Requiring Emergency Hospitalization Research Articles

Jewellery- and ornament-related injuries in children and adolescents.

Unintentional injuries are the leading cause of mortality and morbidity in children and teenagers in Canada. Few publications have addressed injuries caused by jewellery and ornaments in children. To examine the mechanisms and the incidence of injuries caused by jewellery and ornaments in children and teenagers, to identify children at high risk for these type of injuries and to recommend specific injury prevention strategies. Data were analyzed from a Canadian database (Canadian Hospitals Injury Reporting and Prevention Program) of a tertiary paediatric centre. All patients between zero and 18 years of age who were diagnosed in the emergency department with jewellery- and ornament-related injuries during a 10-year period (1997 to 2006) were identified. Patients were categorized according to six age groups (younger than one year of age; one to two years of age; two to four years of age; five to nine years of age; 10 to 14 years of age, and 15 to 18 years of age). For each case, the context and the mechanism of injury were investigated. From a total of 150,771 reported injury cases, 380 (0.25%) were jewellery related. Unlike with most trauma, girls predominate in this kind of injury (n=288; 75.8% of cases). Over one-half of cases (58.1%) were reported for children four years of age or younger. Emergency physicians reported the presence of jewellery as a foreign body in a natural orifice (mouth, nose, ear or genitourinary tract) in 308 cases (81%). No case of intestinal obstruction, strangulation or death was reported. Eleven cases (2.9%) required emergency hospitalization, all for endoscopic evaluation of a foreign body in the airway or in the digestive tract. In the adolescent group, five cases of injuries secondary to piercing were reported. The present study demonstrates that, although jewellery-related injuries are relatively infrequent, some can cause severe injuries that could compromise patients' health. As a primary prevention strategy, doctors and health professionals working with children should make parents and caregivers aware of the possibility of trauma in children wearing or playing with jewellery, especially in the zero- to four-year-old group requiring closer supervision. Specific anticipatory guidance concerning piercing may be helpful to adolescents.

Selection of first-line i.v. antibiotics for acute pyelonephritis in patients requiring emergency hospital admission

Febrile urinary tract infections (UTIs) often require the intravenous infusion of antibiotics and/or hospitalization. Acute pyelonephritis (AP) is one of the most severe forms of UTI, and the antibiotics we should use as the first line and the risk factors for treatment failure remain controversial. The objective of this study was to investigate the efficacy of i.v. antibiotics selected for the treatment of febrile AP and to examine the risk factors for antibiotic resistance. We set risk factors for antibiotic treatment failure such as age, sex, and the presence of underlying urinary tract disease. We classified all cases into 49 cases of complicated AP and 24 cases of uncomplicated AP according to the presence of underlying urinary tract diseases, and examined the characteristics of the patients and the efficacy of the antibiotics used in this study. We investigated risk factors which relate to initial treatment failure and the duration of antibiotic treatment. Initial antibiotic treatment failure was significantly correlated to C-reactive protein in complicated AP and to positive blood culture in uncomplicated AP. We revealed a significant correlation between the duration of the given antibiotics and diabetes mellitus or positive blood culture in uncomplicated AP, and tazobactam/piperacillin was significantly related to prolongation of antibiotic treatment in complicated AP. In conclusion, in this study, a positive blood culture was the representative risk factor that related to both initial treatment failure and longer duration of the given antibiotics in uncomplicated AP.

Case history: Individualized homeopathy and severe chronic idiopathic neutropenia (SCN)

Severe chronic neutropenia (SCN) places the sufferer at increased risk of bacterial infection, often requiring emergency hospital admission and long-term antibiotic treatment. A single clinical case study of idiopathic SCN in a boy of 3 years and 8 months at the start of treatment individualized, classical homeopathic treatment was given. Neutrophil count was measured at: 5, 17, 21, 29 and 41 months after commencing treatment. Low neutrophil count (0.6 and 0.3 x 10(9)/L) was documented for 17 months prior to commencing treatment. After 17 months of individualized homeopathy, neutrophil count was 1.74, rising to 2.22 at 21 and 3.4 at 29 months treatment. Forty-one months after commencing treatment neutrophil count was 3.8 with an intermediate peak of 9 recorded during the year. As the child found the procedure distressing, blood testing was then discontinued by the parents. The child received no other treatment, including complementary medicine or antibiotics, while receiving homeopathic treatment. Individualized homeopathic intervention may be the catalyst for the resolution of idiopathic SCN in this case. However, as this was a single case, a controlled study is recommended as a next step.

Clinical outcomes and prognostic factor for acute heart failure in nonagenarians: Impact of hypoalbuminemia on mortality

In the current aging society, acute heart failure (AHF) is one of the leading causes of hospitalization due to the increased number of older individuals, and the prevalence of HF is increasing, raising a major public health concern in industrialized countries [1,2]. In addition, HF is one of themost important causes of death in elderly patients. The 5year-survival rate after the first admission for HF was reportedly worse than for that for cancer [3]. On the other hand, recent advances in technology and development of medical therapies have improved mortality in heart disease, and their effect include expanding an opportunity for therapy even among very elderly patients. However, the situation in very elderly population, over 90 years of age with heart disease is unclear, and few data are available on outcome and mortality in nonagenarians with HF. The aim of the present of study was to investigate the clinical features of AHF in nonagenarians, and identify prognostic factors by using routine non-invasivemethods and examinations. A retrospective observational review of 146 consecutive patients aged 90 years and older who were admitted to our institution during the period from January 2006 to December 2008 with a diagnosis of AHF was conducted. AHF was defined as new onset decompensated HF or worsening of chronic HF requiring emergency hospitalization. Patients whose course was complicated by acute coronary syndrome and severe renal failure were also included. Clinical records including medical history, co-morbidities, demographic data, and the results of examinations at the time of hospital admission, were retrospectively reviewed. Total mortality was evaluated during the follow-up period, and prognostic factors identified. The study protocol was approved by our institutional review board. Continuous variables were expressed as means±standard deviation, and categorical variables as numbers and proportions. The patients were divided into a survival group and a non-survival group, and characteristics and examination results are compared by Cox proportional hazards regression analysis. The factors with p values b0.10 in univariate analysis were entered in the multivariate Cox proportional hazards regression model to identify independent predictive factors for mortality. Based on the obtained independent predictor, a receiver operating characteristics (ROC) curve was plotted, and cut-off point for ROC curve factor was determined. The

Rationale and design of China intensive lipid lowering with statins in acute coronary syndrome: The CHILLAS study

Current guidelines recommended intensive low-density lipoprotein cholesterol lowering with statins, aiming at the target of 70 mg/dL (1.81 mmol/L) of low-density lipoprotein cholesterol for those with very high risk of coronary artery events. However, there is no multicenter study assessing the effect of intensive lipid lowering therapy with statins on acute coronary syndrome (ACS) in Chinese population. An open-label multicenter study is planned to evaluate whether intensive treatment with statins for 2 to 5 years results in more reduction of cardiovascular events in patients with ACS compared to the standard statin therapy. A total of 1,600 patients will be randomly assigned to receive intensive statin therapy (atorvastatin, 20 or 40 mg/d, or equivalent dose of other statins) or standard statin therapy (atorvastatin, 10 mg/d, or equivalent dose of other statins). Both groups will receive dietary counseling. Over the follow-up period, the primary outcome measure is the time to occurrence of cardiac death, nonfatal acute myocardial infarction, revascularization with either percutaneous coronary intervention or coronary-artery bypass grafting, documented unstable angina or severe heart failure requiring emergency hospitalization, and stroke. The planned duration for enrollment is between December 2006 and December 2009. The CHILLAS study will be the first multicenter study in a Chinese population using a patient-level analysis to compare the effects and safety of intensive statin therapy with that of standard-dose statin therapy, which may provide new evidence and therapeutic standards for the treatment of ACS.

Répétition d’accident à l’adolescence : étude prospective de l’échelle d’évaluation des circonstances de l’accident et du risque de récidive (ECARR)

A study of the predictive validation of a rating scale called scale for the evaluation of the circumstances surrounding an accident and of the risk of recidivism (ECARR). A study was carried out on a population of 350 young 12 to 20 year old accident victims in Poitiers’ and Châtellerault's accident and emergency departments from November 2007 to July 2008. The sociodemographic features and psychological profiles of this population of accident victim adolescents are presented in these first results. Conclusion: a majority of adolescent boys are observed; one out of two have sleeping disorders and seem to suffer from difficulties of a psychoaffective nature; 45% of the boys and 27.5% of the girls regularly consume products, presenting behaviour of an excessive nature amongst 35% of the boys and 17% of the girls; almost four adolescents out of five claim to have been involved in at least one accident beforehand requiring emergency hospital care, occurring predominantly in the two years prior to the accident justifying inclusion in the study. The “ECARR” scale could therefore enable adolescents from the accident and emergency department, at risk from accident recidivism and in psychological distress, to benefit from adapted therapeutic help so avoiding a repetition, which may prove to be more harmful at a somatic level.

Frequency of traumatic lesions alleged by victims of assault during police custody

A retrospective study was undertaken to determine the frequency of traumatic lesions found in individuals alleging police brutality during official custody in the département of Hauts-de-Seine, located in the west suburbs of Paris. All medical certificates relating to the examination of 11,653 individuals detained during the year 2004 were analysed. From this population, there were 119 cases where victimized individuals alleged police assault and 245 revealed aggressive police manhandling, as indicated by traces of tight handcuffs. Among the individuals alleging police violence, most of them showed recent traumatic lesions ( n = 91). The majority of lesions were superficial contusions frequently located in the cervico-cephalic area. All traumatic lesions were compatible with the allegations of police assault. Neurological complications secondary to the application of handcuffs were encountered in less than 2% of the cases. Although no death was recorded in police custody during the period of the study, approximately 5% of the population that had encountered some form of police violence was found to require emergency hospitalization.

Serial NT-proBNP monitoring and outcomes in outpatients with decompensation of heart failure

Background NT-proBNP is useful for heart failure (HF) diagnosis and prognosis. We examined the value of serial NT-proBNP monitoring to predict outcomes in decompensated HF patients attending a structured HF clinic. Methods Patients with decompensation of established optimally treated HF, not requiring emergency hospital admission, were enrolled in the study. Patients received intensive follow-up weekly during 4 weeks and at 3 months in specialist HF clinics. Serial NT-proBNP concentrations were measured at each visit. Primary endpoint was cardiovascular death and hospital admission for HF at 3 months. Results Fifty-nine patients were enrolled (60 ± 14 years, LVEF 27 ± 9%) and 39% had a primary endpoint during follow-up. Baseline NT-proBNP concentration (in ng/L) was 7050 ± 6620, and did not differ significantly in patients with and without events ( p = 0.22). Patients without events showed marked NT-proBNP reduction at week-1 (30% reduction), week-2 (36% reduction), week-3 (34% reduction) and week-4 (37% reduction). By contrast, patients with events showed no significant NT-proBNP reduction during follow-up. Using a general linear model, the relative NT-proBNP reductions (%) at weeks 1–4 were predictors of adverse events ( p = 0.004, p < 0.001, p = 0.001 and p = 0.03, respectively). In a stepwise multiple Cox regression analysis, NT-proBNP relative reduction (in %) at week 2 was a strong predictor of no events during follow-up (OR 0.79, 95% CI 0.70–0.88, p < 0.001). Conclusions Serial NT-proBNP monitoring in decompensated HF patients seen in a structured in-hospital HF clinic predicts cardiovascular events during follow-up. NT-proBNP may be useful in an outpatient basis to identify patients at high risk needing more aggressive therapy.

Alcohol intoxication in children and adolescents requiring emergency hospital admission in 20 major children's hospitals in Germany between 2000–2002

Alcohol intoxication in children and adolescents requiring emergency hospital admission in 20 major children's hospitals in Germany between 2000–2002

Alcohol intoxication in children and adolescents requiring emergency hospital admission in 20 major children's hospitals in Germany between 2000–2002

Alcohol intoxication in children and adolescents requiring emergency hospital admission in 20 major children's hospitals in Germany between 2000–2002

Protocols for Pediatric Poisonings from Nontoxic Substances

Most pediatric poisonings have favorable outcomes and are managed in the home by poison control centers utilizing protocols that deem products or substances as nontoxic. We sought to evaluate the validity of protocols for nontoxics. This is retrospective study in which poison control center case records within a statewide poison control center system during calendar year 2001 were searched for products or substances involved in a pediatric poisoning ingestion and identified in the poison control center nontoxic substance or product list. This was coupled with systematic literature search to ascertain if any significant medical outcomes were associated with ingestion of a nontoxic substance or product. During the 1-year study period, 20,900 pediatric ingestions involving 46 different nontoxic substances or products were analyzed for significant outcomes. Only 6 cases (0.03%) had a potentially serious clinical effect requiring emergency hospital management. The literature search revealed 2326 ingestion cases of nontoxic products from 635,000 citations in 50 different databases. Of these, 28 cases (1.2%) described an effect, although none was described as significant. Poisoning protocols for pediatric ingestions of substances or products we deemed as nontoxic were rarely associated with significant outcomes. However, non-dose-related potentially life-threatening effects are possible. Therefore, use of nontoxic protocols by other health care practitioners for telephone triage or by the public directly requires further study to be valid. Our study suggests that the term nontoxic is misleading and recommends that it be replaced with "minimally toxic" as a more appropriate term for identifying the lowest level of risk of toxicity from a substance or product.

Alcohol intoxication in children and adolescents requiring emergency hospital admission in 20 major children's hospitals in Germany between 2000-2002

Objective: Drug and alcohol (C2H5OH) abuse is an increasing problem in children and adolescents throughout the world. However, precise epidemiological data on acute C2H5OH intoxication in children and adolescents requiring hospital admission are rare (1, 2).

Antiplatelet Treatment with Aggressive Lipid Lowering Therapy and Reduction of Clinical Event after Ischemic Stroke.

The objective of the present study is to investigate the effects of anticoagulation and inhibition of platelet aggregation, which is strongly related with ischemic stroke, with aspirin 100 mg/once daily and clopidogrel 75 mg/once daily together with atorvastatin 80 mg/once daily then evaluating the event free survival in patients who had stroke with LDL-C > 130 mg/dl. An hypolipidaemic diet was given to every patient. As known statins other than reducing LDL-C (silent killer), has many other effects characterized by a wider and wider checklist: reduction of plasmatic levels of C-reactive protein, of MCP-1, and the monocyte traffic, of IL-6, TNF-alfa, of S-VCAM-1, of COX-2 and MMP-9, and upregulate the TPA, and downregulate the PAI-1, statins also reduce the expression of CD40 on the endothelial surface, thus augmenting the EPC (endothelial progenitor cells) involved in neo-vascularization of ischemic tissue, with a final protective effects over the vascular endothelium, including the plaque stabilization.We have studied 67 patients with a previous ischemic stroke aged between 58 and 72 years (25% smoker, 32% with hypertension, 14% with diabetes, 6% with obesity), with LDL-C higher than 130 mg/dl, evaluating in particular the lipidic profile (total cholesterol, HDL, LDL, TG, Lpa), fibrinogen and d-dimer for a total period of 36 months. We observed a clear reduction of lipidic parameters: Total-C <42%, LDL-C <46%, TG <30%, ApoB <35%, d-dimer <10%, and we did not observe any increase in transaminases, CPK, or fibrinogen.We observed 12 patients with relapsing clinical events requiring emergency hospitalization: 1 exitus for second stroke two months after the first event, 11 cases of RIND, with less than 4 transitory ischemic episodes, with the total length of events significantly reduced after the first 18 weeks of treatment. We have observed 22 adverse effects events: 4 cases of epistaxis, 2 case of tooth bleeding, 3 of abdominal pain, 9 of muscular pain, 2 of chest pain, 2 case of headache, however, these events did not influence the course of the pharmacological treatment; 55 patients did not refer any clinical problem, every patient has been followed on the basis of a three months period, and on demand.The present study has demonstrated a secure efficacy of the aggressive combined treatment (antiplatelet + statin) in the management of patients with a previous stroke, showing a symptomatologic benefit (reduction of the total ischemic events and of the emergencies) with an overall improvement of the quality of life.PARAMETERBEFOREAFTERTOTAL-C320.0 mg/dl180.0 mg/dlLDL-C148.0 mg/dl82.4 mg/dlHDL-C38.6 mg/dl44.2 mg/dlTG180.0 mg/dl108.2 mg/dlFIBRINOGEN460.0 mg/dl370.0 mg/dlFASTING GLUCOSE110.0 mg/dl96.0 mg/dl

Impact of an early pregnancy problem service on patient care and Emergency Department presentations

To examine the impact of a 'next day' outpatient clinic, the Early Pregnancy Problem Service, on patients presenting to the Emergency Department with pain or bleeding in the first trimester of pregnancy. This clinic was established in June 1996. This was a retrospective study involving patients presenting to the Emergency Department with pain or bleeding in early pregnancy. Data was collected from the Emergency Department Information System and the medical records and then compared over the same 2-month periods in different years. These were in, 1996 (preclinic), 1997, 2000 and 2003. The primary outcome was length of stay in the Emergency Department for women with first trimester pain or bleeding that did not require hospital admission. Secondary outcomes were the proportion of such patients presenting and re-presenting to the Emergency Department. Following establishment of the clinic there was a significant reduction in the median length of stay in the Emergency Department for patients who were discharged (136 mins in 1996 vs 107 mins in 2003; P < 0.001). There were non-significant reductions in the proportion of patients presenting to the Emergency Department (1.5% in 1996 vs 1.1% in 2003; P = 0.09) and the number re-presenting (16% in 1996 vs 7% in 2003; P = 0.15). Following the introduction of the Early Pregnancy Problem Service, women presenting with first trimester pain or bleeding who did not require emergency hospital admission spent significantly less time in the Emergency Department.

Human Heart-Type Fatty Acid-Binding Protein as an Early Diagnostic and Prognostic Marker in Acute Coronary Syndrome

Although heart-type fatty acid-binding protein (H-FABP) can be a marker of sarcolemmal injury due to acute myocardial ischemia, the diagnostic or prognostic value is not established in patients with acute chest pain. This multicenter prospective study aimed to determine the diagnostic and prognostic values of H-FABP in 133 patients presenting to an emergency room with suspected acute coronary syndrome (ACS) by comparing with those of conventional biomarkers. H-FABP and myoglobin had greater positive results than did creatine kinase-MB or troponin T. Receiver operating characteristics analysis revealed that H-FABP was the most reliable for detection of ACS and that H-FABP had the greatest sensitivities for identification of patients requiring emergency hospitalization, coronary angiography, and interventional therapy within 7 days among the biomarkers. Thus, H-FABP can be an early diagnostic and prognostic biochemical marker, particularly within the first 6 h from the onset of chest symptoms, in patients with chest pain at an emergency department.

Validation of the Crisis Triage Rating Scale for Psychiatric Emergencies

Using a sample of 500 emergency psychiatric patients at Victoria Hospital in London, Ontario, this study replicated part of the research on the Crisis Triage Rating Scale (CTRS) conducted by Bengelsdorf, Levy, Emerson and Barile in 1984. The relationship between the suggested CTRS cut-off score and the decision whether or not to hospitalize the patient was studied, independently of these scores. The relative contribution of each of the subscales (Dangerousness, Support System and Ability to Cooperate) to this decision was also determined. The results of this study suggest that using a cut-off score of 9, the easily administered Crisis Triage Rating Scale could be an additional assessment aid in determining whether patients require emergency hospital admission to a psychiatric unit.

“Bounces”: An analysis of short-term return visits to a public hospital emergency department

From July through September 1987, our emergency department registered 17,214 patients, of whom 569 (3%) returned within two days of initial registration. Cases were reviewed to identify factors associated with return visits. Patient-related factors were responsible for a majority of repeat visits (267 cases, 53%). Illness-related factors, particularly evolution of disease under close outpatient observation, prompted return in 68 cases (13%). An additional 60 patients (12%) returned with new problems unrelated to their initial presentation. Physician-related factors were the primary reason for return in 92 cases (18%). Problems with our public health-care system prompted return in 18 cases (4%). Eighty-seven returning patients (19%) required emergency hospitalization, including 28 discharged due to physician errors. Regular case review of short-term returns to the ED should be included in a comprehensive ED-based program of quality assurance.

Emergency department patient 'dumping': an analysis of interhospital transfers to the Regional Medical Center at Memphis, Tennessee.

To study the extent and nature of transfers of emergency department (ED) patients because of inability to pay, we audited all telephone requests and actual patient transfers from private hospital EDs and their affiliated free-standing emergency centers to the ED of the Regional Medical Center at Memphis (the Med), a publicly subsidized hospital, between June 1 and August 31, 1986. Transfers to the Med's "special care" centers were assumed to represent tertiary care referrals and were excluded. During the 92-day study interval, ED physicians at the Med handled 190 telephone requests for transfer. Requesting physicians explicitly identified "no money" or "no insurance" as the primary reason for transfer in 89 per cent of 164 cases in which these data were recorded. Thirty-seven per cent of requests were refused; half were too unstable or required an intensive care unit (ICU) bed when none were available. One hundred forty-six transfers (55 per cent) arrived without prior telephone authorization, most by private automobile. Almost all transferred patients (91 per cent) were sent for primarily economic reasons. One out of four was found to be unstable on arrival by explicit clinical criteria. Eighty-two patients transferred for economic reasons (34 per cent) required emergency hospitalization and accounted for 564 bed days during a period of extreme inpatient crowding. Three patients died prior to discharge. Two had been transferred for primarily economic reasons.

Can old people on oral anticoagulants be safely managed as out-patients?

Of 62 patients (mean age 75, range 65-92 years) referred to an out-patient anticoagulant clinic specifically for those aged 65 years or more, treatment was considered unsafe in only one patient and was discontinued. Minor bleeding which did not require a significant change in management was recorded on 25 (7%) of 381 clinic visits and one major haemorrhage occurred requiring emergency hospital admission. Anticoagulation was maintained within the therapeutic range on 284 (75%) visits. The results confirm that with appropriate out-patient care and supervision, the risks of oral anticoagulant therapy in the elderly need be no greater than in younger patients.

A system of alias assignment for unidentified patients requiring emergency hospital admission.

Many patients are admitted to emergency facilities without positive identification. In the past, these patients were usually assigned a temporary alias name (i.e., John Doe, Jane Doe) which was then changed after positive identification. We have discerned several problems with this procedure and have subsequently developed a coordinated system of alias identification in our hospital. This system allows for: a large pool of distinct alias identities, pre-assignment of hospital numbers to unidentified patients before arrival, and a smooth administrative transition as records are changed from the alias to the true identity.