Hospital Admission Outcomes Research Articles

Vitamin D Status in Hospitalized Chronically Ill Patients

ABSTRACTObjectives: Vitamin D deficiency is rarely considered or treated in critically ill patients. Deficiency of 25-hydroxy vitamin D [25(OH)D] prior to hospital admission might be a significant predictor of short- and long-term all cause patient mortality in a critically ill patient. The aim of this work is to investigate the prevalence of vitamin D deficiency in hospitalized patients and its relation to the length of stay and outcome of hospitalization.Methods: Prospective cohort study performed on 80 patients admitted with acute deterioration of their chronic illness. Four groups of diseases were included, namely, chronic liver diseases (CLD), chronic obstructive pulmonary diseases (COPD), cerebrovascular stroke (CVS), and heart failure (HF). The patients were followed up until their discharge, or transfer, or death. Patients were sampled for their vitamin D level on admission and were divided according to their vitamin D status into sufficient, insufficient, and deficient. Statistical methods and analysis of the present study were conducted using the SPSS V17 program.Results: Vitamin D level had a significant inverse correlation with length of hospital stay (r = –0.648) (p < 0.001). In vitamin D-deficient and -insufficient groups, there was a significant difference between survivors and nonsurvivors as regards vitamin D levels and an inverse correlation between vitamin D level and outcome of hospital admission.Conclusions: Vitamin D deficiency and insufficiency are significantly associated with a longer hospital stay and a poor outcome of hospital admission in comparison to control.

4 GEDI WISE: Evaluation of the Transitional Care Nurse Intervention Impact on Hospital Admissions from the Emergency Department

With the recognition that inpatient costs continue to rise and the population is aging and will require greater health care services, the emergency department (ED) sits at the crossroads of multiple health care settings and plays a critical role in decisionmaking toward either inpatient or outpatient care and the transitions surrounding these decisions. GEDI WISE (Geriatric ED Innovations in care through Workforce, Informatics, and Structural Enhancements) is a CMMI Health Care Innovation Award program (1C1CMS331055-01). We will examine the impact of the GEDI WISE ED-based transitional care nurse (TCN) program on the outcome of hospital admission. Three US hospitals located in the Midwest and Northeast received CMMI support to implement interdisciplinary models of care and interventions that follow nationally endorsed Geriatric ED Guidelines. One of these interventions, the TCN program, consisted of emergency nurses at each site trained to facilitate care transitions for older ED patients with the goal of safely avoiding hospital admission. Patients targeted for assessment by the TCN included those with Identification of Senior At Risk score (ISAR) scores 2+, Emergency Severity Index (ESI) 2+, and those referred by ED clinicians for consultation by the TCN. Within each site, patients seen by a TCN will be compared to those not seen by a TCN using either coarsened exact matching (CEM) or entropy balancing. We will use these methods to account for selection bias and ensure patients in the TCN and comparison groups are similar on observed characteristics thought to be associated with both TCN use and hospital admission while preserving sample size. Patients will be matched on age, sex, night or weekend ED visit, acuity (ESI), ISAR, Charlson comorbidity score, and whether they had a hospital admission and discharge in the prior 30 days. Within each matched sample, we will use logistic regression to examine relationships between TCN use and hospital admission from the ED and subsequent hospital readmission within 30 days. Regression models will be adjusted for chief complaint, comorbidities, and variables used in matching. We will evaluate unique patient (age 65+) ED visits during the GEDI WISE implementation (1/1/13-6/30/15) at the 3 participating hospitals. Projected sample sizes: site 1 16,591; site 2 20,895; site 3 22,599. Of the older patients who visited the ED during the first 18 months of the study (combined sample 37,419), approximately 10% were seen by a TCN. Preliminary use of CEM, at least 90% of the TCN patients and 80% of the comparison group patients were found suitable for matched comparison. By site, early findings in adjusted analyses indicate the TCN intervention is associated with reduced likelihood of hospital admission: Odds Ratio (OR) ranging from 0.32 to 0.61 when compared to matched controls (ref=1). Early evaluation of a preliminary set of data for older ED patients evaluated by transitional care nurses demonstrate a reduced likelihood of hospital admission. We anticipate completed analyses with matched intervention to control subjects on a 30-month dataset (combined total sample 60,085) for 3 sites that also include readmission outcomes. The TCN intervention may be a promising and effective way to not only improve care transitions, but also reduce likelihood of hospital admission and readmissions.

Factors associated with hospital admission after rotator cuff repair: the role of peripheral nerve blockade

Study objectiveThe objective was to analyze the impact of a peripheral nerve block in addition to general anesthesia on hospital admission after surgical rotator cuff repair. DesignThis was a population-based outcome study. The cost effectiveness of ambulatory rotator cuff repair relies on the discharge of patients on the day of surgery. As the impact of a peripheral nerve block in addition to general anesthesia on this outcome is unknown, we sought to elucidate this subject using population-based data. Patients and methodsInformation on patients undergoing rotator cuff surgery under general anesthesia with or without the addition of a peripheral nerve block (GN vs G) from a retrospective database provided by Premier Perspective, Inc, Charlotte, NC (http://www.premierinc.com), was analyzed. Using multilevel multivariable regressions, we evaluated the independent impact of the type of anesthesia on the outcomes hospital admission, combined major complications, and increased hospital costs. ResultsWe identified 27,201 patients who underwent surgical rotator cuff repair. Approximately 89% (24,240) of patients were discharged on the day of surgery, whereas 11% (2961) were admitted to the hospital. The admission rates for the GN group were 9.1% and 11.2% for the G group (P=.0001). The multivariable regression models showed that patients with the addition of a peripheral nerve block had 18% less risk of being admitted to the hospital (relative risk [RR]=0.82; 95% confidence interval [CI], 0.74-0.91; P=.0003) compared with those without this intervention. Differences in risk for combined major complications (RR=1.00; 95% CI, 0.83-1.20; P=.9751) or increased hospital costs (RR=0.97; 95% CI, 0.93-1.02; P=.2538) were nonsignificant. DiscussionFor patients undergoing surgical rotator cuff repair under general anesthesia, the addition of a peripheral nerve block may be associated with a reduction in the need for postoperative hospital admission after ambulatory surgery. Although the reason for this finding has to remain speculative, better pain control may play a role.

P-126 YI Inflammatory Bowel Disease-Related Presentations in Children to The Emergency Department

Our aim was to study the presentation of pediatric cases of inflammatory bowel disease (IBD) to the emergency department (ED). We used the Nationwide Emergency Department Sample (NEDS) for the years 2006–2010. The predictor variable was a diagnosis of IBD; both Crohn's as well as ulcerative colitis (UC) in children 5 to 19 years of age. International Classification of Diseases, Ninth Revision (ICD-9) codes were employed to extract variables of interest. The IBD-related ED visit rate was expressed per 100,000 census population. Univariate and multiple variable logistic regression models were used to study the association of variables of interest with the outcome of hospital admission from the ED. For trend analysis, we used the Cochrane–Armitage test. In the United States, during the calendar years 2006–2010, there were an estimated total of 62–63 million ED visits related to children ages 5–19 years. In a corresponding time period and age group, the number of ED visits for children with a diagnosis of IBD increased from 14,527 (2006) to 18,193 (2010) (P < 0.01). An increased incidence (ED visits/100,000 estimated census population) and linear trend was observed for both Crohn's and UC patients across all age groups. However, for Crohn's the greatest increase in ED visits were in children 5–9 years of age (33.1% increase), whereas for UC it was 15–19 years of age (31.2% increase). In comparison to children with UC, children with Crohn's had greater complaints of abdominal pain (18.8% versus 12.5; P < 0.01) and nausea and/or vomiting (8.0% versus 6.9%; P < 0.01). However, children with UC had an increased rate of lower GI bleeding (12.4% versus 4.4%; P < 0.01), diarrhea (5.3% versus 3.9%; P < 0.01) and Clostridium difficile diarrhea (2.8% versus 0.8%; P < 0.01). There was no difference in the incidence of fever between the 2 groups (3.9% both; P = 0.78). The rate of CT imaging of the abdomen and pelvis obtained in the ED increased substantially for children with IBD (60.5%; P < 0.01); however this was noted to be more in Crohn's (65.0%) than UC (41.0%). The rate of hospital admission for children with Crohn's ranged between 42.6% (2006) to 36.5% (2010) and for UC between 58.4% (2006) and 53.6% (2010). The rate of hospital admissions significantly decreased from 2006 to 2010 and was greater in children with Crohn's (14.3%; P < 0.01) than UC (8.22%; P < 0.01). On multiple variable regression analysis, risk factors for hospital admission included 3 or more comorbidities (aOR 29.9; 95% CI 25.7, 34.7), presentation to a metropolitan facility (aOR 3.2, 95% CI 3.1, 3.4), presentation to an ED in the Northeast region (aOR 1.8, CI 1.7, 1.9) and a diagnosis of UC compared to Crohn's (aOR 1.7, 95% CI 1.6, 1.7). IBD-related ED visits increased substantially from 2002 to 2010. The rate of associated CT imaging obtained in the ED also increased significantly during this period of time. Further studies should address the appropriateness of obtaining cross-sectional imaging in children with IBD, given strong concerns regarding ionizing radiation in this age group.

Prevalence and predictors of hypoxaemia in respiratory and non-respiratory primary diagnoses among emergently ill children at a tertiary hospital in south western Nigeria

Hypoxaemia is a potentially harmful complication of both acute lower respiratory tract infections (ALRI) and non-ALRI in children but its contribution to burden and outcomes of hospital admissions in Africa is unclear. We investigated prevalence and predictors of hypoxaemia in ALRI and non-ALRI according to age and primary diagnoses in emergently ill children in south western Nigeria. In 1726 emergently ill children admitted to a tertiary hospital in Ibadan, south western Nigeria, oxygen saturation was measured shortly after admission. Hypoxaemia was defined as oxygen saturation <90%. Clinical features and the primary admission diagnoses were recorded. Prevalence of hypoxaemia according to age and diagnoses was calculated. Symptoms and signs associated with hypoxaemia were compared between children with ALRI and those with non-ALRI. Hypoxaemia was detected in 28.6% (494/1726) of admissions. Prevalence of hypoxaemia varied in different conditions: it was 49.2% (154/313) in ALRI, 41.1% (188/454) in neonates, 27.2% (6/22) in post-neonatal tetanus, 23.3% (14/60) in sickle cell anaemia, 22.6% (38/168) in septicaemia and 14.4% (76/527) of malaria cases. Nasal flaring (OR 3.86; 95% CI 1.70 to 8.74) and chest retraction (OR 4.77; 95% CI 1.91 to 11.92) predicted hypoxaemia in ALRI but not in non-ALRI. Hypoxaemia is common among Nigerian children admitted to an emergency unit and is associated with a poor outcome irrespective of primary admission diagnosis. Provision of equipment to measure oxygen saturation and facilities for effective oxygen delivery might substantially reduce mortality.

Association of Admission Red Cell Distribution Width with Outcome in Acute Liver Failure

Purpose: The goal of this retrospective case series was to evaluate the association of admission RDW with outcome in acute liver failure. Methods: 205 consecutive patients with acute liver injury/failure (ALI/ALF) were enrolled in the ALF Study Group Registry from Virginia Commonwealth University Medical Center between July, 2001 and September, 2011. Admission RDW was retrospectively collected and analyzed for association with outcome of hospital admission. Outcome of admission was recorded as transplant free survival (TFS), transplant, or mortality. Results: Of the 205 patients, 158 had ALF, 47 had ALI. TFS was observed in 122 patients (59%), death in 65 (31%) and liver transplantation in 21 (10%). TFS was strongly associated with lower admission INR (P=0.0007), total bilirubin, phosphate, venous ammonia, lactate, PTT, and RDW (all P<0.0001). Death or liver transplantation was observed in 18 of 85 patients (21%) with normal RDW (≤14.1%), 21 of 47 patients (45%) with moderately elevated RDW (14.6-15.9%), and 44 of 73 patients (60%) with markedly elevated RDW (≥16.0%) on admission to the hospital (P <0.0001). For TFS, the area under the receiver operating characteristic curve for admission RDW was 0.700, and was greater than for INR (0.647). Conclusion: In this retrospective case series, an elevation in admission RDW is associated with increased risk of transplant or mortality in ALF. ALF is a prototypical syndrome of intense systemic inflammatory response, which results in multi-organ system failure, and often death. The relationship between high RDW and poor outcome remains undefined. Concentrations of key proinflammatory cytokines involved in the propagation of the ALF syndrome (TNFα, IL-1β, and IL-6) have been proposed to increase RDW. We hypothesize that the association between high RDW and poor outcome in ALF reflects increased pro-inflammatory cytokines and systemic inflammation. As RDW is routinely gathered and automatically calculated as part of the complete blood count, it may provide additional prognostic data to the physician at no additional cost. Understanding how this measure is associated with outcome may provide new insight into the pathophysiology of acute liver failure.Figure: No Caption available.

Trend of emergency department presentations for influenza like illness: Differences between pandemic (2009-2010) and post-pandemic (2010-2011) season

The aim of this paper is to analyze differences between incidence, characteristics and out-comes of patients with Influenza Like Illness (ILI) presenting to a teaching public hospital in Central Italy during pandemic influenza season (2009-2010) and during the post-pandemic outbreak (2010-2011). We performed a retrospective descriptive study, and we identified Emergency Department (ED) presentations for ILI, relying on hospital discharge data administrative database. Bivariate analyses for the outcome of hospital admission were performed for both seasons and a multiple logistic regression model has been developed to evaluate which factors were independently associated with hospital admission. Among all the ED presentations (51,757), visits for ILI were respectively 821 (3.1%) during the pandemic season, and 704 (2.8%) during the post-pandemic one. The pandemic cohort differs significantly from the post-pandemic cohort for every characteristic investigated, with the exception of the length of stay in the ED. Overall in 2009-2010 there were more ED presentations compared to the following season, but hospital admission rates were less than in 2010-2011. Further studies are needed to assess if other variables may affect the use of the ED for ILI in order to try to plan staff and hospital organization.

Outcome of Hospital Admissions in HIV-infected Children at the Korle Bu Teaching Hospital, Accra, Ghana

The burden of paediatric HIV infection remains high in resource-poor settings. Information on morbidity leading to hospitalisation as well as outcome is limited. The objective of this study was to determine the reasons for hospital admissions of HIV-infected paediatric patients to a tertiary teaching hospital and the outcome of these admissions. Retrospective chart review of inpatient records of all HIV-infected children aged 0 to 13 years admitted to the paediatric unit at Korle-Bu Teaching Hospital from 30 June 2007 to 30 June 2008 was performed. Abstracted data included age, gender, weight, presenting conditions, diagnosis, duration of hospitalisation, antiretroviral treatment, and outcome. A total of 102 admissions occurred among 76 children. The mean age of the children was 4.5 ± 3.79 years and 42 (55%) were males. HIV diagnosis was made during hospitalisation in 23 (30%) of the 76 patients. Overall, 55 (64%) of the 76 patients had a weight for age less than second percentile and 67% were not on antiretroviral therapy at time of admission. Of the 102 admissions, the predominant diagnosis included pneumonia (40%), gastroenteritis (24%), pulmonary tuberculosis (22%), and/or malaria (19%). Death occurred in 12 of the 102 admissions. Age, gender, and admitting diagnosis were not associated with death. Failure to thrive and common prevalent infections were the predominant reasons for hospitalisation for paediatric HIV/AIDS patients in Accra. Hospitalisations with these conditions should prompt early HIV testing. Efforts should be intensified to prevent maternal to child transmission of HIV infection.

The potential impact of native Australian trypanosome infections on the health of koalas (Phascolarctos cinereus)

Whole blood collected from koalas admitted to the Australian Zoo Wildlife Hospital (AZWH), Beerwah, QLd, Australia, during late 2006-2009 was tested using trypanosome species-specific 18S rDNA PCRs designed to amplify DNA from Trypanosoma irwini, T. gilletti and T. copemani. Clinical records for each koala sampled were reviewed and age, sex, blood packed cell volume (PCV), body condition, signs of illness, blood loss, trauma, chlamydiosis, bone marrow disease, koala AIDS and hospital admission outcome ('survival'/ 'non-survival') were correlated with PCR results. Overall 73.8% (439/595) of the koalas were infected with at least 1 species of trypanosome. Trypanosoma irwini was detected in 423/595 (71.1%), T. gilletti in 128/595 (21.5%) and T. copemani in 26/595 (4.4%) of koalas. Mixed infections were detected in 125/595 (21%) with co-infections of T. irwini and T. gilletti (101/595, 17%) being most common. There was a statistical association between infection with T. gilletti with lower PCV values and body condition scores in koalas with signs of chlamydiosis, bone marrow disease or koala AIDS. No association between T. gilletti infection and any indicator of health was observed in koalas without signs of concurrent disease. This raises the possibility that T. gilletti may be potentiating other disease syndromes affecting koalas.

Pattern of paediatric HIV/AIDS – the Awka experience

Background: Paediatric HIV/AIDS has become a significant cause of morbidity and mortality in our environment Objectives: The aim is to determine the clinical features on presentation, routes of transmission and outcome of hospital admissions in children with Paediatric HIV/AIDS at Amaku General Hospital Awka Anambra State Nigeria.Materials and Methods: A retrospective study of children with Paediatric HIV/AIDS admitted into the hospital between March 1, 2007 and February 28, 2009 was done. Diagnosis for HIV infection was based on double ELISA and clinical criteria as recommended by WHO. Results: Thirty-nine HIV positive children aged 10weeks to 12years were admitted into the ward, accounting for about 10% of total admissions. There were 22 males and 17 females. Majority of the patients (38.5%) were &le; 3 years old. Major clinical features were fever (76.9%), diarrhoea (53.8%), weight loss (51.3%) and cough (46.1%). Vertical transmission was the major route accounting for 66.7% and was statistically significant (p< 0.05). Twenty-nine patients (74.3%) were discharged, while mortality rate was 15.4% Conclusion: The finding indicates that Paediatric HIV/AIDS occurs predominantly by vertical route in Amaku General Hospital Awka. We recommend intensification of efforts to implement the existing prevention of mother to child transmission programme.

The pattern of paediatric HIV/AIDS as seen at the National Hospital Abuja Nigeria.

Paediatric HIV/AIDS has become a significant cause of mortality and morbidity in our environment. The objective of this paper is to determine the mode of transmission, clinical presentations and outcome of hospital admissions in children with Paediatric HIV/AIDS at the National Hospital Abuja Nigeria. A retrospective study of children with Paediatric HIV/AIDS admitted into the hospital from January December 2000 was done. Screening for HIV infection was based on clinical criteria as recommended by WHO except in 3 children with previously diagnosed HIV seropositivity. One positive ELISA and one positive Western Blot assay diagnosed HIV seropositivity. Forty-three HIV positive children aged six weeks to nine years (mean 16.5 months, SD 26.32) were admitted into the Paediatric unit (exclusive of the newborn unit) of the hospital, accounting for 5.7% of all admissions into the unit. There were 35 infants (81.4%). There were 18 males and 25 females (male: female ratio 1:0.72). The presumed modes of transmission were mother to child transmission 40(93.02%), blood transfusion 2 (4.6%) and an unidentified route 1 (2.3%). All parents were in the reproductive age group and there were 6 discordant couples identified (mother HIV positive, father HIV negative). Common presenting symptoms were fever 16 (37.2.8%), diarrhoea 13 (30.2%), difficult/fast breathing 12 (27.9%) and vomiting 8 (18.6%), while clinical signs were crepitations in the lungs 27 (62.7%), pallor 22 (51.2%), oral thrush 20 (46.5%), hepatomegaly 18 (41.9%), and dehydration 16 (37.2%). Admitting diagnoses were pneumonia 26 (60.5%), septicaemia 4 (9.3%), diarrhoea with dehydration, intestinal obstruction and malnutrition 2 (4.7%) each. There were 14 deaths (mortality rate 32.6%); accounting for 28.57% of total deaths in the paediatric unit during the period. Thirteen (13) (92.8%) deaths occurred in children aged 2 years old and below. The greatest contributors to mortality were pneumonia 10 (71.4%) and septicaemia 2 (14.3%). Poor nutritional status was associated (p<0.05) with increased mortality. The findings indicate that paediatric HIVAIDS occurs predominantly by mother to child transmission and constitutes a significant cause of childhood morbidity and mortality at the National Hospital Abuja Nigeria. We recommend intensification of efforts to implement the existing prevention of mother to child transmission programme and further evaluation ofpneumonia in HIV positive children.

A systematic literature review of factors affecting outcome in older medical patients admitted to hospital

The ACMEplus project aims to devise a standardised system for measuring case-mix and outcome in older patients admitted to hospitals in different parts of Europe for primarily 'medical' (i.e. not surgical or psychiatric) reasons. As a first step in this project, a systematic review was carried out to identify factors which had a significant influence on outcome in such patients. The systematic search used Medline 1966-2000, Cinahl 1982-2000, Web of Science 1981-2000, reference lists of relevant papers and a hand search of Age and Ageing 1974-2000. A six-category grading system was devised to classify the 313 identified papers with regard to their relevance to the ACMEplus project, study design and power. The analysis of the 14 'category 1' papers is presented. The main areas of assessment of case-mix were function, cognition, depression, illness severity, nutrition, social elements, aspects of diagnosis and demographic details. Statistically significant predictors, for the four outcome measures, listed below were: For length of stay: functional status score, illness severity, cognitive score, poor nutrition, comorbidity score, diagnosis or presenting illness, polypharmacy, age and gender. For mortality: functional status score, illness severity, cognitive score, comorbidity score, diagnosis or presenting illness, polypharmacy, age and gender. For discharge destination: functional status score, cognitive score, diagnosis or presenting illness and age. For readmission rate: functional status score, illness severity, co-morbidity, polypharmacy, diagnosis or presenting illness and age. Factors affecting outcome in older medical patients are complex. When looking at outcomes of hospital admission in older people it is important not just to look at routinely available statistics such as age, gender and diagnosis but also to take into account multifaceted aspects such as functional status and cognitive function.

Wird der Algorithmus des European Resuscitation Council zur kardiopulmonalen Reanimation eingehalten?

Introduction In the year 2000 the ERC published an algorithm for ACLS including early defibrillation. Aim of the present study was to investigate whether paramedics or physicians adhere to the algorithm for ACLS during out of hospital cardiopulmonary resuscitation in the metropolitan area of Hamburg, Germany. Methods A retrospective series of 200 cases of sudden out-of-hospital cardiac arrest in 2001 and 2002 was studied. We analyzed the emergency protocols and the digital records of the automated external defibrillators (AED). The following parameters were recorded: time needed after dispatching emergency personnel until arrival of the paramedics at the patient's side, the time elapsed from the call until the first analysis and to the first defibrillation, the initial recorded cardiac rhythm, the time intervals between the analyses and defibrillations, the applied shock energy, and the patient's outcome until the arrival at the hospital. Results The paramedics arrived at the patient's side after 5 min, the first analysis was performed after 7 min, the first defibrillation after 8 min. The initial cardiac rhythm was ventricular fibrillation in 69%, pulseless electrical activity in 21% and asystole in 10%. Of the patients, 38% were admitted to the hospital with spontaneous circulation. Paramedics did not adhere to the algorithm in 50%, the physicians in 84% of the cases: the recommended interval between the analyses or defibrillations of 60 s was delayed to 95 s by the paramedics and to 130 s by the emergency physicians. Between the defibrillations it was delayed to 117 s (paramedics) and 168 s (emergency physicians). In 69 cases of defibrillation the applied shock energy was not the recommended energy. Conclusion Neither paramedics nor emergency physicians strongly adhere to the recommended algorithm for ACLS of the ERC. This should influence the training program for both professional groups. Overall the observed deviations in each patient was not related independently to the outcome hospital admission.

CHEST PAIN ??? WEIGHT LIFTING

HISTORY A 23 year old white male active duty soldier presented with a sudden onset of 7/10 retrosternal chest pain radiating to his neck, which occurred 3 hours after heavy bicep and triceps weight exercises. The pain occurred while the patient was sitting, was made worse with leaning forward, and was relieved by IM ketorolac in the emergency department. There was no associated palpitations, diaphoresis, nausea, arm, back or jaw pain. No fevers, cough, or pleurisy. No orthopnea or dyspnea. No dysphagia or voice changes. The patient denied any trauma to his neck or chest, or any strain of the chest wall musculature during weight lifting. The patient was stationed in Korea for the last two years and was unsure of his PPD status. The patient denied tobacco or illicit drug use. PHYSICAL EXAM Examination in the emergency department showed that the trachea was midline without crepitus, without jugular venous distension, or pulsus paradoxus. His upper extremities had full range of motion, with normal strength, sensation, and deep tendon reflexes. The patient's chest was symmetric without deformities and was non-tender to palpation. Cardiac auscultation revealed a normal S1 and S2 without murmur, but a course, crackling, holosystolic sound synchronous with the heartbeat was best heard at the left sternal border with radiation to the neck and increased with forward lean. Abdominal exam revealed a flat, symmetric abdomen with normoactive bowel sounds, no masses or organomegaly. DIFFERENTIAL DIAGNOSIS Pericarditis; Pneumothorax; Pneumomediastinum; Esophageal perforation Infectious mediastinitis; Pulmonary embolism; Coronary artery vasospasm Chest wall muscle strain; Acute coronary syndrome; Aortic dissection TEST AND RESULTS EKG: Sinus bradycardia with diffuse ST segment elevations in leads V2-V6, thought to be consistent with early repolarization, also with questionable PR segment depressions CBC: WBC 16.4 (60 segs, 0 bands) CK: 8877, CK-MB: 1.7, Troponin I: 0.0 ESR: 0 CXR: The heart was normal in size with evidence of pneumomediastinum supported by a thin line of radiolucency outlining the left heart border. Both lungs were clear without evidence of focal pneumonic infiltrate or interstitial lung changes. There was no evidence of pleural effusion or pneumothorax. High resolution CT Scan of Chest: The study demonstrated pneumomediastinum with air dissected up to the lower neck. No evidence of consolidation of pleural effusion. There was no evidence of emphysematous change in either lung field. No evidence of pneumothorax or pneumoperitineum. No evidence of apical blebs or microalveolar disease. FINAL/WORKING DIAGNOSIS Pneumomediastinum TREATMENT AND OUTCOMES Hospital admission and observation. Serial CXR, cardiac enzymes, and physical exams. Pulmonology appointment 5 days post event. Primary care appointment 7 days post event with repeat chest radiograph. Complete resolution of symptoms. Returned to sports at a limited level 10 days post event, with full participation 1 month post event, after a normal follow-up chest CT.

The changing impact of HIV/AIDS on Kenyatta National Hospital, Nairobi from 1988/89 through 1992 to 1997.

Consequences of the growing HIV/AIDS epidemic for health services in sub-Saharan Africa remain poorly defined. Longitudinal data from the same centre are scarce. We aimed to describe the impact of a rapidly rising HIV/AIDS disease burden on an urban hospital over the last decade. Cross-sectional observational study in 1997, compared to similar data from 1988/89 and 1992. The study was carried out in the Kenyatta National Hospital, Nairobi, Kenya. Consecutive adult medical patients were enrolled on admission and then followed up until death or discharge. The main outcome measures were clinical stage, HIV status, bacteraemia, length of stay, bed occupancy, final diagnosis and outcome of hospital admission. In 1997, 518 patients, 493 with HIV serology, were enrolled: HIV prevalence was 40.0%, bed occupancy 190%, the mean length of stay 9.5 days (SD 12) and overall mortality 18.5%. The mean number of HIV-positive admissions per day steadily rose from 4.3 [95% confidence interval (CI), 0.6] patients in 1988/89, through 9.6 (95% CI, 1.4) in 1992, to 13.1 (95% CI, 2.8) or 13.9 adjusted for those enrolled without HIV serology in 1997. In contrast the mean number admitted with clinical AIDS, 1.7 in 1988/89 and 3.3 in 1992, fell to 2.6 cases per day in 1997. With HIV-negative admissions increasing by 37% and bed occupancy nearly doubling in 1997, HIV prevalence appeared to be stabilizing (19 then 39 and 40% respectively). Over time fewer HIV-infected patients were bacteraemic (26, 24 and 14%; P < 0.01); had clinical AIDS (39, 34 and 24% respectively; P < 0.01); or died (36, 35 and 22.6%; P < 0.02). HIV-negative mortality, 14% in 1988/89, rose to 23% in 1992 but fell to 15% in 1997. The mean length of hospital stay (9.5-10 days) did not differ according to HIV status nor did it change across the decade. The HIV/AIDS disease burden in Kenyatta National Hospital medical wards has risen inexorably over the last decade. Most recently, the number of HIV-uninfected patients has also risen, leading to bed occupancy figures of 190%. Despite overcrowding and irrespective of HIV status, in-patient mortality has fallen. Time trends suggest fewer clinical AIDS patients are presenting for hospital care, implying a rising community burden of chronic HIV/AIDS disease. Although widely predicted, it is not inevitable that medical services in urban African hospitals dealing with large volumes of HIV/AIDS disease, will collapse or become overwhelmed with chronic, end-stage disease and death.

Evaluation of paramedic programs using outcomes of prehospital resuscitation for cardiac arrest

Two evaluation methods, one statistical and one comparative, were developed to assess the effectiveness of paramedic programs in King County, Washington. The outcome of hospital admission following prehospital cardiac arrest was used as a measure of effectiveness. In the statistical method, actual outcomes were compared with predicted outcomes. Predictive variables for admission were time from collapse to initiation of cardiopulmonary resuscitation and time from collapse to definitive care. Given knowledge of the predictive variables, the statistical evaluation enabled us to determine the probability of the outcome following cardiac arrest. In the comparative method, outcomes were compared with a standard in an adjacent community. Using this method, we identified program elements that could lead to improved outcome. Both evaluation methods are easily implemented.