Overview of shorthand medical glossary (OMG) study.

BACKGROUND: Shorthand is commonplace in clinical notation. While many abbreviations are standard and widely accepted, an increasing number are non-standard and/or unrecognisable. AIM: We sought to describe the frequency of inappropriate and ambiguous shorthand in discharge summaries. METHODS: Eighty electronic discharge summaries from the four General Medical Units at the Royal Melbourne Hospital were randomly extracted from the hospital's electronic records. Extraction was stratified by the four units and by the four quarters between July 2012 and June 2013. All abbreviations were assigned into one of four categories according to appropriateness: 1. 'Universally accepted and understood even without context'; 2. 'Understood when in context'; 3. 'Understood but inappropriate and/or ambiguous'; and 4. 'Unknown'. These categories were determined by the authors, which included junior and senior medical staff. RESULTS: The 80 discharge summaries contained 840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations. Of the 6269 occasions of shorthand, 6.8% were categorised as 'Understood but inappropriate and/or ambiguous' or 'Unknown' (category 3 or 4), equating to 1.4% of all words, and an average of 5.4 words per discharge summary. CONCLUSION: Abbreviations are common in electronic discharge summaries, occurring at a frequency of one in five words. While the majority of shorthand used seems to be appropriate, the use of inappropriate, ambiguous or unknown shorthand is still frequent. This has implications for safe and effective patient care and highlights the need for better awareness and education regarding use of shorthand in clinical notation.

Echocardiography has minimal yield and may not be warranted in Staphylococcus aureus bacteremia without clinical risk factors for endocarditis.

Current guidelines recommend performing echocardiography in all patients with Staphylococcus aureus bacteremia (SAB), but patients at very low risk of endocarditis may not benefit from this investigation. This study seeks to identify patients at very low risk of endocarditis. A retrospective single-center consecutive case series of patients with SAB was examined. Microbiological and echocardiographic data were used to identify patients with community onset, prolonged bacteremia, and intracardiac prosthetic devices. The diagnostic performance of these criteria for endocarditis as measured against transesophageal echocardiography (TEE) was calculated. 593 episodes of SAB were examined over a period of 6 years. 10 % were excluded from analysis due to death or discharge less than 48 h after the first positive blood culture or no admission to hospital, leaving 532 episodes for analysis. 64 % of the included episodes were investigated with echocardiography: 39 % with TEE and 26 % with transthoracic echocardiography (TTE) only. 16 % of the episodes investigated with echocardiography were demonstrated to have endocarditis. The rate of endocarditis was higher for episodes undergoing TEE (24 %) than TTE only (5 %). There were no instances of endocarditis amongst the 23 episodes investigated with TEE where none of the three risk factors were present. This group represented 57 % of the nosocomial (non-community-onset) episodes investigated with TEE. Patients with none of the three criteria examined in this study have a very low rate of endocarditis and may fall below the test threshold for echocardiography.

Factors Affecting Perceptual Threshold in Argus II Retinal Prosthesis Subjects.

PURPOSE: The Argus II epiretinal prosthesis has been developed to provide partial restoration of vision to subjects blinded from outer retinal degenerative disease. Participants were surgically implanted with the system in the United States and Europe in a single arm, prospective, multicenter clinical trial. The purpose of this investigation was to determine which factors affect electrical thresholds in order to inform surgical placement of the device. METHODS: Electrode-retina and electrode-fovea distances were determined using SD-OCT and fundus photography, respectively. Perceptual threshold to electrical stimulation of electrodes was measured using custom developed software, in which current amplitude was varied until the threshold was found. Full field stimulus light threshold was measured using the Espion D-FST test. Relationships between electrical threshold and these three explanatory variables (electrode-retina distance, electrode-fovea distance, and monocular light threshold) were quantified using regression. RESULTS: Regression analysis showed a significant correlation between electrical threshold and electrode-retina distance (R2 = 0.50, P = 0.0002; n = 703 electrodes). 90.3% of electrodes in contact with the macula (n = 207) elicited percepts at charge densities less than 1 mC/cm2/phase. These threshold data also correlated well with ganglion cell density profile (P = 0.03). A weaker, but still significant, inverse correlation was found between light threshold and electrical threshold (R2 < 0.52, P = 0.01). Multivariate modeling indicated that electrode-retina distance and light threshold are highly predictive of electrode threshold (R2 = 0.87; P < 0.0005). CONCLUSIONS: Taken together, these results suggest that while light threshold should be used to inform patient selection, macular contact of the array is paramount. TRANSLATIONAL RELEVANCE: Reported Argus II clinical study results are in good agreement with prior in vitro and in vivo studies, and support the development of higher-density systems that employ smaller diameter electrodes. (clinicaltrials.gov identifier: NCT00407602).

Mobilized peripheral blood stem cells provide rapid reconstitution but impaired long-term engraftment in a mouse model.

In this study, we use competitive repopulation to compare the quality and frequency of stem cells isolated from mobilized blood with stem cells isolated from bone marrow (BM) in a mouse model. Lin(-)Sca-1(+)c-Kit(+) (LSK) cells were harvested from control BM and peripheral blood of mice following granulocyte colony-stimulating factor (G-CSF) administration. LSK cells were used because of their resemblance to human CD34(+) cells. We confirmed that transplantation of phenotypically defined mobilized peripheral blood (MPB) stem cells results in rapid recovery of blood counts. However, in vitro results indicated that LSK cells purified from MPB had lower cobblestone area-forming cell day 35 activity compared to BM. Additionally, evaluation of chimerism after co-transplantation of LSK cells purified from blood and BM revealed that MPB stem cells contained 25-fold less repopulation potential compared to BM stem cells. Competitive repopulating unit frequency analysis showed that freshly isolated MPB LSK cells have 8.8-fold fewer cells with long-term repopulating ability compared to BM LSK cells. Secondary transplantation showed no further decline in contribution of hematopoiesis relative to BM. We conclude that the reduced frequency of stem cells within the LSK population of MPB, rather than poorer quality, causes the reduced repopulation potential.Bone Marrow Transplantation (2007) 39, 401-409. doi:10.1038/sj.bmt.1705601; published online 12 February 2007.

Delayed diffuse lamellar keratitis after laser in situ keratomileusis.

Two cases are reported of delayed diffuse lamellar keratitis after uneventful laser in situ keratomileusis. The first patient presented with an epithelial defect 6 weeks after laser in situ keratomileusis. Three days later the defect was healed but diffuse lamellar keratitis was noted. This was treated with topical dexamethasone and ketorolac with complete resolution of the diffuse lamellar keratitis over 3 weeks. The second patient presented with an epithelial defect and gross diffuse lamellar keratitis 10 weeks after laser in situ keratomileusis. Treatment was with topical dexamethasone and ciprofloxacin with gradual resolution of the diffuse lamellar keratitis. Common to both patients was a background of rosacea, implanted debris with no initial reaction, and epithelial defects leading to diffuse lamellar keratitis. It is suggested that these two cases represent epithelial defect associated corneal infiltration, which resembles classical diffuse lamellar keratitis with the spread of inflammatory cells through a path of least resistance.

Management of spontaneous pneumothorax-a Welsh survey.

The authors sought to determine to what degree current practice by hospital physicians and accident and emergency (A&E) departments in Wales conformed to the British Thoracic Society's guidelines for the management of spontaneous pneumothorax. Questionnaires were posted to all consultants involved in emergency medical admissions in Wales (149 consultant physicians and 23 A&E consultants) of whom 101 (59%) replied. Only 45% used the classification, "small, moderate, or complete" to describe the size of pneumothorax. Just 44% would do as recommended by the British Thoracic Society and discharge an asymptomatic patient with a primary pneumothorax and 34% would discharge a patient with a primary pneumothorax after successful aspiration. Only 20% were prepared to try aspiration initially for a secondary pneumothorax with a complete lung collapse. Thirty four per cent would follow the recommendation to remove a chest drain without prior clamping of the tube 24 hours after bubbling had stopped. In the event of a persistent air leak 69% would refer patients or seek a specialist opinion. Physicians with an interest in respiratory medicine tolerated persistent air leaks for significantly longer than did non-respiratory physicians (median of 7 v 5 days, p=0.001). The survey indicates that fewer than expected consultant physicians and A&E consultants in Wales manage spontaneous pneumothoraces in the way recommended by the guidelines. Physicians with an interest in respiratory medicine tended to comply with these guidelines more than general physicians with interests other than respiratory medicine or A&E consultants but the trend was not significant at the 5% level. It is felt that the guidelines should be disseminated more widely, ensuring that emergency admissions units and A&E departments have copies on display or easily accessible, and that they could be expanded to cover other aspects such as timing for surgery.

Dobutamine stress echocardiography in the elderly Asian patients.

Dobutamine stress echocardiography (DSE) is an established non-invasive technique for the evaluation of coronary artery disease (CAD). It has been shown to be both safe and accurate. However, its utility and safety in the elderly, in particular, elderly Asian patients has not been studied. Between September 1992 and December 1994, we performed a total of 75 consecutive DSE studies in patients over the age of 65. Of these, 50 (67%) were females. Forty-nine patients had hypertension, 26 had diabetes mellitus, 10 were smokers, 5 had a recent or previous myocardial infarction and another 4 had a history of heart failure. Indications for DSE were, inability to perform the standard treadmill exercise test (40 patients), an abnormal resting electrocardiogram (ECG) (14 patients), a prior false positive or inconclusive treadmill test, risk stratification post myocardial infarction (4 patients) or preoperative cardiac evaluation (23 patients). The test was terminated in the majority of patients following attainment of the target heart rate. Atropine stimulation was required in 61 (81%) patients. Chest pain was provoked in 11 patients. No death or myocardial infarction occurred. Minor non-cardiac symptoms occurred in another 6 patients but this did not necessitate termination of the procedure. Three patients had transient hypotension, none of which was symptomatic. Arrhythmia occurred in 23 patients but the majority were isolated atrial or ventricular premature beats (20); 1 patient had atrial fibrillation and another developed transient junctional rhythm. Only one patient developed ventricular tachycardia but this was not haemodynamically significant and terminated easily with an intravenous dose of lignocaine. A conclusive result could be obtained in 72 (96%) patients. We concluded that DSE could be performed and interpreted in the majority of elderly Asian patients studied. Despite supplemental atropine, an aggressive dosing protocol and the inclusion of patients with a myocardial scar or history of heart failure, adverse effects were rare and often did not require any specific therapy.

Selection of library services by post-registration nursing, midwifery and health visiting students.

This paper describes a small-scale survey undertaken with 300 nurses, midwives and health visitors on post-registration courses and registered for the ENB Higher Award. The aim was threefold: first to examine reasons for electing to use particular libraries; second, the relationship between workplace, home, teaching site and choice of library services; and third, the use of library enquiry services. There was a 56% response rate to the postal questionnaire and results indicated that the key factor in selecting a library was availability of resources rather than convenience to home or workplace. The third largest group of respondents worked in community organizations with little or no on-site access to resources and were dependent on access to other libraries. Most who used the library for literature searching needed to seek help in spite of preliminary user education sessions. Similar levels of assistance were needed to locate journals and use the computerized book catalogue. The paper recommends explicit information on strategic entry points, necessity of a broad central collection, integration of information retrieval into post-registration courses, use of self-study packs, better trust/university liaison and recognition of the need for resource transfer from teaching to learning.

Dobutamine stress echocardiography: angiographic correlates.

We started a dobutamine stress echocardiography (DSE) programme in September 1992. Until January 1994, we had performed 300 such procedures. Of these patients, 81 underwent cardiac catheterisation within 6 months of DSE without a cardiac event in the interim. Eleven DSEs were performed to assess myocardial viability and another 6 were inconclusive for myocardial ischaemia. The remaining 64 were correlated with the angiographic data to determine the utility of this technique in our institution. The mean age of the cohort was 57 years. Thirty-six patients were referred for DSE in the workup for chest pain, either anginiform (22) or atypical (14). Fourteen patients had a recent (6) or remote (8) myocardial infarction. Thirteen patients were asymptomatic. Significant obstructive coronary artery disease (CAD) was identified in 36 patients of whom 17 and 19 had single and multivessel disease respectively. The sensitivity of DSE in the entire cohort was 89% and the specificity 82%. Positive and negative predictive values of DSE were 86% and 85% respectively. Although the numbers involved were small, sensitivity figures for single and multivessel disease were 94% and 84% respectively. Of the patients with single vessel CAD, prediction of the artery involved by presumed territorial supply was accurate in 81%. DSE is a highly accurate tool for evaluating CAD, identifying both the patient with CAD and the location of disease.

Diagnosis of left atrial myxoma following systemic embolism.

Cardiac myxomas are rare and noted for their varied clinical manifestations. Consequently, the diagnosis is often unsuspected until the symptoms and signs become advanced and obvious, or when the diagnosis is made fortuitously during echocardiography. This report illustrates a case in point in which the diagnosis was made on transthoracic echocardiography and amplified using transesophageal echocardiography.

Percutaneous transluminal angioplasty of anomalous right coronary artery arising from the ascending thoracic aorta.

Coronary arteries with anomalous aortic origin are infrequently encountered in patients undergoing cardiac catheterization and pose potential technical difficulties for performing both diagnostic and angioplasty procedures. Percutaneous transluminal coronary angioplasty (PTCA) of atherosclerotic disease in anomalous right coronary artery (RCA) has been described in only a few reports. In all the cases reported to date, the anomalous vessel arose from the left sinus of Valsalva. We report a case of a technically straight-forward PTCA performed in an anomalous RCA arising from the anterior aspect of the ascending thoracic aorta.

Phylloides tumor of the breast: a report of 14 cases.

The objective of this retrospective study is to determine the role of radiation therapy in the management of benign phylloides tumors. Fourteen patients with a diagnosis of benign phylloides tumor (PT) and registered at the Princess Margaret Hospital are included in the study. Definitive surgery consisted of either lumpectomy in seven patients or mastectomy in the other seven patients. One patient died of her disease, and the remaining patients had no evidence of disease at last follow-up (median 38.4 months). Among these 13 patients, 4 had at least one recurrence and the recurrence rate was higher for the group who underwent lumpectomy (43% compared with 28%). One patient was treated by lumpectomy and adjuvant radiation therapy, and had no subsequent recurrence (follow-up time 35.5 months). The role for radiation therapy in the management of this disease remains unclear.

Doppler-echocardiographic assessment of Carbomedics prosthetic values in the mitral position.

We prospectively studied 37 consecutive patients implanted with the Carbomedics prosthetic heart value in the mitral position (without clinical evidence of prosthetic valve dysfunction) with two-dimensional and Doppler echocardiography. The peak mitral prosthetic gradient ranged from 4.60 to 14.63 (mean 8.97 +/- 2.29) mm Hg; mean mitral prosthetic gradient ranged from 1.67 to 6.18 (mean 3.24 +/- 0.95) mm Hg; pressure half-time derived mitral valve area ranged from 1.67 to 5.30 (mean 2.70 +/- 0.80) cm2. These values compare favorably with that of another bileaflet valve (i.e., the St. Jude Medical valve). There was a wide overlap in peak and mean transmitral gradients, even with the valves of the same size, with a significant but weak inverse relationship between peak mitral gradients and valve size (p = 0.03, r = -0.36). The performance index showed a smaller range of values, again with a significant but weak inverse relationship with valve size (p = 0.001, r = -0.54). The inverse relationship between valve size and peak mitral gradient and performance index should be borne in mind when analyzing Doppler hemodynamic data.

Total occlusion of left main coronary artery in Orientals: profile of 4 cases.

The authors report 4 Oriental cases of total occlusion of the left main coronary artery (LMCA) with differing presentations. The first patient had a twelve-year history of stable angina pectoris. The second patient had angina for a year, which became unstable two months prior to diagnosis. The third patient had myocardial infarction seven years ago and presented with a one-month history of rest angina. The fourth patient had stable effort angina for six years but presented with accelerated angina three months prior to diagnosis. The incidence of total occlusion of the LMCA is rare and survival depends on the existence of collateral circulation. In LMCA disease, there is usually disease in other parts of the coronary arterial tree, and hence, the need for urgent coronary bypass surgery.

Reader activity in a multidisciplinary health sciences library: a case study at St George's Library.

This paper reports on a survey of user activity in a London teaching hospital with a multidisciplinary health sciences library. Library users were asked to complete a simple survey form on each visit to the library over a week long period. Information was required to help establish a formula for funding. The user survey examined reasons for visiting the library, frequency of visits, length of visit and also asked for comments and suggestions. Finally there is discussion regarding the effectiveness of the survey in terms of the practical framework utilized and of the gains obtained.

Clinical significance and origin of artifacts in transesophageal echocardiography of the thoracic aorta.

OBJECTIVES: The aim of this study was to identify the mechanism and features of artifacts encountered during transesophageal echocardiography of the aorta. BACKGROUND: Artifacts are an important potential limitation of transesophageal echocardiography of the aorta. METHODS: The mechanism of the artifacts was examined by in vitro modeling. The frequency and clinical correlates of artifacts were examined by retrospective review of transesophageal echocardiograms in 36 patients with aortic pathologic lesions. RESULTS: Two classes of artifact were seen: linear artifacts in the ascending aorta, which may mimic intimal flaps, and mirror image artifacts in the transverse and descending thoracic aorta. Linear artifacts in the ascending aorta, seen in 44% of patients, were shown in vitro to be multiple path artifacts caused by reflection of ultrasound within the left atrium. Linear artifacts in the ascending aorta were associated with dilatation of the ascending aorta and were more frequent when the aortic diameter exceeded the left atrial diameter (p < 0.001). The mirror image artifacts of the transverse and descending thoracic aorta give the appearance of a double-barrel aorta and were shown in vitro to be caused by the aorta-lung interface, which acts as a total reflector of ultrasound. Mirror image artifacts were seen in > 80% of patients. Artifacts were equally frequent with the sagittal and transverse imaging planes when biplane transesophageal echocardiography was used. CONCLUSIONS: Artifacts occur frequently during transesophageal echocardiography of the aorta. An understanding of why they occur and the features that distinguish them from true abnormalities should enhance the diagnostic accuracy of transesophageal echocardiography for aortic disease.

Ectopic corticotropin syndrome and small-cell carcinoma of the lung. Clinical features, outcome, and complications.

BACKGROUND: Ectopic corticotropin syndrome is a rare complication of small-cell lung cancer (SCLC). There is little information concerning this syndrome available in the literature. We therefore reviewed all cases of ectopic corticotropin syndrome seen at our institution during a 20-year period. METHODS: Cases were identified by searching a computerized database and reviewing the charts of all 840 patients with SCLC seen between 1971 and 1991. Patients were included if they met at least two of the following criteria: spontaneous hypokalemia (potassium level, < 3.2 mmol/L); plasma cortisol level greater than 600 nmol/L; 24-hour urinary free cortisol level greater than 400 nmol/d; and plasma corticotropin level greater than 22 pmol/L. Data were abstracted from the patients' medical records. RESULTS: Of 840 patients with SCLC, 14 (1.6%) had ectopic corticotropin production. This was diagnosed at the time of presentation with SCLC in seven patients and from 3 to 19 months later in the remainder. Five patients had limited disease and nine had extensive disease. One or more features of Cushing's syndrome were observed in 57% of patients, but the entire syndrome occurred rarely. Spontaneous hypokalemia was present in all patients, and 10 patients (71%) had hyperglycemia. There were two complete responses and one partial response to chemotherapy, giving an overall response rate of 21%, and the median survival was 5.5 months. Ten patients died of progressive growth of tumor, while three patients died of infections. In one other patient, infection probably contributed to death. A high rate of nonfatal infections was also seen. CONCLUSIONS: The occurrence of SCLC with ectopic corticotropin syndrome is associated with poor survival, and a high incidence of infective complications, in patients treated with chemotherapy.

A review of patients with a 'normal' coronary angiogram over a 3-year period.

Over a period of 36 months, we detected 54 patients with normal coronary arteries or non-critical coronary artery stenosis within our study series of coronary angiography. We studied these patients to determine their clinical, electrocardiographic, stress testing and angiocardiographic characteristics. We detected among them a preponderance of female sex and a higher incidence of ethnic Indians. The majority of the patients studied had one or more coronary risk factors. 52% had a normal resting ECG. In those with a positive stress test and reports available for review, there is a near equal distribution of horizontal and J-type ST depression. Those patients with a positive treadmill tend to have a higher left ventricular end diastolic pressure (LVEDP) at cardiac catheterization. We also noted in this group of patients a higher proportion with a small distal left anterior descending artery. These patients also tend to have higher LVEDP even in the presence of normal left ventriculogram. Our current series suggests the possibility of raised left ventricular end-diastolic pressure and the presence of a "small distal left anterior descending artery" syndrome in association with patients with a 'false positive' treadmill test.

Second primary malignancies following diagnosis of small-cell lung cancer.

PURPOSE AND METHODS: The records of 800 patients with small-cell carcinoma of the lung (SCLC) treated between 1971 and 1985 at University of Toronto-affiliated hospitals were reviewed for the occurrence and relative risk of second primary malignancies (SPMs). Almost all patients who developed a SPM were treated previously with chemotherapy and radiation therapy. RESULTS: Nineteen metachronous SPMs (MSPMs) and 11 synchronous SPMs (SSPMs) were identified. SSPMs were detected between 1 and 12 months after the diagnosis of SCLC. The MSPMs were identified between 1 and 10 years after the diagnosis of SCLC. MSPMs included non-small-cell lung cancer (NSCLC) (four patients), hematologic malignancies (HM) (three patients), and 12 with other solid tumors (OST). The median survival times after the diagnosis of MSPM was 33 months, 10 months, and 1 month, respectively, for those with NSCLC, OST, and HM. Expected cancer incidence rates were used to compute a relative risk rate for developing a MSPM in a subset of 392 patients on whom accurate follow-up information was available. The calculated relative risk for all tumors was 3.73. The relative risk for the development of secondary NSCLC was 6.83. CONCLUSION: We suggest that increased predisposition to SPM may relate to secondary effects of multimodality treatment and biologic considerations.