Initial Patient Care Research Articles

Psychosocial risk factors for chronic low back pain in primary care--a systematic review

Low back pain (LBP) is a major public health problem, often encountered in primary care. Guidelines recommend early identification of psychosocial factors that could prevent recovery from acute LBP. To review the evidence on the prognostic value of psychosocial factors on transition from acute to chronic non-specific LBP in the adult general population. Systematic review is the design of the study. A systematic search was undertaken for prospective studies dealing with psychosocial risk factors for poor outcome of LBP in primary care, screening PubMed, PsychInfo and Cochrane Library databases. The methodological quality of studies was assessed independently by two reviewers using standardized criteria before analysing their main results. Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome. Few independent psychosocial risk factors have been demonstrated to exist. Randomized clinical trials aimed at modifying these factors have shown little impact on patient prognosis. Qualitative research might be valuable to explore further the field of LBP and to define new management strategies.

Preparedness for Terrorism: Managing Nuclear, Biological and Chemical Threats

The management of nuclear, biological and chemical (NBC) terrorism events is critical to reducing morbidity and mortality in the next decade; however, initial patient care considerations and protective actions for staff are unfamiliar to most front-line clinicians. High explosive events (bomb and blast) remain the most common type of terrorism and are easy to detect. Conversely, some types of terrorist attacks are more likely to be unsuspected or covert. This paper explains the current threat of terrorism and describes clues for detection that an event has occurred. Specific criteria that should lead to a high suspicion for terrorism are illustrated. The manuscript outlines initial actions and clinical priorities for management and treatment of patients exposed to nuclear/radiological, biological, chemical and combined agents (for example an explosion involving a chemical agent). Examples of terrorist events include: a nuclear explosion, an aerosolised release of anthrax (biological), dissemination of sarin in a subway (chemical), and the detonation of a radiologic dispersion device or "dirty bomb" (combined explosive and radiological). Basic principles of decontamination include potential risks to healthcare providers from secondary exposure and contamination. Unique issues may hinder clinical actions. These include coordination with law enforcement for a crime scene, public health entities for surveillance and monitoring, hazardous materials teams for decontamination, and the media for risk communications. Finally, the importance of personal preparedness is discussed.

A Prospective, Randomized, Double‐Blinded, Placebo‐Controlled Study of Human Intravenous Immunoglobulin for the Acute Management of Presumptive Primary Immune‐Mediated Thrombocytopenia in Dogs

Immune-mediated thrombocytopenia (IMT) is a common hematologic disorder in dogs. Human intravenous immunoglobulin (hIVIG) may have a beneficial effect in canine IMT. A single hIVIG infusion (0.5 g/kg) in dogs with presumed primary IMT (pIMT) is a safe adjunctive emergency treatment to accelerate platelet count recovery and shorten hospitalization time without increasing the cost of patient care. Eighteen client-owned dogs with a presumptive diagnosis of pIMT. Prospective, randomized, double-blinded, placebo-controlled clinical trial. There were no identifiable immediate or delayed adverse reactions associated with hIVIG administration over a 6-month period. The median platelet count recovery time for the hIVIG group was 3.5 days (mean + or - SD: 3.7 + or - 1.3 days; range, 2-7 days) and 7.5 days (mean + or - SD: 7.8 + or - 3.9 days; range, 3-12 days) for the placebo group. The median duration of hospitalization for hIVIG group was 4 days (mean + or - SD: 4.2 + or - 0.4 days; range, 2-8 days) and 8 days (mean + or - SD: 8.3 + or - 0.6 days; range, 4-12 days) for the placebo group. There was no significant difference between groups with respect to expense of initial patient care, whereas significant reduction in platelet count recovery time (P= .018) and duration of hospitalization (P= .027) were detected in the hIVIG group. Compared with corticosteroids alone, adjunctive emergency therapy of a single hIVIG infusion was safe and associated with a significant reduction in platelet count recovery time and duration of hospitalization without increasing the expense of medical care in a small group of dogs with presumed pIMT.

Successfully Managing Attending Physicians

Successfully Managing Attending Physicians

Caring for the Critically Ill Patient

FOR A QUARTER CENTURY, JAMA HAS SERVED AS A VENUE for articles relating to care of critically ill patients, beginning with the Concepts in Emergency and Critical Care section, in which these fields were initially described as “spanking new medical disciplines.” At the time, knowledge of the biology of critical illness was rudimentary, the focus was on initial patient care, such as airway management and resuscitation, and the few physicians trained in emergency or critical care medicine worked mainly in large teaching hospitals. During the following years, critical care and emergency medicine grew rapidly, training and accreditation became more standardized, and the focus changed to the definition, management, and outcome of postresuscitation syndromes, such as sepsis, shock, and organ dysfunction. Approximately 10 years ago, the section name was changed to Caring for the Critically Ill Patient, ushering in increased focus on high-quality multicenter randomized trials, organization and delivery of care, and attention to patient-centered outcomes. Today, the Caring for the Critically Ill Patient section of JAMA is devoted to publication of important articles in critical and emergency care at a time when the clinical and research landscape has shifted again. Advances in molecular biology now provide a wealth of information on the humoral and cellular responses to acute trauma, infection, and ischemia. This understanding has helped delineate the mechanisms of shock, sepsis, and organ dysfunction syndromes, such as acute respiratory distress syndrome (ARDS), acute renal failure, and traumatic brain injury, generating a plethora of therapeutic targets. The scale of critical care and emergency medicine services has also changed. Every acute care hospital in the United States boasts an intensive care unit (ICU), half of the nation’s ICU beds are located in small hospitals, and many teaching hospitals have built huge ICU services, often with 60 or more beds. Six million Americans, or 2% of the population, are admitted to the ICU each year, severe sepsis and ARDS affect hundreds of thousands of individuals annually, and 1 in 5 Americans receive ICU care at the end of life. All this care is provided by a workforce of hundreds of thousands of highly trained physicians, nurses, and allied health care personnel who function in integrated team systems, not just in the ICU and emergency department, but increasingly on hospital general units and in the community. With substantial investment of resources and advancement in knowledge, care of critically ill patients has no doubt improved. Mortality appears to have decreased for sepsis and ARDS, and headway has been made toward safer, quicker, more effective care. However, considerable challenges lie ahead on the path from basic science to improved public health, including a translational block between basic science and clinical trials; challenges in conducting clinical trials in critically ill patients; failure of clinical research to fully frame health issues facing critically ill patients; an inadequate evidence base for many aspects of care; and public health policy that is either lacking or uninformed by evidence. The first challenge, overcoming translation from basic science to clinical trials, is exemplified by the sepsis syndromes. Among the more than 30 large trials involving agents designed to modify the host response to infection, only 2 were positive (and neither of these are considered definitive). While trial design may be partly to blame, the problems run deeper. Severe sepsis, the subset of sepsis with acute organ dysfunction, is often difficult to define and encompasses a highly heterogeneous group of patients. Outcome and probably response to therapy are linked to multiple host, pathogen, and health care–related factors that neither in vitro nor in vivo models adequately address. Therapies enter clinical trials with little information on appropriate dosing or methods to monitor their biologic activity. A particular challenge for sepsis and other critical illnesses is that the pathways targeted for modification are as often helpful as harmful, and current clinical trial entry criteria provide no guarantee that the host response pathway of interest is either active in a particular patient or behaving in an injurious manner. Thus, clinical research needs better tools to select and monitor patients and their therapies, and basic science needs

Otologic Blast Injuries due to the Kenya Embassy Bombing

Otologic injuries are frequently associated with large blasts. On August 7, 1998, a large truck bomb exploded next to the U.S. Embassy in Nairobi, Kenya. Initial patient findings and care are reviewed. Five months later, an otologic screening and care mission was then sent to comprehensively screen all remaining blast victims on site in Nairobi and to determine degree of persistent injury. Surgical care appropriate for an outpatient environment was provided. Five of 14 tympanic membranes without intervention failed to heal, while 3 of 3 with previous intervention had. Blast injury severity did not correlate to distance from blast epicenter. This may be due to channeling of the blast through the embassy building and an unpredictable pattern of blast overpressure within the building. It is recommended that comprehensive otologic screening be performed after blast events to identify occult injuries and improve outcomes. Early intervention for tympanic membrane perforation (suctioning, eversion of perforations, and paper patch) is recommended.

Impact of the in-house trauma surgeon on initial patient care, outcome, and cost.

The purpose of this study is to evaluate the effect of having attending trauma surgeons with added qualifications in surgical critical care present for the initial resuscitation at a regional trauma center. This study is a retrospective review of patients admitted between August of 1994 and December of 1995 from our trauma registry. The patients were categorized by the call preference of the admitting physician as in-house (IH) or call-back from home (CB), day of admission (weekend vs. weekday), time of admission (AM VS. PM), and a value of the injury severity scale < or = 15 or > 15. Demographics, admission vital signs, Injury Severity Scale, Glasgow Coma Score, and elapsed time to diagnostic, therapeutic, and/or operative interventions were studied. The effect on intensive care unit length of stay, mortality, and hospital cost for resuscitation were also studied. The study population consisted of 1,043 patients. The IH and CB groups each included two attending surgeons. IH significantly reduced the average time to completion of diagnostic peritoneal lavage (22 vs. 34 minutes; p < 0.05), therapeutic intervention (21 vs 38 minutes; p < 0.05), and transport to the operating room (206 vs. 312 minutes; p < 0.05) during the AM compared with CB. There was no difference in these times for the PM admissions. There was no significant difference in intensive care unit length of stay. Among patients with severe head and thoracoabdominal injury (Abbreviated Injury Score > 4 and 3, respectively) there was no difference in mortality. Analysis of cost for emergency room resuscitation in severely injured patients (Injury Severity Score > or = 15), seen during weekdays, was significantly less when evaluated by IH (IH = $5,097 vs. CB = $6,779; p < 0.05). During the initial resuscitation of patients with severely injured during the weekdays, IH significantly reduced the cost, and elapsed time to diagnostic testing, therapeutic intervention, and to the operating room, respectively. IH reduced fatalities compared with CB.

Severe community-acquired pneumonia in ICUs: prospective validation of a prognostic score.

To determine predictors of intensive care unit (ICU) mortality in patients with community-acquired pneumonia (CAP), to develop a pneumonia-specific prognostic index, and to evaluate this index prospectively. Combined retrospective and prospective clinical study over two periods: January 1987-December 1992 and January 1993-December 1994. Four medical ICUs in the north of France. Derivation cohort: 335 patients admitted to one ICU were retrospectively studied to determine prognosis factors and to develop a pneumonia-specific prognostic index. Validation cohort: 125 consecutive patients, admitted to four ICUs, were prospectively enrolled to evaluate this index. In the derivation cohort, 16 predictors of mortality were identified and assigned a value directly proportional to their magnitude in the mortality model: aspiration pneumonia (-0.37), grading of sepsis > or = 11 (-0.2), antimicrobial combination (-0.01), Glasgow score > 12+mechanical ventilation (MV) (+0.09), serum creatinine > or = 15 mg/l (+0.22), chest involvement shown by X-ray > or = 3 lobes (+0.28), shock (+0.29), bacteremia (+0.29), initial MV (+0.29), underlying ultimately or rapidly fatal illness (+0.31), Simplified Acute Physiology Score > or = 12 (+0.49), neutrophil count < or = 3500/ mm3 (+0.52), acute organ system failure score > or = 2 (+0.64), delayed MV (+0.67), immunosuppression (+1.38), and ineffective initial antimicrobial therapy (+1.5). An index was obtained by adding each patient's points. According to a receiver operating characteristic curve, the cut-off value of this index was 2.5. In the validation cohort, an index of > or = 2.5 could predict death with a positive predictive value of 0.92, sensitivity 0.61, and specificity 0.98. This index, which performs well in classifying patients at high-risk of death, may help physicians in initial patient care (appropriateness of the initial antimicrobial therapy) and guide future clinical research (analysis and design of therapeutic trials).

Resident management of emergency department patients: Is closer attending supervision needed?

To determine the extent of supervision necessary for emergency medicine residents practicing in the emergency department. ED of a university-affiliated tertiary care facility with an annual census of 32,000 visits. All ED patients presenting during study hours during a four-month period. A prospective study was conducted of changes made by emergency medicine attendings in the management of ED patients seen initially by second-year emergency medicine residents. Second-year emergency medicine residents presented all patients seen by them to a specified emergency medicine attending, who also interviewed and examined these patients. Initial patient care was designed by the resident and modified by the emergency medicine attending. Attending modification was recorded by the emergency medicine attending in the study log. Modifications of the residents' proposed care were designated as major (change resulted in an alteration in patient disposition, detection of unsuspected pathology, or marked revision of intended treatment); minor (change resulted in lesser modification of patient management); or no change. Four hundred eight patient encounters were included in the study. Sixteen patients (4%) had major modifications of their care, 134 (33%) had minor modifications, and 258 (63%) had no change. Supervision is required for all patients managed by second-year emergency medicine residents, regardless of complaints. This evaluation should include a direct patient interview and examination by the emergency medicine attending and should not be limited to a case discussion or ED record cosignature.