Outpatient Management Of Patients Research Articles

Effect of Dexamethasone in Acute Laryngotracheitis

Fifty eight patients between the ages of six months and five years were studied in a randomized double-blind trial to determine whether dexamethasone has a role in the outpatient management of patients with acute viral croup of moderate severity. For various reasons, twelve were excluded from the final results. In the 46 patients who completed the study (32 males, 14 females) the only significant differences detected between the treatment groups were that the duration ofrhinorrhea was longer in the dexamethasone group compared with placebo (median 2,5 days vs 1,5 day) and the pre-discharge croup score was higher in the dexamethasone group compared with placebo (2 vs 0). Conclusion: The use of dexamethasone in the outpatient management of viral croup is associated with a reduction in the severity of illness within 24 hours of treatment. Patients with viral croup of moderate severity should be considered candidates for the use of dexamethasone before discharge from the paediatric emergency clinic.

Interpretation and Application of Stored Electrograms

Detailed recordings of the electrical events surrounding delivered or aborted implantable cardioverter de~brillator (ICD) therapy has improved dramatically our outpatient management of patients with complex ventricular arrhythmias. Current generation ICDs offer an array of diagnostic storage features including electrogram recordings from ventricular, and more recently, atrial leads. Review of stored electrograms allows the clinician to: (1) retrospectively identify the rhythm diagnosis that prompted device therapy, (2) recognize problems with overand undersensing and lead integrity and (3) gain insights into the triggers of ventricular tachycardia (VT) and mechanisms of sudden cardiac death.

Clarithromycin in the management of community-acquired pneumonia

Objective To review the epidemiology and diagnosis of community-acquired pneumonia (CAP) and examine factors that influence the choice of empiric antimicrobial therapy. Background CAP remains a common disease with substantial associated morbidity and mortality. Outpatient management of patients with CAP has become increasingly complex because of the availability of newer antimicrobial agents, evolving patterns of resistance, and the increasing recognition of atypical pathogens. Although Streptococcus pneumoniae remains a commonly encountered pathogen, the development and increasing prevalence of antibiotic resistance has become an area of concern, especially in outpatients. The newer macrolide antimicrobial drugs—clarithromycin and azithromycin—are effective against commonly encountered pathogens, are well tolerated, and have an established tolerability profile, although the low serum levels achieved by azithromycin hinder its use in patients with suspected bacteremia. Methods A MEDLINE ® search was performed of English-language articles published from 1990 to 2000 on the treatment of CAP. This article reviews the treatment of CAP, with emphasis on the use of clarithromycin. Conclusion Although laboratory surveillance studies have reported macrolide-resistant S pneumoniae, recent evidence defining the mechanism of this resistance, coupled with the pharmacokinetic properties of the macrolide agents, suggests that the actual rate of clinical macrolide resistance is low.

Outpatient Management of Patients with Ten to Twenty-five Percent Burns

Outpatient Management of Patients with Ten to Twenty-five Percent Burns

Replacing Inpatient Care by Outpatient Care in the Treatment of Deep Venous Thrombosis – An Economic Evaluation

Two clinical trials in patients with acute deep venous thrombosis have indicated that the outpatient management with fixed-dose, subcutaneous low-molecular-weight heparin is at least as effective and safe as inpatient treatment with unfractionated intravenous heparin with respect to recurrent venous thromboembolism and major bleeding. We performed an economic evaluation alongside one of these trials to assess the cost consequences of the outpatient management strategy. Data were collected through case record forms, complemented by a prospective questionnaire in 78 consecutive patients, interviews with health care providers, and hospital data bases. Our study demonstrated that seventy-five percent of patients allocated to low-molecular-weight heparin received treatment either entirely at home or after a brief hospital stay. Fifteen percent of these patients required professional domiciliary care. Within-centre comparisons of resource utilisation in terms of natural units showed that outpatient management with low-molecular-weight heparin reduced the average number of hospital days in the initial treatment period in nine centres by 59 percent (95% CI: 43 to 71 percent) accompanied by a limited increase in outpatient and professional domiciliary care. The average reduction in hospital days at the end of follow up was 40 percent (95% CI: 25 to 54 percent). A cost-minimisation analysis, focusing on resource utilisation directly related to the treatment of deep venous thrombosis and associated costs in one centre demonstrated a cost reduction of 64 percent (95% CI: 56 to 72 percent) with the outpatient management with low-molecular-weight heparin. These data suggest that outpatient management of patients with proximal venous thrombosis using low-molecular-weight heparin reduces resource utilisation and total treatment cost. Implementation should be preceded by a cautious evaluation of a potential cost shifting and organisational prerequisites.

Outpatient management of patients with large multinodular goitres treated with fractionated radioiodine.

The efficacy of fractionated out-patient radioiodine therapy in 38 patients with compressive symptoms due to long-standing large multinodular goitres was assessed. The diagnosis was established by clinical assessment in addition to technetium-99m pertechnetate thyroid scan or computed tomography scan of the thyroid and mediastinum. Oral iodine-131 therapy was administered as a 2.22 GBq (60 mCi) cumulative dose over 4 months (555 MBq per month). All patients were monitored with serum thyroid-stimulating hormone and free thyroxine (+/- free tri-iodothyronine) assays before the treatment and after each dose fraction. Clinical and biochemical follow-up was performed on all patients and ranged from 6 to 45 months after therapy. The patients consisted of 35 female and three male patients with a median age of 59 years (range 37-87 years). Prior to treatment 20 patients were biochemically hyperthyroid and 18 were euthyroid. Overall, 71% of patients reported a subjective improvement in compressive symptoms and 29% reported no change. Clinically assessed reduction in goitre size occurred in 92% of patients while there was no change in 8%. At 3 months of follow-up, 31% of patients had become hypothyroid and at 18 months 66% were hypothyroid. Seven hyperthyroid patients (35%) became euthyroid and 13 hyperthyroid patients (65%) became hypothyroid. Three patients who became hypothyroid experienced neck soreness (transient in one patient, persistent in two patients). There were no differences in outcome between patients who were hyperthyroid and those who were euthyroid prior to treatment. Fractionated out-patient radioiodine therapy showed excellent short- and medium-term safety, was very well tolerated and offered a satisfactory alternative treatment to surgery.

Use of Dexamethasone in the Outpatient Management of Acute Laryngotracheitis

Recent studies have demonstrated that a single intramuscular injection of dexamethasone (0.6 mg/kg) shortens the duration and severity of illness in hospitalized patients with acute viral laryngotracheitis (croup). Our objective was to determine if dexamethasone has a role in the outpatient management of patients with acute viral croup of moderate severity. Patients, 6 months to 5 years of age, who came to the emergency department (ED) with acute viral croup, a croup score of at least 2 (range 0 to 17), and a disposition of discharge were randomized in a double-blind fashion to receive a single intramuscular injection of dexamethasone, 0.6 mg/kg, or an equal volume of normal saline before discharge from the ED. Patients were excluded if they had any structural abnormalities, had received any steroids in the preceding 24 hours, or if they required beta-agonist therapy, more than one racemic epinephrine treatment, or hospitalization. Patients were followed up by telephone 24 hours and 7 to 10 days after discharge to determine whether additional medical attention was sought for perceived lack of improvement or worsening of symptoms. Secondary outcome included the parents' perception of how the child was doing at 24 hours, based on a 4-point ordinal scale: worse (1), same (2), improved (3), symptoms resolved (4), and the number of days it took for complete recovery. Of the 38 patients comprising the study group, 19 received dexamethasone. The median age was 19 months (range 6 to 66 months), and median pretreatment croup score was 3 (range 2 to 5) for both groups. The number of patients requiring racemic epinephrine was similar in both groups. Five patients sought additional medical attention within 48 hours. Four of the five patients had received placebo (21% of the placebo group) and one had received dexamethasone (5% of the steroid group) (not statistically significant). At the 24-hour telephone follow-up, significantly more patients in the dexamethasone group had a score consistent with improvement compared with placebo (84% vs 42%, P = .003). There was no difference in the number of days for symptoms to completely resolve between the two groups. The use of dexamethasone in the outpatient management of viral croup was associated with a reduction in severity of illness within 24 hours after treatment. Patients with viral croup of moderate severity should be considered as candidates for the use of dexamethasone before discharge from the ED.

Use of Terbutaline Sulfate in a Subcutaneous Infusion

The subcutaneous infusion of terbutaline sulfate (Brethine) by an external, portable pump offers an innovative new approach for treating preterm labor. Care of women receiving this therapy modality requires a basic understanding of the pump and its function. Researchers indicate pump tocolysis has numerous advantages over oral tocolysis: daily medication doses are lower, causing fewer side effects; onset of the medication is faster, resulting in the ability to control contractions before cervical changes occur; there is improved patient compliance; and there are higher pregnancy prolongation rates. Successful use of the pump requires in-depth education of the patient and her family. Home support and follow-up are also critical to the success of outpatient management of patients being treated with pump tocolysis.

The Efficacy of Atenolol in the Outpatient Management of the Alcohol Withdrawal Syndrome

We conducted a randomized, double-blind, clinical trial of atenolol compared with placebo in the outpatient management of patients with the alcohol withdrawal syndrome. In addition to receiving customary therapy, 88 patients were randomly assigned to receive atenolol and 92 to receive placebo. Outcome during the next 14 days was assessed using two main measures: the patient's clinical course as assessed by an alcohol withdrawal severity index; and the occurrence of treatment failure (composite measure including return to drinking, dropouts, and withdrawal lasting longer than 5 days). In addition, levels of craving for alcohol were assessed as an associated response variable. Overall, treatment failure occurred for 37% of the patients receiving atenolol and 52% of those receiving placebo. Among patients who had withdrawal symptoms at baseline, vital signs became normal more rapidly in the patients receiving atenolol, and their abnormal behavioral characteristics also resolved more rapidly. Levels of craving for alcohol were strongly associated with treatment failure; the group of patients who received atenolol included significantly fewer who reported high levels of craving 24 hours after treatment began (7% of patients receiving atenolol and 20% of those receiving placebo). We conclude that the outpatient management and treatment outcomes of the alcohol withdrawal syndrome are improved in patients who receive atenolol, and that the beneficial effects are associated with reduced levels of craving for alcohol. If these results are confirmed by other investigators, atenolol may prove to play an important role in the outpatient management of the alcohol withdrawal syndrome.

Pneumothorax

Annals of Emergency Medicine collaborated with an educational Web site, Academic Life in Emergency Medicine (ALiEM) to host a public discussion featuring the 2014 Annals article on the outpatient management of patients with a spontaneous pneumothorax by using pigtail catheters. The objective was to curate a 14-day (November 10 to 23, 2014) worldwide academic dialogue among clinicians about the article. Four online facilitators hosted the multimodal discussion on the ALiEM Web site, Twitter, and Google Hangout. Comments across the social media platforms were curated for this report, as framed by 4 preselected questions. Engagement was tracked through Web analytic tools. Blog comments, tweets, and video expert commentary involving the featured article are summarized and reported. The dialogue resulted in 1,023 page views from 347 cities in 49 countries on the ALiEM Web site, 279,027 Twitter impressions, and 88 views of the video interview with experts. This Global Emergency Medicine Journal Club created a virtual community of practice from around the world and identified common themes around the management of spontaneous pneumothorax, which included substantial practice variation in regard to inpatient versus outpatient management, location of chest tube, the use of aspiration, and chest radiography after placement.

MULTICENTRE TRIAL OF PHYSIOTHERAPY IN THE MANAGEMENT OF SCIATIC SYMPTOMS

Four treatments for sciatic symptoms— traction, exercises, manipulation, and corset -were assessed in a randomised controlled trial in 322 outpatients. The design was factorial. There were thus sixteen treatment groups, enabling a comparison of combinations of methods as well as of individual methods. Treatment lasted for four weeks. Patients were reviewed at the end of this period and at four and sixteen months after entry to the trial. Progress was measured by the patient's account of symptomatic improvement or deterioration and by return to work or normal activities. At four weeks each of the treatments was associated with a small degree of benefit over and above the high rate of spontaneous improvement. For manipulation, the benefit was statistically significant on one of the scales used to measure progress. There was a significant increase in symptomatic improvement with increasing numbers of treatments used in combination. This was complemented by a clear tendency for those who had received fewer types of treatment during the trial to have further treatment in the ensuing three months. There were no beneficial effects of treatment detectable at four or sixteen months. In the short-term, active physiotherapy with several treatments appears to be of value in the outpatient management of patients with sciatic symptoms, but it does not seem to confer any longer-term benefit.

Verapamil in the management of hypertensive patients.

The hypotensive action of verapamil given orally was assessed in the outpatient management of patients with raised blood pressure, in a single blind study. Twenty-six hypertensive patients on no therapy, 14 on beta blockers and eight on methyldopa were more satisfactorily controlled when verapamil was substituted for the initial drug. There was a marked reduction in the number of side-effects, and the drug was given in many situations where beta blockade was contra-indicated.