Non-emergency Setting Research Articles

Safety and usefulness of acetylcholine provocation test in patients with no culprit lesions on emergency coronary angiography

BackgroundVasospastic angina (VSA), which often causes acute coronary syndrome (ACS), can be diagnosed by intracoronary acetylcholine (ACh) provocation test. However, the safety and usefulness of ACh provocation test in ACS patients on emergency coronary angiography (CAG) compared to non-emergency settings are unclear. MethodsA total of 529 patients undergoing ACh provocation test during emergency or non-emergency CAG were included. Patients with resuscitated cardiac arrest were excluded. The primary endpoint was adverse events defined as a composite of death, ventricular fibrillation or sustained ventricular tachycardia, myocardial infarction, cardiogenic shock, cardiac tamponade, and stroke within 24 h after ACh provocation test. ResultsThere were no significant differences of the clinical characteristics between the groups of emergency (n = 84) and non-emergency (n = 445) ACh provocation test. The rate of positive ACh provocation test was similar between the 2 groups (50% vs. 49%, p = 0.81). Similarly, the incidence of adverse events in patients with emergency and non-emergency ACh provocation test did not significantly differ (1.2% vs. 1.3%, p = 1.00). ConclusionACh provocation test can be safely performed in ACS patients with no obstructive culprit lesions on emergency CAG, and may be useful to diagnose VSA in those patients.

Factors associated with delay in carotid endarterectomy for patients with symptomatic severe internal carotid artery stenosis: a case-control study.

The Canadian Best Practice Recommendations for Stroke Care (2008 update) recommend that patients with neurologic symptoms secondary to severe internal carotid artery stenosis undergo carotid endarterectomy within 14 days of symptom onset to prevent stroke. The purpose of this study was to identify patient and system factors associated with meeting, or failing to meet, the guideline. In this case-control study, potential study participants were identified through an electronic search of the Discharge Abstract Database. We reviewed the charts of patients who presented to our centre with neurologic symptoms ipsilateral to internal carotid artery stenosis of 70%-99% and underwent carotid endarterectomy in our centre between Jan. 1, 2009, and Dec. 31, 2014. We performed logistic regression analysis to identify factors associated with meeting, or failing to meet, the guideline. Of the 412 patients who underwent carotid endarterectomy during the study period, 219 met the inclusion criteria. Sixty-seven patients (30.6%) met the 14-day guideline. Thirty (14.2%) of the 212 patients who could be classified as case or control subjects did not access the health care system within 14 days. Once in the health care system, failure to meet the guideline was associated with a presentation of amaurosis fugax (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05-0.96 compared to completed minor stroke) and presentation to a nonemergency outpatient setting (OR 9.08, 95% CI 2.51-32.80 compared to emergency department). Improvements in meeting the goal of carotid endarterectomy within 14 days of symptom onset for severe internal carotid artery stenosis should be directed at patient and system factors. A system for rapid diagnosis and referral of symptomatic patients to an appropriate surgeon should be established.

Chapter 7 - Epidemiology of sports concussion in the United States

Sports and recreation-related (SRR) activities are common in the United States. Beyond the benefits to health, SRR activities can create new friendships, give people a sense of belonging, foster teamwork and other leadership skills, and develop sportsmanship and a respect for rules that govern play. Public awareness about the risk of concussion has grown as the long-term consequences of traumatic brain injury (TBI) have become better known, and likely explains the increasing concussion incidence rates. Currently, surveillance systems capture SRR concussions among high school and college athletes participating in sanctioned sports. National estimates of SRR TBI presenting to an emergency department also exist. Persons under the age of 19 sustain a majority of SRR concussions. Concussion risk is greatest for boys in contact/collision sports like football, ice hockey, and lacrosse, and is more likely to occur in competition versus practice settings. Girls have elevated concussion rates in gender-comparable sports. Despite better data, concussions are still underreported, undermanaged, and often not properly identified. This is especially true for concussions occurring outside organized sports, in nonsport recreational activities, and for concussions either not seen or evaluated in nonemergency department settings. A new surveillance system proposed by the Centers for Disease Control and Prevention aims to fill the gap.

Transfusion-associated circulatory overload: A survey among Dutch intensive care fellows

ObjectivesTransfusion-associated circulatory overload (TACO) is a severe pulmonary transfusion reaction and leading cause of transfusion-related morbidity and mortality in Europe. TACO is of particular importance in critically ill patients, since they often receive blood transfusions and have multiple risk factors for TACO. This study investigates transfusion practices in patients at risk of developing TACO, and furthermore knowledge concerning risk factors, diagnoses and treatment strategies among Dutch intensive care unit (ICU) fellows. Material and methodsAn unannounced paper-based survey was conducted among Dutch ICU fellows during an educational conference. The survey consisted of 16 multiple and open choice questions. ResultsOf all 65 Dutch ICU fellows 56.8% completed the survey; of respondents 88.9% identified the correct constellation of symptoms for TACO. In total, 29.7% of the respondents are aware they are obligated to report TACO cases to the blood bank. Major risk factors for TACO that respondents identified were reduced left ventricular function, infusion volume and infusion rate. In a non-emergency setting, 45.9% of fellows start red blood cell transfusion with 2 units or more. Transfusion rates exceeded national guidelines in 15.4% of fictitious cases. TACO is treated with furosemide by 94.5% of the fellows, however goals of the therapy varied greatly. ConclusionDutch ICU fellows are knowledgeable of TACO symptoms, risk factors and treatment, however knowledge on reporting and transfusion practice in the setting of at risk patients for TACO should be improved.

Pitfalls in Imaging of Female Pelvic Masses

The purpose of this review is to highlight potential magnetic resonance (MR) imaging pitfalls that may mask and simulate ovarian cancer. MR imaging is the standard method for evaluating female pelvic masses of indeterminate origin, especially sonographically indeterminate adnexal masses. To define the correct origin and nature of a pelvic mass has an enormous clinical impact, namely in females of child-bearing age. This is particularly true in adnexal lesions. Ovarian cancer usually requires a cytoreductive surgery in a specialized oncological centre. In contrast, a benign ovarian lesion may be treated by simple resection in a general hospital. To help preventing diagnostic errors and in order to guide appropriate therapeutic management, radiologists should be aware of potential MR pitfalls that may mask and simulate ovarian cancer. The first section of this article will describe the MR imaging protocol that authors perform in their oncological centre, highlighting how imaging techniques can be optimized in order to reduce pitfalls in the characterization of an indeterminate pelvic mass. In the next section, authors will revise the main anatomic and organ-specific signs that may allow the radiologist to determine the ovarian origin of a pelvic mass. Finally, benign gynaecological masses that may simulate ovarian cancer in a non-emergency setting will be discussed, with emphasis on features that may provide important clues to their diagnosis.

Ultrasound probe grip: the afternoon tea technique.

Globally, ultrasound is being used to assist in central venous and difficult peripheral intravenous access in a variety of emergency and non-emergency clinical settings. After reading Flood's paper on safe central venous access and noting the difficulties clinicians find in probe stabilisation whilst performing dynamic intravenous access, we decided to share our teaching technique. The purpose of this correspondence is to highlight the 'afternoon tea technique' as a potential teaching method for probe stabilisation. It is hoped that this technique will improve the image quality in dynamic procedures and increase the success rate of ultrasound-guided intravenous access in clinical practice.

Complications and Morbidity associated with Loop Ileostomies in Patients with Ulcerative Colitis.

Loop ileostomies are frequently used as diversion of the fecal stream to protect a distal anastomosis. The aim of this study was to identify complications and morbidity related to loop ileostomies in patients with ulcerative colitis at a nonemergent setting. Consecutive patients with ulcerative colitis who received a loop ileostomy at a tertiary referral center in Sweden from January 2006 until December 2012 were included and studied retrospectively. In total, 71 patients were identified, and the median age was 39 years. A majority (94%) of the patients underwent proctectomy or proctocolectomy with primary construction of an ileal pouch-anal anastomosis. In total, 38 patients (54%) had one or more postoperative complications at index surgery. Stoma-related complications were seen in 49% where parastomal skin irritation was most common. In total, 18% of the patients were re-admitted due to morbidity related to the ileostomy, and the leading cause was high volume output. Complications related to closure were seen in 29% of the patients, and of these, 30% required surgical intervention. In total, five patients (7%) developed a symptomatic leakage in the ileo-ileal anastomosis. There was no mortality. Loop ileostomies in this young patient cohort resulted in considerable morbidity. Closure of the ileostomy was also associated with complications. Although the diverting loop ileostomy is constructed to decrease the clinical consequences of an anastomotic leakage, the inherent morbidity should be considered. Preventive measures for parastomal skin problems could improve results.

Graves' Ophthalmopathy in a Paediatric Population.

Background Graves' disease is an autoimmune disorder leading to hyperthyroidism. It is often associated with ophthalmic manifestations. Graves' disease is reported to be rare in the paediatric population. Patients and Methods We performed a retrospective analysis on all patients diagnosed with ophthalmopathy related to Graves' disease at a paediatric age (less than 18 years old) in our institution between 2004 and 2015. Results Eight patients were identified: 6 females and 2 males. The median age at diagnosis was 11.5 years (range 3-16). Ophthalmic signs were: proptosis (6/8), superficial punctate keratitis (5/8), eyelid retraction (4/8), lagophthalmos (2/8), and oculomotor dysfunction (2/8). No patients showed signs of complication such as ocular hypertension or compressive optic neuropathy. Orbital decompression was performed in one patient in a non-emergency setting. Conclusion Ophthalmic involvement in Graves' disease is rarely encountered in paediatric patients. Ophthalmologists should be aware of this entity to ensure that patients with thyroid dysfunction are identified at an early point in time.

Insurance Reimbursement for Complementary Healthcare Services.

Insurance reimbursement for clinical services provided by complementary healthcare professionals in the United States likely differs by provider specialty. It is hypothesized that a lower likelihood of insurance reimbursement demonstrates that complementary healthcare services are not utilized to an optimal level and are not financially accessible to all who may need or want these services. The purpose of this project was to evaluate the likelihood of insurance reimbursement for complementary healthcare services compared with other complementary services and with conventional primary care medical services in New Hampshire. The authors studied health claims for services provided in a nonemergent outpatient setting in New Hampshire in 2014. The study population consisted of New Hampshire residents aged 18-99 years with claims for selected clinical services commonly provided by complementary healthcare providers. The authors modeled the proportion of reimbursed claims by specialty of complementary healthcare service provider, compared with the reimbursement rate for primary care physicians' claims. The authors modeled first for the proportion of reimbursement for any selected clinical service, next for any evaluation and management (E&M) service, and finally for the most commonly used E&M procedure code, current procedural terminology (CPT) 99213 (reevaluation of established patient). Compared with primary care physicians, the likelihood of reimbursement for any service was 69% lower for acupuncturists, 71% lower for doctors of chiropractic medicine, and 62% lower for doctors of naturopathic medicine. For any E&M service, likelihood of reimbursement was 69% lower for acupuncturists, 78% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine. With further restriction to CPT 99213 only, likelihood of reimbursement was 34% lower for acupuncturists, 77% lower for doctors of chiropractic medicine, and 60% lower for doctors of naturopathic medicine. In New Hampshire, the likelihood of health insurance reimbursement for certain clinical services differs significantly by provider specialty. More research is needed to evaluate the extent and cause of such differences and the effect of such differences on the utilization of complementary healthcare services in the United States.

Severe acute malnutrition in children aged under 5years can be successfully managed in a non-emergency routine community healthcare setting in Ghana.

This study investigated the performance of community-based management of severe acute malnutrition (CMAM) within routine healthcare services in Ghana. This was a retrospective cohort study of n=488 children (6-59months) who had received CMAM. Data for recovery, default, and mortality rates were obtained from enrolment cards in 56 outpatient centres in Upper East region, Ghana. Satisfactory rates of recovery of 71.8% were reported. Children who were enrolled with higher mid-upper arm circumference (MUAC) ≥11.5cm had seven times greater chance of recovery compared with children who were enrolled with lower MUAC <11.5cm, OR=7.35, 95% CI [2.56, 21.15], p<.001. Children who were diagnosed without malaria at baseline were 30 times, OR=30.39, 95% CI [10.02, 92.13], p<.001, more likely to recover compared with those with malaria (p<.001). The average weight gain was 4.7g-1 ·kg-1 ·day-1 , which was influenced by MUAC status at baseline, β=.78, 95% CI [0.46, 1.00], p<.001, presence of malaria, β=-1.25, 95% CI [-1.58, 0.92], p<.001, and length of stay, β=0.13, 95% CI [0.08, 0.18], p<.001. The default rate (28.5%) was higher than international standards recommendations by Sphere. Mortality rate (1.6%) was lower than international standards. Our findings suggest that community-based management of SAM can achieve similar success when delivered in routine non-emergency settings. However, this success can be diluted by a high default rate, and the factors contributing to this need to be explored to improve programme effectiveness within communities.

Para-infectious seizures: A retrospective multicentre study

Abstract Introduction Para-infectious seizures are afebrile seizures that are associated with mild infections, and occur in children with no pre-existing neurological illness. They are still little known in our environment. Methods A multicentre retrospective study was conducted that included patients with normal psychomotor development and had presented with one or more seizures in the context of a mild afebrile infection. Results A total of 38 patients (47% male, 53% female) were included in the study over a period of three years (2012–2015). The mean age was 2.1 years. A previous history of febrile seizures was found in 7.9% of them. Mean number of seizures per patient was 2.2, with 57.9% of them being tonic-clonic seizures. The mean duration of seizures was 3.2 min. An EEG was performed during admission in 73.7% of cases. Lumbar punctures were performed in 34.2% of cases. All were normal. Neuroimaging tests were carried out in 36.9% of cases. Brain MRI was the imaging test performed in most cases (21.1%), with no any pathological findings. The most frequent infection found was acute gastroenteritis (68%), followed by upper respiratory tract infection (32%). Almost two-thirds (63.2%) of patients did not require anticonvulsant medication. Rectal diazepam was the most frequently used drug in emergencies. Intravenous medication was required by 28.9% of patients due to repeated seizures. The most frequently used drug in the non-emergency setting was valproic acid. Anticonvulsant treatment was continued after discharge in 16% of patients. Para-infectious seizures was the diagnosis in 76.3% of cases when discharged. Conclusions Knowledge of para-infectious seizures, their clinical diagnosis and benign course is crucial, as this would avoid further testing and unnecessary treatments.

Genetic Variants in LRP1 and ULK4 Are Associated with Acute Aortic Dissections

Acute aortic dissections are a preventable cause of sudden death if individuals at risk are identified and surgically repaired in a non-emergency setting. Although mutations in single genes can be used to identify at-risk individuals, the majority of dissection case subjects do not have evidence of a single gene disorder, but rather have the other major risk factor for dissections, hypertension. Initial genome-wide association studies (GWASs) identified SNPs at the FBN1 locus associated with both thoracic aortic aneurysms and dissections. Here, we used the Illumina HumanExome array to genotype 753 individuals of European descent presenting specifically with non-familial, sporadic thoracic aortic dissection (STAD) and compared them to the genotypes of 2,259 control subjects from the Atherosclerosis Risk in Communities (ARIC) study matched for age, gender, and, for the majority of cases, hypertension. SNPs in FBN1, LRP1, and ULK4 were identified to be significantly associated with STAD, and these results were replicated in two independent cohorts. Combining the data from all cohorts confirmed an inverse association between LRP1 rs11172113 and STAD (p = 2.74× 10(-8); OR = 0.82, 95% CI = 0.76-0.89) and a direct association between ULK4 rs2272007 and STAD (p = 1.15× 10(-9); OR = 1.35, 95% CI = 1.23-1.49). Genomic copy-number variation analysis independently confirmed that ULK4 deletions were significantly associated with development of thoracic aortic disease. These results indicate that genetic variations in LRP1 and ULK4 contribute to risk for presenting with an acute aortic dissection.

Using the Community Assessment for Public Health Emergency Response (CASPER) to assess barriers to healthy eating and active living in a low-income community

Insufficient physical activity and unhealthy eating behaviors are major contributors to the obesity epidemic in the United States. Identifying health behaviors and disparities in underserved communities is needed to guide the development of targeted interventions. The Community Assessment for Public Health Emergency Response (CASPER) is a set of tools designed for public health emergencies, but the utility of CASPER in non-emergency settings has not been explored. The purpose of this study was to use CASPER to obtain information on household-based behaviors of and barriers to fruit/vegetable consumption and physical activity, and explore the utility of these methods for future health assessments. Cross-sectional survey data included households (n=100) in a low-income neighborhood. Half of adults did not meet recommendations for fruit/vegetable consumption and 20% reported no physical activity during the previous week. Cost was significantly associated with healthy eating and physical activity in our community. Four primary advantages of using CASPER methodology included a user-friendly CDC toolkit, yield of a representative community sample with a relatively low sample size, low-cost/low-tech requirements for implementation, and the strengthening of an academic-practice-community partnership. Our work demonstrates the utility of CASPER for assessing healthy living in a geographically-defined community where household health behaviors and barriers are unknown.

Next Steps for Ebola Vaccination: Deployment in Non-Epidemic, High-Risk Settings.

The catastrophic West Africa Ebola epidemic that resulted in approximately 28,200 cases and 11,300 deaths over 22 months has been reduced to intermittent and, thus far, rapidly controlled flare ups in Liberia, Guinea, and Sierra Leone. During the period of most widespread and intense transmission, extraordinary efforts to develop, produce, and field-test an Ebola vaccine in the outbreak setting generated promising results. The combined findings of four parallel Phase I studies on healthy adults in Gabon, Kenya, Germany, and Geneva demonstrated safety and immunogenicity of the recombinant vesicular stomatitis virus (rVSV)-vectored Zaire ebolavirus (rVSV-ZEBOV) vaccine [1]. Glycoprotein-binding antibodies were detected for all vaccinated participants irrespective of dose and, although arthralgia, fever, and maculopapular rash were correlated with immunization, the mild symptoms were transient and easily treated; the vaccine was deemed safe with a high likelihood of acceptance [1]. More recently, it has been suggested that the rVSV vaccine effectively protects against Ebola virus disease (EVD) infections among the contacts of symptomatic cases in intense transmission settings [2,3]. Other candidates include the chimpanzee adenovirus type 3 Ebola vaccine (cAd3-EBO), which has been demonstrated as immunogenic and safe in humans [4]. Additionally, sustained protection against lethal Zaire ebolavirus (EBOV) challenge in macaques was achieved using ChAd3, given a modified vaccinia Ankara (MVA) boost after two months [5]. Largely mediated by CD8+ cells, a protective effect against EBOV has likewise been established in macaques for a vaccine based on recombinant adenovirus virus serotype 5 (rAd5) encoding Ebola virus glycoprotein (GP) [6–8]. Across all vaccine candidates [9], large-scale trials in human populations are unlikely to yield sufficient statistical power for determining efficacy and duration of protective immunity given the fortunate downturn in transmission events. However, if an Ebola vaccine is approved for post-marketing surveillance without additional Phase III efficacy studies, there is an opportunity to prepare vaccine infrastructure, including stockpiling and administration systems, in non-emergency but high-risk settings.

Adaptable Lessons Learnt on Procurement from Deployment to a Deadly Emergency Outbreak: The Case of Sierra Leone during Ebola Outbreak 2015

Background: The WHO has standard operating procedures for procurement, travel and logistics for use at country level. Some of the guidance is waived during public health emergencies of international concern. Practical acumen on using the standards for emergency settings is limited at country level. WHO Zambia was one of the countries that responded to the call by WHO HQ to support the 2014 Ebola outbreak in West Africa. This paper aims to document lessons learnt by procurement staffs that were deployed to emergency settings.Methods: Desk review of documents on procurement during emergency settings, terms of reference of the mission, materials on prevention of getting infected by Ebola and general rules governing international deployment were analysed. The staff member was deployed for the duration of eight weeks in 2015 from where experiences gained were reviewed and systematically recorded.Results: Deployment and exposure to an emergency setting was the first such experience to WCO Zambia staff. During the Ebola outbreak in Sierra Leone there was the “no touch person” practice from inherent profound fear of contracting the deadly disease. While the job description was similar with what was prevailing in nonemergency setting in Zambia, the quantities and implementation speed on assignments on average were more than ten times on emergencies. In that environment the procedure for procurement involved Invitation to Bid and Request for Proposal to interested parties occurring at the same time which is done differently from normal situations where there is first a request for quotations and procurement committee deliberate before making selection. In the Ebola set-up, there is a waiver of the competitive bidding requirements.Discussion: The exposure of WCO staff to emergency setting allowed WCO staff to be more knowledgeable about preparation and award contract using additional procurement methods in compliance with WHO policies as adopted for emergencies.Conclusion: Secondment of staff to a setting of emergencies is beneficial to WCO staff in terms of capacity building and handling similar situations in future. Country Offices are encouraged in future to share human resources when situations dictate.

Management of endobronchial tumors.

Owing to the high morbidity and mortality rates related to airways obstruction, an effective management of endobronchial tumors is essential to improve survival and symptoms in these patients. As interventional pulmonology plays a major role in this context, the purpose of the present review is to focus on current evidence and indications of therapeutic bronchoscopy, in particular of ablative techniques. Several ablative techniques are currently available and include 'immediate' or 'delayed' procedures according to the expected time to restore airways patency. In case of critical lesions, it is mandatory to promptly restore ventilation through the immediate techniques, whereas the delayed approaches, with a prolonged effect, should be reserved for a nonemergency setting, according to clinical and prognostic factors. Recent data confirmed that almost every technique, in experienced hands, when the specific indications are met, is highly effective in restoring airways patency, with a valuable risk-benefits profile. Owing to the complex heterogeneity of different clinical settings, management of endobronchial tumors requires a multimodal approach to assess the best strategy. Despite the lack of high-quality prospective studies comparing the individual techniques or strategy, it is undisputed that therapeutic bronchoscopy should not be considered as a last resort, but rather as a key step of such multimodal management.

Epidemiology and Severity of Sports and Recreation Injuries Presenting to a Tertiary Adult Emergency Department

ABSTRACTObjective: This study aims to evaluate all sports and recreation injuries that present to an emergency department, identify the activity and injury patterns associated with hospital admission, and determine injuries that could be better treated in alternative care settings.Methods: This is a retrospective review of all sports injuries that presented to the emergency department of a high volume, urban, tertiary referral center from 1/1/2010 to 12/31/2011. These were identified by a sports term search algorithm applied to all emergency department records. The main outcome measured was hospital admission status after sports injury. Univariate and multivariate regression analysis was performed to identify risk factors for hospital admission in the sports injury population.Results: 1,101 of the 191,259 encounters (0.6%) had 1,210 sports injuries. 84 were admitted (7.6%). Basketball injuries were most prevalent (31.6%). All-terrain vehicle (ATV) related injuries was most often admitted (46.4%). Logistic regression identified ATV riding (95% CI 6.15–23.37, p < 0.001) and age over 50 years-old (4.09–17.40, p < 0.001) as independent risk factors for admission while basketball (0.101–0.985, p = 0.047) and black race (0.17–0.77, p = 0.008) were independently protective. Isolated sprains/strains and soft tissue injuries (4/649, 0.6%) rarely required admission.Conclusions: The 7.6% admission rate is higher than previously reported, likely because the study institution is a tertiary referral center. ATV riding is associated with higher severity injuries that are more likely to require hospital admission. Most sports injuries that present to an emergency department, specifically isolated soft tissue injuries of the extremities, may be more efficiently treated in a non-emergent setting.

Crisis parainfecciosas: estudio retrospectivo multicéntrico

IntroductionPara-infectious seizures are afebrile seizures that are associated with mild infections, and occur in children with no pre-existing neurological illness. They are still little known in our environment. MethodsA multicentre retrospective study was conducted that included patients with normal psychomotor development and had presented with one or more seizures in the context of a mild afebrile infection. ResultsA total of 38 patients (47% male, 53% female) were included in the study over a period of three years (2012-2015). The mean age was 2.1 years. A previous history of febrile seizures was found in 7.9% of them. Mean number of seizures per patient was 2.2, with 57.9% of them being tonic-clonic seizures. The mean duration of seizures was 3.2minutes. An EEG was performed during admission in 73.7% of cases. Lumbar punctures were performed in 34.2% of cases. All were normal. Neuroimaging tests were carried out in 36.9% of cases. Brain MRI was the imaging test performed in most cases (21.1%), with no any pathological findings. The most frequent infection found was acute gastroenteritis (68%), followed by upper respiratory tract infection (32%). Almost two-thirds (63.2%) of patients did not require anticonvulsant medication. Rectal diazepam was the most frequently used drug in emergencies. Intravenous medication was required by 28.9% of patients due to repeated seizures. The most frequently used drug in the non-emergency setting was valproic acid. Anticonvulsant treatment was continued after discharge in 16% of patients. Para-infectious seizures was the diagnosis in 76.3% of cases when discharged. ConclusionsKnowledge of para-infectious seizures, their clinical diagnosis and benign course is crucial, as this would avoid further testing and unnecessary treatments.

Handwashing promotion in humanitarian emergencies: strategies and challenges according to experts

Diarrhea and acute respiratory infections account for nearly 30% of deaths among children displaced by humanitarian emergencies. Handwashing with soap reduces the risk of diarrhea and acute respiratory infection in non-emergency settings. However, the practice and the effectiveness of handwashing promotion efforts and the health benefits are not well documented in emergency settings. We conducted key informant interviews with 12 experts working in water, sanitation, and hygiene and examined current approaches, challenges, and knowledge gaps in relation to handwashing promotion in emergency settings. We identified many constraints to implementing effective handwashing promotion efforts including a failure to define objectives and targets for improvements in handwashing rates, lack of technical expertise and attention to the development and implementation of effective behavior change communication approaches, and limited understanding of the appropriateness, use, and acceptability of different handwashing hardware. Respondents identified multiple knowledge gaps and research needs that could improve current efforts. Collaborations between response agencies and research institutions could generate high quality data and facilitate contextualized and potentially more effective and robust handwashing promotion strategies.

Use of Community Assessments for Public Health Emergency Response (CASPERs) to Rapidly Assess Public Health Issues - United States, 2003-2012.

Community Assessment for Public Health Emergency Response (CASPER) is an epidemiologic technique designed to provide quick, inexpensive, accurate, and reliable household-based public health information about a community's emergency response needs. The Health Studies Branch at the Centers for Disease Control and Prevention (CDC) provides in-field assistance and technical support to state, local, tribal, and territorial (SLTT) health departments in conducting CASPERs during a disaster response and in non-emergency settings. Data from CASPERs conducted from 2003 through 2012 were reviewed to describe uses of CASPER, ascertain strengths of the CASPER methodology, and highlight significant findings. Through an assessment of the CDC's CASPER metadatabase, all CASPERs that involved CDC support performed in US states and territories from 2003 through 2012 were reviewed and compared descriptively for differences in geographic distribution, sampling methodology, mapping tool, assessment settings, and result and action taken by decision makers. For the study period, 53 CASPERs were conducted in 13 states and one US territory. Among the 53 CASPERS, 38 (71.6%) used the traditional 2-stage cluster sampling methodology, 10 (18.8%) used a 3-stage cluster sampling, and two (3.7%) used a simple random sampling methodology. Among the CASPERs, 37 (69.9%) were conducted in response to specific natural or human-induced disasters, including 14 (37.8%) for hurricanes. The remaining 16 (30.1%) CASPERS were conducted in non-disaster settings to assess household preparedness levels or potential effects of a proposed plan or program. The most common recommendations resulting from a disaster-related CASPER were to educate the community on available resources (27; 72.9%) and provide services (18; 48.6%) such as debris removals and refills of medications. In preparedness CASPERs, the most common recommendations were to educate the community in disaster preparedness (5; 31.2%) and to revise or improve preparedness plans (5; 31.2%). Twenty-five (47.1%) CASPERs documented on the report or publications the public health action has taken based on the result or recommendations. Findings from 27 (50.9%) of the CASPERs conducted with CDC assistance were published in peer-reviewed journals or elsewhere. The number of CASPERs conducted with CDC assistance has increased and diversified over the past decade. The CASPERs' results and recommendations supported the public health decisions that benefitted the community. Overall, the findings suggest that the CASPER is a useful tool for collecting household-level disaster preparedness and response data and generating information to support public health action.