Can computer aided teaching packages improve clinical care in patients with acute abdominal pain?

OBJECTIVE: To compare three methods of support for inexperienced staff in their diagnosis and management of patients with acute abdominal pain--namely, with (a) structured data collection forms, (b) real time computer aided decision support, and (c) computer based teaching packages. DESIGN: Prospective assessment of effects of methods of support on groups of doctors in one urban hospital and one rural hospital. SETTING: Accident and emergency department at Whipps Cross Hospital, London, and surgical wards of Airedale General Hospital, West Yorkshire. PATIENTS: Consecutive prospective series of all patients presenting to each hospital in specified time periods with acute abdominal pain; total patients in the various periods were 12,506. MAIN OUTCOME MEASURES: Diagnostic accuracy of participating doctors, admission rates of patients with non-specific abdominal pain, perforation rates in patients with appendicitis, negative laparotomy rates. RESULTS: Use of any one modality resulted in improved diagnostic accuracy and decision making performance. Use of structured forms plus computer feedback resulted in better performance than use of forms alone. Use of structured forms plus a computer teaching package gave results at least as good as those with direct feedback by computer. CONCLUSIONS: The results confirm earlier studies in suggesting that the use of computer aided decision support improves diagnostic and decision making performance when dealing with patients suffering from acute abdominal pain. That use of the computer for teaching gave results at least as good as with its use for direct feedback may be highly relevant for those who are apprehensive about the real time use of diagnostic computers in a clinical setting.

Iatrogenic epilepsy due to antidepressant drugs.

AN ANALYSIS OF THE CASE HISTORIES OF NINE PATIENTS WHO DEVELOPED EPILEPTIC FITS SHORTLY AFTER STARTING TRICYCLIC ANTIDEPRESSANT DRUGS SHOWED THAT ALL OF THEM HAD ONE OR MORE OF THE FOLLOWING FACTORS: previous or family history of epilepsy, pre-existing brain damage, cerebral arteriosclerosis, alcoholism, withdrawal of barbiturates, and history of previous electric convulsive therapy. Before prescribing antidepressant drugs these factors should be sought for in the history, and if any are present prophylactic anticonvulsant medication is indicated. From a limited experience we do not think that chlordiazepoxide is adequate to counteract the convulsant effect of antidepressant drugs.

The ingrowing toenail: a modified segmental matrix excision operation.

A series of 528 patients with ingrowing toenails has been operated on under local anaesthetic by one surgeon using a simple technique in which a segment of germinal matrix is completely excised without cutting skin and with minimal interference with the nail wall. Normal footwear was worn by the fifth day in 79 per cent of patients. The recurrence rate was 1--7 per cent.

Use of amantadine in Parkinson's disease. Results of a double-blind trial.

In a four-week double-blind trial of 62 patients with Parkinsonism 29 were treated withamantadine and 33 with a placebo. Modest but statistically significant improvement was observed in the first group, optimum benefit occurring after the first two weeks. Patients' reactions to the drug were favourable in 79%, and side effects were insignificant. Though amantadine appears to be a useful additive drug in the treatment of Parkinsonism, its value as a single treatment is as yet undetermined.

Activated charcoal in tricyclic antidepressant poisoning: pilot controlled clinical trial.

1 A randomised clinical trial was carried out to assess the effects of activated charcoal in the management of suspected tricyclic antidepressant poisoning. 2 Forty-eight patients entered the study, twenty receiving supportive care plus activated charcoal (10 g) and twenty-eight supportive care alone. 3 Drug screening showed that only seventeen patients had taken tricyclic antidepressants alone. 4 Activated charcoal had no effect on either the rate of lightening of coma or the fall in plasma antidepressant concentration in the 'pure' tricyclic antidepressant poisoning group. 5 No serious side-effects of activated charcoal were reported.

Activated charcoal in tricyclic antidepressant poisoning.

Tricyclic antidepressants (TCA) bind to activated charcoal both in vitro and in vivo in healthy volunteers after a therapeutic dose of TCA. These findings provide a basis for the routine use of activated charcoal in TCA poisoning. The object of this study was to examine the effect of a single dose of 20 g of activated charcoal in overdose patients. Ninety-one patients from four centres with suspected TCA overdose were entered into a randomized study. Gastric lavage was performed on all patients. Thirty-four received 20 g of activated charcoal and 43 served as controls. Fourteen patients were excluded. Plasma drug concentrations were taken on admission and at 1, 2, 4, 8 and 24 h. The incidence of toxic symptoms was registered during 24 h. There was no significant difference in the area under the plasma drug concentration versus time curve, the peak plasma concentrations or plasma half-lives between the two groups. Toxic symptoms were more frequent in the non-treated groups although this difference was not statistically significant. In patients with TCA overdose initially treated with gastric lavage, a single dose of 20 g of activated charcoal had no effect on the systemic absorption or elimination of TCA.

Predicting severity of tricyclic antidepressant overdose.

The measurement of plasma concentration, a prolonged QRS interval, and level of consciousness have all been recommended as useful indicators of toxicity following tricyclic antidepressant overdose. The aims of this study were firstly, to determine the relative prognostic value of each of these indicators and secondly, to assess when a patient can be discharged safely from the intensive care unit. Data were evaluated on 67 patients with tricyclic antidepressant overdose from four centers. Plasma tricyclic antidepressant concentrations were measured, coma grade was evaluated using the Matthew-Lawson Coma Scale and a ECG was obtained from 23 patients on admission. Complications such as convulsions, hypotension, arrhythmias, and need for intubation and ventilation were recorded. Thirty patients developed complications and no patient died. Coma grade was the best predictor of outcome. The development of serious complications is unlikely in patients whose level of consciousness is grade II or less and who are admitted to hospital more than 6 h after overdose. Plasma tricyclic antidepressant concentration was of no additional value in predicting toxic complications or deciding when the patient could leave the intensive care unit. Our study suggests that an alert and orientated patient with a QRS duration less than 100 ms is the best indicator for safe transfer to a medical or psychiatric ward.

Computer aided diagnosis of acute abdominal pain: a multicentre study.

A multicentre study of computer aided diagnosis for patients with acute abdominal pain was performed in eight centres with over 250 participating doctors and 16,737 patients. Performance in diagnosis and decision making was compared over two periods: a test period (when a small computer system was provided to aid diagnosis) and a baseline period (before the system was installed). The two periods were well matched for type of case and rate of accrual. The system proved reliable and was used in 75.1% of possible cases. User reaction was broadly favourable. During the test period improvements were noted in diagnosis, decision making, and patient outcome. Initial diagnostic accuracy rose from 45.6% to 65.3%. The negative laparotomy rate fell by almost half, as did the perforation rate among patients with appendicitis (from 23.7% to 11.5%). The bad management error rate fell from 0.9% to 0.2%, and the observed mortality fell by 22.0%. The savings made were estimated as amounting to 278 laparotomies and 8,516 bed nights during the trial period--equivalent throughout the National Health Service to annual savings in resources worth over 20m pounds and direct cost savings of over 5m pounds. Computer aided diagnosis is a useful system for improving diagnosis and encouraging better clinical practice.