Utility of laboratory markers in evaluating for acute compartment syndrome in the emergency department.

BACKGROUND: Acute compartment syndrome is diagnosed by clinical examination with the aid of direct compartmental measurement. Previous work suggested using several laboratory markers that may suggest ongoing acute compartment syndrome in hospitalized patients. Serum creatinine kinase (CK) levels >4000 U/L, chloride (Cl) levels >104 mg/dL, and blood urea nitrogen (BUN) levels <10 mg/dL were found to have 100% association with the diagnosis of acute compartment syndrome. This strategy has not been studied in emergency department (ED) patients. METHODS: A retrospective chart review of all patients diagnosed with acute compartment syndrome of the upper and lower extremity or tibia/fibula fracture was performed from 13 EDs between February 22, 2008 and October 1, 2018. Serum values were collected for each patient: CK, sodium (Na), potassium (K), Cl, bicarbonate (HCO3), glucose, BUN, creatinine (Cr), calcium, lactic acid (LA), and ionized calcium (iCa). A control group composed of patients without acute compartment syndrome who had tibia and/or fibula fractures was analyzed to compare with our cohort. RESULTS: We identified 930 patients who meet inclusion criteria (389 acute compartment syndrome patients and 541 tibia/fibula fracture patients). Sex and ethnicity were similar in each population. A majority of the patients were evaluated at EDs without a trauma center designation. Using univariate modeling, HCO3, CK, iCa, Cr, BUN, and K values were found to be individual significant predictors of acute compartment syndrome (P < 0.05). Multivariate regression models found that HCO3 and Cr were significant predictors of acute compartment syndrome with a C-statistic of 0.77. The Valdez model had a prediction accuracy of 0.52 and a specificity of 99.2% but had a sensitivity of only 2.9%. CONCLUSION: Our model demonstrates that use of serum biomarkers in the ED does aid in the diagnosis of acute compartment syndrome in patients in the ED with 99.2% specificity but has a sensitivity of only 2.9%. Further research and prospective evaluation of serum markers are needed.

Pain management of pancreatic head adenocarcinomas that are unresectable: celiac plexus neurolysis and splanchnicectomy.

BACKGROUND: Pancreatic adenocarcinoma is often incurable at the time of diagnosis. For patients with unresectable or recurrent disease, palliation of pain is a key component of care. Medical management with narcotics has numerous side effects and may be ineffective. Interventions for pain control include celiac plexus neurolysis (CPN) and splanchnicectomy. The purpose of this review is to outline pertinent anatomy, techniques, side effects, complications, and efficacy of interventions for palliation of pain from pancreatic cancer. METHODS: We reviewed current literature, as well as our own patients, to assess the role and outcomes of CPN and splanchnicectomy. Short descriptions of procedural techniques and functional illustrations are provided. RESULTS: Both CPN and splanchnicectomy have excellent outcomes with regard to pain control. Quality of life and survival, however, have not been conclusively demonstrated to improve with either technique. Data regarding head-to-head comparisons of the two interventions is lacking. CONCLUSIONS: Patients with incurable pancreatic carcinoma should be offered either CPN or splanchnicectomy when medical management with narcotics has failed.

Improving community-based mental health care for children: a commentary.

In their article, "Improving Community-Based Mental Health Care for Children," Garland and colleagues explore and confront quality issues that are endemic to outpatient specialty mental health care for children in the United States. Their article presents evidence supporting the lack of effectiveness of usual care and draws on implementation science to explore areas for improving the quality of outpatient mental health care for young people. This commentary accepts these basic arguments and strategies, explores policy options that support the suggested reforms, and examines evidence-based programs in a broader context that draws on the systems of care approach. Specific issues addressed in this commentary include workforce capacity, policy options for improving care quality, provider incentives, systematic implementation supports, strategies to incorporate evidence-based approaches into practice, youth-guided and family-driven care, and the need to expand the definition of evidence-based practice to include the concepts of community-defined evidence and practice-based evidence.

Sustaining and expanding systems of care to provide mental health services for children, youth and families across America.

The Substance Abuse and Mental Health Services Administration has been instrumental in supporting the development and implementation of systems of care to provide services to children and youth with serious mental health conditions and their families. Since 1993, 173 grants have been awarded to communities in all 50 states, Puerto Rico, Guam, the District of Columbia, and 21 American Indian/Alaska Native communities. The system of care principles of creating comprehensive, individualized services, family-driven and youth-guided care and cultural and linguistic competence, supported by a well-trained and competent workforce, have been successful in transforming the field of children's mental health and facilitating the integration of child-serving systems. This approach has achieved positive outcomes at the child and family, practice and system levels, and numerous articles have been published using data collected from system of care communities, demonstrating the effectiveness of this framework. This article will describe lessons learned from implementing the system of care approach, and will discuss the importance of expanding and sustaining systems of care across the country.