body weight when using low dose protocols to detect ureteral calculi. MATERIALS AND METHODS: Three cadavers of increasing weight (55, 85 and 115 kg) were prepared by inserting 721 calcium oxalate stones (range 3 to 7 mm) in 33 random configurations into urinary tracts. Cadavers were then scanned using a GE LightSpeed® at 7 radiation settings. An independent, blinded review by a radiologist was conducted to generate ROC curves, with areas under the curve compared using a 1-way ANOVA (α = 0.05). RESULTS: Sensitivity and specificity were significantly lower in the low and high weight cadavers compared to the medium weight cadaver at 5 mAs (p <0.001) and 7.5 mAs (p = 0.048). Differences in sensitivity and specificity at radiation settings of 15 mAs or greater were not significant. CONCLUSIONS: The sensitivity and specificity for the detection of ureteral calculi on computerized tomography were decreased for underweight and overweight subjects when using extremely low dose radiation settings (less than 1 mSv). Low dose protocols of 15 mAs (2 mSv) can still be used for these subjects without jeopardizing the ability to identify ureteral stones.

Prostate specific antigen levels and prostate cancer detection rates in patients with end stage renal disease.

PURPOSE: Patients with end stage renal disease plus prostate cancer are ineligible to receive a renal transplant at most centers until an acceptable cancer-free period is demonstrated. To our knowledge previously established prostate specific antigen reference ranges have not been validated in patients with end stage renal disease. We determined age stratified 95th percentile prostate specific antigen reference ranges and the prostate cancer detection rate at specific prostate specific antigen intervals for patients with end stage renal disease. MATERIALS AND METHODS: We retrospectively reviewed the records of 775 male patients with end stage renal disease on the waiting list for a renal transplant who had undergone a serum prostate specific antigen test. Prostate specific antigen was stratified by age at the time of the blood test and 95th percentile reference ranges were calculated for each decade. A total of 80 patients underwent prostate biopsy for increased prostate specific antigen and/or abnormal digital rectal examination. The cancer detection rate was calculated for specific prostate specific antigen reference ranges. RESULTS: The age specific 95th percentile prostate specific antigen references ranges were 0 to 4.0 ng/ml for ages 40 to 49 in 137 patients, 0 to 5.3 ng/ml for ages 50 to 59 in 257, 0 to 10.5 ng/ml for ages 60 to 69 in 265 and 0 to 16.6 ng/ml for ages 70 to 79 years in 69. The cancer detection rate was 44%, 38% and 67% for prostate specific antigen 2.5 to 4.0, 4 to 10 and greater than 10 ng/ml, respectively. CONCLUSIONS: In our study population of patients with end stage renal disease age stratified prostate specific antigen was higher than in the general population. The cancer detection rate was increased in our patients with end stage renal disease compared to that in patients with normal renal function at specific prostate specific antigen intervals. Lower prostate specific antigen cutoffs may be appropriate to recommend prostate biopsy in patients with end stage renal disease.

Faciliation of Mandarin tone perception by visual speech in clear and degraded audio: implications for cochlear implants.

Cochlear implant (CI) users in tone language environments report great difficulty in perceiving lexical tone. This study investigated the augmentation of simulated cochlear implant audio by visual (facial) speech information for tone. Native speakers of Mandarin and Australian English were asked to discriminate between minimal pairs of Mandarin tones in five conditions: Auditory-Only, Auditory-Visual, CI-simulated Auditory-Only, CI-simulated Auditory-Visual, and Visual-Only (silent video). Discrimination in CI-simulated audio conditions was poor compared with normal audio, and varied according to tone pair, with tone pairs with strong non-F0 cues discriminated the most easily. The availability of visual speech information also improved discrimination in the CI-simulated audio conditions, particularly on tone pairs with strong durational cues. In the silent Visual-Only condition, both Mandarin and Australian English speakers discriminated tones above chance levels. Interestingly, tone-naïve listeners outperformed native listeners in the Visual-Only condition, suggesting firstly that visual speech information for tone is available, and may in fact be under-used by normal-hearing tone language perceivers, and secondly that the perception of such information may be language-general, rather than the product of language-specific learning. This may find application in the development of methods to improve tone perception in CI users in tone language environments.

Robot-assisted radical prostatectomy in patients with previous renal transplantation.

PURPOSE: To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) in patients with previous renal transplantation. PATIENTS AND METHODS: We retrospectively identified all patients who had undergone RARP for localized prostate cancer between 2005 and 2008 at a single institution (N=228). Of these, three patients were renal transplant recipients. A four-arm robotic configuration was used in all patients. Port placement was modified in two of the three renal transplant recipients to avoid trauma to the renal allograft. Preoperative demographics, perioperative parameters, and postoperative outcomes were reviewed. RESULTS: RARP was completed successfully in all three renal transplant recipients. As expected, the American Society of Anesthesiologists score (3.3 vs 2.4) and Charlson weighted index of comorbidity (4.7 vs 2.4) were greater in previous transplant patients. There were no major differences in mean age, Gleason score, body mass index, estimated blood loss, operative time, complications, or oncologic outcomes between the two groups. Each of the patients with renal allografts had an undetectable prostate-specific antigen level and was continent (needing no pads) at 13 months of follow-up. CONCLUSIONS: RARP is feasible in patients with a previous renal transplant. Although technically more challenging, RARP can be performed in previous transplant patients with acceptable morbidity and oncologic outcomes similar to those of other prostate cancer patients.

Higher plant cortical microtubule array analyzed in vitro in the presence of the cell wall.

Plant morphogenesis depends on an array of microtubules in the cell cortex, the cortical array. Although the cortical array is known to be essential for morphogenesis, it is not known how the array becomes organized or how it functions mechanistically. Here, we report the development of an in vitro model that provides good access to the cortical array while preserving the array's organization and, importantly, its association with the cell wall. Primary roots of maize (Zea mays) are sectioned, without fixation, in a drop of buffer and then incubated as desired before eventual fixation. Sectioning removes cytoplasm except for a residuum comprising cortical microtubules, vesicles, and fragments of plasma membrane underlying the microtubules. The majority of the cortical microtubules remain in the cut-open cells for more than 1 h, fully accessible to the incubation solution. The growth zone or more mature tissue can be sectioned, providing access to cortical arrays that are oriented either transversely or obliquely to the long axis of the root. Using this assay, we report, first, that cortical microtubule stability is regulated by protein phosphorylation; second, that cortical microtubule stability is a function of orientation, with divergent microtubules within the array depolymerizing within minutes of sectioning; and third, that the polarity of microtubules in the cortical array is not uniform. These results suggest that the organization of the cortical array involves random nucleation followed by selective stabilization of microtubules formed at the appropriate orientation, and that the signal specifying alignment must treat orientations of +/- 180 degrees as equivalent.