Time Of Initial Assessment Research Articles

Wound Healing Society 2015 update on guidelines for pressure ulcers.

Wound Healing Society 2015 update on guidelines for pressure ulcers.

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system.

OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.

Chronic effects of stroke on hip bone density and tibial morphology: a longitudinal study.

The study aimed to quantify the long-term effects of stroke on tibial bone morphology and hip bone density. Only the trabecular bone mineral density and bone strength index in the hemiparetic tibial distal epiphysis showed a significant decline among individuals who had sustained a stroke 12-24months ago. This study aims to determine the changes in bone density and morphology in lower limb long bones during a 1-year follow-up period and their relationship to muscle function in chronic stroke patients. Twenty-eight chronic stroke patients (12-166months after the acute stroke event at initial assessment) and 27 controls underwent bilateral scanning of the hip and tibia using dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, respectively. Each subject was re-assessed 1year after the initial assessment. Twenty stroke cases and 23 controls completed all assessments. At the end of the follow-up, the paretic tibial distal epiphysis suffered significant decline in trabecular bone density (-1.8 ± 0.6%, p = 0.006) and bone strength index (-2.7 ± 0.6%, p < 0.001). More severe decline in the former was associated with poorer leg muscle strength (ρ = 0.447, p = 0.048) and motor recovery (ρ = 0.489, p = 0.029) measured at initial assessment. The loss in trabecular bone density remained significant among those whose stroke onset was 12-24months ago (p < 0.001), but not among those whose stroke onset was beyond 24months ago (p > 0.05) at the time of initial assessment. The changes of outcomes in the tibial diaphysis, except for cortical bone mineral content on the non-paretic side (-1.3 ± 0.3%, p = 0.003), and hip bone density were well within the margin of error for precision. There is evidence of continuous trabecular bone loss in the paretic tibial distal epiphysis among chronic stroke patients, but it tends to plateau after 2years of stroke onset. The steady state may have been reached earlier in the hip and tibial diaphysis.

Persistence of Upper Blepharoptosis After Cosmetic Botulinum Toxin Type A.

Upper eyelid ptosis after cosmetic botulinum toxin is generally considered short-lived and responsive to apraclonidine ophthalmic drops. The authors present a series with persistent ptosis. To report a series of patients with persistent upper eyelid ptosis after cosmetic botulinum toxin. A retrospective case review series of 7 patients referred for management after developing visually significant upper eyelid ptosis after cosmetic botulinum toxin type A treatment. Patients in this series experienced persistent visually significant ptosis after cosmetic botulinum toxin lasting from 6 weeks to 13 months. Six of the 7 patients were treated with apraclonidine ophthalmic solution. Apraclonidine drops appeared to be clinically effective within 4 to 6 weeks of the resolution of ptosis. Upper eyelid ptosis after cosmetic botulinum toxin can persist for many months after treatment. Based on this series, the authors propose that apraclonidine drops can be used at the time of initial assessment to predict the relative longevity of ptosis after cosmetic botulinum toxin treatment (Level 4 evidence recommendation). After a 1-week trial, responders can be advised that ptosis is likely to resolve in 4 to 6 weeks. Nonresponders should be counseled that resolution may take longer than 6 weeks.

80.: Cardiac effects of high-dose fingolimod ingestion

Fingolimod is associated with first dose transient atrioventricular conduction defects mandating cardiac monitoring at initiation. This side effect is not seen with chronic use. Theoretically, overdose of fingolimod should not lead to cardiac side effects, but there are very few reports. We present a case and review the literature of fingolimod overdoses. We report an intentional overdose of 21 mg of fingolimod in a patient with relapsing remitting multiple sclerosis and depression. We retrospectively reviewed the clinical notes of our patient and searched for any similar reports in the literature. At the time of initial assessment and during the subsequent observation period of approximately 4 h, no cardiovascular symptoms, signs or atrioventricular conduction delay were noted. Though there has been a recent report of cardiac side effects noticed after intentional fingolimod overdose, in our patient no such side effects were observed. This highlights the relative safety of fingolimod and that the adverse effects can be variable. We expect further reports of effects of overdoses of this drug with more widespread use.

C-Reactive Protein and other Hematological parameters for diagnosis of Neonatal Sepsis

Background : Sepsis is one of the most common causes of morbidity and mortality in the newborn. Early diagnosis and treatment is vital to improve outcome. The present study was therefore carried out to determine the usefulness of C-reactive protein (CRP) for evaluation of neonatal sepsis in teaching hospital of central India. Method: 82 neonates with clinical suspicion of sepsis were prospectively studied over a 12 month period. Blood was obtained from each subject recruited for the qualitative estimation of CRP. Blood culture was used as gold standard for diagnosis of NNS. Results: Of 82 neonates studied, 67 (81.7%) had positive CRP while 58 (70.73%) had positive blood culture. The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of CRP were 81.7%, 88.0%, 95.7%, 59.5% and 83.2%. respectively. Conclusion : The qualitative method of estimating CRP which is cheap and rapid has moderate sensitivity, specificity and negative predictive value. It is a good diagnostic test and can identify the infection in neonates at the time of initial assessment.

A longer diagnostic interval is a risk for depression in amyotrophic lateral sclerosis

Recognizing depressive symptoms in patients with amyotrophic lateral sclerosis (ALS) remains problematic given the potential overlap with the normal psychological responses to a terminal illness. Understanding mental health and disease-related risk factors for depression is key to identifying psychological morbidity. The present study aimed to determine the prevalence of depressive symptoms in ALS and to explore mental health and disease-related risk factors for depression. Structured medical and psychiatric history questionnaires and a validated depression scale (Depression, Anxiety, Stress Scale-21) were completed by 27 ALS patients (60% female; 59% limb onset; age 65.11 ± SE 2.21) prior to their initial review at a multidisciplinary clinic. Physical function was assessed with the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R). At the time of initial assessment, 44% of patients had a previous psychiatric history, although the majority (62%) reported no symptoms of depression. The mean ALSFRS-R score was 37.78 ± SE 1.22, with an average diagnostic interval of 16.04 ± SE 2.39 months. Logistic regression analysis revealed that the length of the diagnostic interval alone predicted depressive symptoms (χ²(3, n = 26) = 9.21, Odds Ratio (OR) = 1.12, p < 0.05. The illness experiences of ALS patients rather than established mental health risk factors influence the manifestation of depressive symptoms in the early stages of the disease, with clinical implications for the assessment and treatment of psychological morbidity. Patients with lengthy diagnostic intervals may be prime targets for psychological assessment and intervention, especially in the absence of ALS-specific tests and biomarkers.

Dysphagia in head and neck cancer

Swallowing difficulties are among the most problematic outcomes associated with head and neck cancer (HNCA) and the strategies employed to treat it. With a rising incidence of human papilloma virus-associated HNCA, a larger number of patients are expected to survive their cancer, and therefore will be more susceptible to long-term treatment toxicities. Optimization of long-term swallowing outcomes is an important objective for those working with patients with HNCA. The role of the swallowing therapist in the management of patients with HNCA cannot be overstated. This begins with pretreatment evaluation of swallowing. At the time of initial assessment, education should be provided regarding treatment toxicities and the importance of prophylactic swallowing exercises and oral intake. Recent evidence suggests that maintaining an oral diet and engaging in swallowing exercise during radiation have a positive impact on diet level, swallowing physiology, patient-perceived swallowing-related quality of life, and reduced feeding tube use. Although treatment strategies such as radiation de-intensification and transoral surgical treatments show promise for reducing toxicities, evidence regarding their impact is still being amassed. Maintaining an oral diet and performing prophylactic swallowing exercises are currently the most evidence-based strategies for dysphagia prevention in HNCA.

Lithium treatment of chronic nail biting.

To the Editor: Nail biting or onychophagia has been variously described as a habit to release tension, self-mutilation behavior, or an impulse control disorder. In the DSM-5, nail biting is classified as an obsessive-compulsive and related disorder.1 Studies have found that between 28% and 33% of children between ages 7 and 10 years, 44% of adolescents, and 19%–29% of young adults engage in nail biting.2 Nail biting usually occurs in combination with other problematic body-focused repetitive behaviors such as hair pulling disorder and skin picking disorder. Nail biting in adults is underrecognized because patients often fail to seek help due to feelings of shame and embarrassment, and, consequently, the disorder has received little attention in the psychiatric literature. In most cases, nail biting seems to be only a cosmetic issue, and no treatment is required. But, in severe cases, untreated nail biting can result in a host of complications such as severe damage to the cuticles and nails, paronychia and secondary bacterial infection, dental problems, and temporomandibular dysfunction.3 Studies on drug treatment of nail biting are sparse and limited to antidepressants and N-acetylcysteine.4 We present a case of chronic, severe onychophagia comorbid with bipolar II disorder and substance use disorder and discuss the successful treatment of these disorders with lithium monotherapy. Case report. Ms A, a 28-year-old woman, was referred by her family physician for assessment and management of depression. She met DSM-5 criteria for bipolar II disorder and was noted to be in remission for substance use disorder (alcohol dependence and cocaine use). At the time of initial assessment, Ms A endorsed various symptoms of depression including thoughts of suicide. Due to concerns regarding her safety, lithium 900 mg daily was started, and the dose was optimized to achieve a serum level of 0.7 mmol/L. Within 2 months of lithium treatment, Ms A experienced remission of depression and has been symptom free for 2 years. A serendipitous finding was remission of symptoms of chronic nail biting that Ms A had struggled with since she was 12 years old. Various strategies including habit reversal training, self-monitoring, and competing response had been ineffective.5 The condition was severe because Ms A had to regularly cover the nail beds with Band-Aids to control the bleeding. Moreover, it affected her self-esteem and caused a great deal of emotional distress. The marked improvement following lithium treatment was noted by Ms A’s family and friends, who had not seen her undamaged nails in at least 15 years. Clomipramine and selective serotonin reuptake inhibitors are generally recommended in severe cases of nail biting, but the use of these drugs can cause treatment-emergent mania in individuals with bipolar disorder. Thus, the drug choice for onychophagia should be informed by the nature of the comorbid psychiatric disorder. There are reports of effectiveness of lithium in body-focused repetitive behaviors such as hair pulling disorder and skin picking disorder with comorbid bipolar disorder. It is not known if lithium is effective in patients with onychophagia in the absence of bipolar disorder. To our knowledge, this is the first reported case of lithium effectiveness in nail biting. Studies are needed to clarify the role of lithium in the management of severe nail biting in the absence of comorbid bipolar disorder.

Pre-Emptive Value of Methylprednisolone Intravenous Infusion in Patients With Vertebral Metastases. A Double-Blind Randomized Study

ContextThe vertebral column is the most common site of bone metastases irrespective of the primary tumor. Vertebral metastases are a major cause of motor deficit of the lower extremities. The use of radiotherapy is the treatment of choice in these patients. A temporary worsening of pain shortly during the course of palliative radiotherapy is clinically a common problem. Steroid infusion has well-documented neuroprotective effects. ObjectivesOur study objective is to evaluate the effect of pre-emptive infusion of methylprednisolone on pain flare and motor function in patients with vertebral metastases. MethodsOne hundred twenty patients with vertebral metastases received short-course external beam radiotherapy as high-voltage irradiation with a 6 MeV, via linear accelerator. In addition to the short-course radiotherapy, 60 patients received pre-emptive methylprednisolone infusion (5 mg/kg) the day just before initiation of radiotherapy (Group 1 [G1]). The other 60 patients received short-course radiotherapy without pretreatment methylprednisolone infusion, and only normal saline was infused (Group 2 [G2]). The Brief Pain Inventory, incidence of pain flare during radiotherapy, and motor functions were evaluated using the Tomita scale at the time of initial assessment, at the end of external beam radiotherapy, and after two weeks. ResultsFour patients (6.6%) in G1 experienced pain flare compared with 12 patients (20%) in G2 during the two-week short-course radiotherapy. The mean values of pain scores were significantly reduced in both groups at the end of radiotherapy; the mean value of worst, average, and current pain scores in G1 remained statistically significant in comparison to pretreatment and G2 mean values two weeks later. Significant increase was noticed in patients with normal motor and ambulatory status in G1 at two and four weeks of initial assessment. ConclusionPre-emptive methylprednisolone infusion is an effective prophylactic agent in the prevention of radiation-induced pain flare and improves functional motor status after short-term radiotherapy in patients with vertebral metastases.

SURVEY OF POTENTIAL DRUG INTERACTIONS IN ACUTE HOSPITAL INPATIENTS RECEIVING SPECIALIST PALLIATIVE CARE (SPC)

AimPolypharmacy is common in palliative care and is associated with an increased risk of potentially harmful drug interactions. In order to identify common interactions and explore the SPC approach to...

Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times

BackgroundInternationally, emergency departments are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction. The objective was to evaluate the addition of a MDRNSTAT (Physician (MD)-Nurse (RN) Supplementary Team At Triage) on emergency department patient flow and quality of care.MethodsPragmatic cluster randomized trial. From 131 weekday shifts (8:00–14:30) during a 26-week period, we randomized 65 days (3173 visits) to the intervention cluster with a MDRNSTAT presence, and 66 days (3163 visits) to the nurse-only triage control cluster. The primary outcome was emergency department length-of-stay (EDLOS) for patients managed and discharged only by the emergency department. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm.ResultsThe intervention’s median EDLOS for discharged, non-consulted, high acuity patients was 4:05 [95th% CI: 3:58 to 4:15] versus 4:29 [95th% CI: 4:19–4:38] during comparator shifts. The intervention’s median EDLOS for discharged, non-consulted, low acuity patients was 1:55 [95th% CI: 1:48 to 2:05] versus 2:08 [95th% CI: 2:02–2:14]. The intervention’s median physician initial assessment time was 0:55 [95th% CI: 0:53 to 0:58] versus 1:21 [95th% CI: 1:18 to 1:25]. The intervention’s left-without-being-seen rate was 1.5% versus 2.2% for the control (p = 0.06). The MDRNSTAT subgroup analysis resulted in significant decreases in median EDLOS for discharged, non-consulted high (4:01 [95th% CI: 3:43–4:16]) and low acuity patients (1:10 95th% CI: 0:58–1:19]), as well as physician initial assessment time (0:25 [95th% CI: 0:23–0:26]). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage.ConclusionsThe intervention reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients.Trial registration numberNCT00991471 ClinicalTrials.gov

Temporal Nodal Regression and Regional Control After Primary Radiation Therapy for N2-N3 Head-and-Neck Cancer Stratified by HPV Status

To compare the temporal lymph node (LN) regression and regional control (RC) after primary chemoradiation therapy/radiation therapy in human papillomavirus-related [HPV(+)] versus human papillomavirus-unrelated [HPV(-)] head-and-neck cancer (HNC). All cases of N2-N3 HNC treated with radiation therapy/chemoradiation therapy between 2003 and 2009 were reviewed. Human papillomavirus status was ascertained by p16 staining on all available oropharyngeal cancers. Larynx/hypopharynx cancers were considered HPV(-). Initial radiologic complete nodal response (CR) (≤1.0 cm 8-12 weeks after treatment), ultimate LN resolution, and RC were compared between HPV(+) and HPV(-) HNC. Multivariate analysis identified outcome predictors. A total of 257 HPV(+) and 236 HPV(-) HNCs were identified. The initial LN size was larger (mean, 2.9 cm vs 2.5 cm; P<.01) with a higher proportion of cystic LNs (38% vs 6%, P<.01) in HPV(+) versus HPV(-) HNC. CR was achieved is 125 HPV(+) HNCs (49%) and 129 HPV(-) HNCs (55%) (P=.18). The mean post treatment largest LN was 36% of the original size in the HPV(+) group and 41% in the HPV(-) group (P<.01). The actuarial LN resolution was similar in the HPV(+) and HPV(-) groups at 12 weeks (42% and 43%, respectively), but it was higher in the HPV(+) group than in the HPV(-) group at 36 weeks (90% vs 77%, P<.01). The median follow-up period was 3.6 years. The 3-year RC rate was higher in the HPV(-) CR cases versus non-CR cases (92% vs 63%, P<.01) but was not different in the HPV(+) CR cases versus non-CR cases (98% vs 92%, P=.14). On multivariate analysis, HPV(+) status predicted ultimate LN resolution (odds ratio, 1.4 [95% confidence interval, 1.1-1.7]; P<.01) and RC (hazard ratio, 0.3 [95% confidence interval 0.2-0.6]; P<.01). HPV(+) LNs involute more quickly than HPV(-) LNs but undergo a more prolonged process to eventual CR beyond the time of initial assessment at 8 to 12 weeks after treatment. Post radiation neck dissection is advisable for all non-CR HPV(-)/non-CR N3 HPV(+) cases, but it may be avoided for selected non-CR N2 HPV(+) cases with a significant LN involution if they can undergo continued imaging surveillance. The role of positron emission tomography for response assessment should be investigated.

Management of the paediatric patient with acute head trauma

Head trauma leading to brain injury is an important cause of morbidity and mortality in childhood. Injury severity is related to the mechanism of trauma, which itself varies with age. The vast majority of head trauma in paediatric patients is mild, requires no specific therapy and leaves no sequelae. However, it is important to identify individuals at risk of significant injury, and thus in need of specific evaluation. The purpose of this statement is to describe issues related to head trauma in infants, children and youth, including clinical manifestations, initial management priorities, guidelines for imaging, and subsequent observation and treatment. It addresses the evaluation of patients with acute trauma to the head at the time of initial assessment; it does not describe the subsequent management of such patients in the paediatric intensive care unit.

Polymorphisms in the glucocorticoid receptor co-chaperone FKBP5 predict persistent musculoskeletal pain after traumatic stress exposure

Individual vulnerability factors influencing the function of the hypothalamic-pituitary-adrenal axis may contribute to the risk of the development of persistent musculoskeletal pain after traumatic stress exposure. The objective of the study was to evaluate the association between polymorphisms in the gene encoding FK506 binding protein 51, FKBP5, a glucocorticoid receptor co-chaperone, and musculoskeletal pain severity 6weeks after 2 common trauma exposures. The study included data from 2 prospective emergency department-based cohorts: a discovery cohort (n=949) of European Americans experiencing motor vehicle collision and a replication cohort of adult European American women experiencing sexual assault (n=53). DNA was collected from trauma survivors at the time of initial assessment. Overall pain and neck pain 6weeks after trauma exposure were assessed using a 0–10 numeric rating scale. After adjustment for multiple comparisons, 6 FKBP5 polymorphisms showed significant association (minimum P<0.0001) with both overall and neck pain in the discovery cohort. The association of rs3800373, rs9380526, rs9394314, rs2817032, and rs2817040 with neck pain and/or overall pain 6weeks after trauma was replicated in the sexual assault cohort, showing the same direction of the effect in each case. The results of this study indicate that genetic variants in FKBP5 influence the severity of musculoskeletal pain symptoms experienced during the weeks after motor vehicle collision and sexual assault. These results suggest that glucocorticoid pathways influence the development of persistent posttraumatic pain, and that such pathways may be a target of pharmacologic interventions aimed at improving recovery after trauma.

Severity of Diabetic Foot Infection and Rate of Limb Salvage

Foot infections are limb-threatening complications in patients with diabetes mellitus (DM), and proper classification of the severity of diabetic foot infection (DFI) is important in determining an effective antibiotic regimen, the need for hospitalization and surgery, and the risk of amputation. Our hypothesis was that patients with severe DFI would have a longer hospitalization than those with moderate DFI. The purposed of this study was 2-fold. The first purpose was to define DFI using readily available clinical information and objective parameters outlined by consensus statements. The second purpose of this study was to assess rates of amputation and limb salvage for hospitalized patients with DFI. The database of a single academic foot and ankle program was reviewed for patients who were hospitalized for a DFI from 2006 to 2011. Inpatient and outpatient electronic medical records identified 100 patients. Severe DFI was defined as having 2 or more objective findings of systemic toxicity and/or metabolic instability at the time of initial assessment. The length of stay was significantly shorter for patients with a moderate infection than for those with a severe infection (median 5 days vs 8 days, P = .021). A nonsignificant trend was observed that indicated higher rates of limb salvage in patients with moderate infections compared with patients with severe infections (94% vs 80%, P = .081). Patients with severe DFI had a median hospital stay that was 60% longer than that of patients with moderate DFI. In this sample, 55% of patients with a severe DFI required some type of amputation compared with 42% of patients with a moderate DFI. Level III, retrospective control cohort study.

Recruiting Postmenopausal Women into Randomized Controlled Trials: A Patient Perspective

Purpose: To identify barriers to, and motivations for, recruitment and retention in osteoporosis related clinical trials among postmenopausal women. Methods: We explored the self reported reasons for and against participation in clinical trials among women who expressed an interest in participating in the Nitrates and Bone Turnover (NABT) study: an ongoing randomized controlled trial based at an urban tertiary care centre (Women’s College Hospital, University of Toronto). The study was designed to compare the effects of different doses and formulations of nitrates on markers of bone turnover among postmenopausal women not diagnosed and/or receiving treatment for osteoporosis. We administered a standardized interviewer questionnaire to 53 women to determine their reasons for participation in the NABT trial. To determine reasons for non-participation, we administered a questionnaire to 9 women and reviewed data collected at the time of initial assessment in 56 women who were not interested in participating in the trial. We conducted qualitative analyses using thematic coding of these responses. Results: The most common reasons for participation were: altruism (26.4%) and potential personal benefits (22.6%). The two most common reasons for non-participation included fear associated with taking medication (23.1%) and lack of time (16.9%). Conclusions: Postmenopausal women participate in clinical trials to help others and potentially themselves. Barriers to participation in trials may include the intervention being evaluated and time required to participate in the trial. Researchers should consider these motivations and barriers when recruiting postmenopausal women for RCTs.

Microcalcifications Detected as an Abnormality on Screening Mammography: Outcomes and Followup over a Five-Year Period

Objectives. This study reviewed the outcome of women attending a breast screening program recalled for assessment of microcalcifications and examined the incidence of a breast carcinoma detected during the following five years in any of the women who were given a benign diagnosis at assessment. Method. A retrospective study consisted of 235 clients attending an Australian BreastScreen program in 2003, who were recalled for investigation of microcalcifications detected on screening mammography. Records for the following five years were available for 168 women in the benign outcome group including those who did not require biopsy at initial assessment. Results. Malignant disease was detected in 26.0% (n = 146) of the women who underwent biopsy. None of the women in the benign outcome group, with available five-year follow-up records, developed a subsequent breast cancer, arising from the calcifications initially recalled in 2003. Conclusions. This study highlights the effectiveness of an Australian screening program in diagnosing malignancy in women with screen detected microcalcification. This has been achieved by correctly determining 38% (n = 235) of the women as benign without the need for biopsy or early recall. A low rate of open surgical biopsies was performed with no cancer diagnoses missed at the time of initial assessment.

Methicillin‐resistant and methicillin‐sensitive Staphylococcus aureus laryngitis

Despite the fact that a wide variety of head and neck methicillin-resistant Staphylococcus aureus (MRSA) infections have been described, only four cases of MRSA laryngitis are reported in the literature. Our clinical experience suggests that this diagnosis is more common and can be more subtle that previously reported. The objective of this study was to identify and describe the clinical presentation, diagnosis, treatment, and outcomes of MRSA and methicillin-sensitive S aureus (MSSA) laryngitis, highlighting the in-office workup of these patients. Retrospective case series. All patients with a culture-proven diagnosis of S aureus laryngitis treated within the Emory Voice Center, Department of Otolaryngology-Head and Neck Surgery at Emory University between 2007 and 2011. Demographic, diagnostic, and treatment data were retrospectively collected from the patients' hospital records. Three patients with culture-proven MRSA laryngitis were identified. Three further cases of MSSA were also identified. Patients ranged in age from 34 to 74 years. All three patients with MRSA were diabetics. All six patients in the study were current or past users of cigarettes. The most common presenting symptoms were vocal roughness, vocal fatigue, and decreased vocal endurance. There were no symptoms of airway or swallowing compromise. The duration of symptoms at the time of initial assessment ranged from 3 months to 5 years, and most patients had undergone numerous previous treatments. Common signs on laryngeal examination included thickened vocal fold epithelium, whitish debris or the appearance of leukoplakia, edema, and crusting. Signs and symptoms were similar in MRSA and MSSA patients. The diagnosis was made in all patients via awake in-office culture of the larynx. All patients were treated with a prolonged course of trimethoprim-sulfamethoxazole (2-4 weeks). Although repeated courses of treatment were required, most patients had an excellent response to treatment. This is the largest, single, case series of patients with MRSA laryngitis. Our study findings suggest that the diagnosis may be more common than previously recognized, and that the presenting signs and symptoms may be subtle and similar to MSSA. Diagnosis can be made via in-office laryngeal culture. Clinicians must have a high index of suspicion for this diagnosis.

Editorial

The ability to identify and discharge the low-risk patient, and to predict those cases where deterioration is likely is already a key element of the practice of acute medicine . This is an area which has been extensively examined in the past, but two articles in this edition add an interesting dimension to the literature. The use of physiological variables to calculate risk enables fluctuations in a patient’s condition over time can be monitored, allowing appropriate escalation measures to be instituted. The National Early Warning Score has already been implemented in Wales and roll-out across England is expected imminently. Austen and colleagues have highlighted some of the advantages that a standardised system will provide in comparison to their locally-developed Early Warning Score; however the problem of under-scoring due to incomplete or inaccurate recording remains and will continue until electronic solutions are more widespread. Scoring systems utilising laboratory data from admission are less useful for ongoing monitoring but could provide clinicians with an objective measure of risk at the time of initial assessment. As austerity measures bite, the pressure to direct our limited resources to the most appropriate cases will undoubtedly intensify, making this increasingly important. The rigorous quality control mechanisms in laboratories ensure the reliability of biochemical test results; furthermore most hospitals have electronic systems for recording and displaying results which limits the risk of errors from human transcription. O’Sullivan et al have utilised the extensive database from St James’ hospital in Dublin to develop a score based on a number of biochemical and haematological tests. Although this will need to be prospectively validated, retrospective analysis using a huge sample over a number of years, suggests their score may be highly predictive of good and poor outcome. This has great potential to support clinical decision making at the ‘front door’ and improve utilisation of resources. If variety is the ‘spice of life’, then Acute Medicine is certainly the ‘vindaloo’ of the modern hospital. The enormous breadth of clinical problems encountered on the AMU is apparent from the data gathered in York Hospital during the 15 months prior to April 2011. Variety is a key attraction for many junior doctors considering their career choice, at a time when many areas of hospital practice are becoming increasingly specialised. The acute medicine curriculum has ensured that trainees undertake blocks of training in respiratory medicine and cardiology, which is clearly important given that these areas reflected almost 50% of patients. However the authors highlight that the infrequency of certain problems, such as cord compression and diabetic ketoacidosis might also need to be addressed with training outside the AMU in neurology and endocrinology to ensure adequate exposure to these conditions. The rise in alcohol-related admissions is also highlighted in this article, and our trainee section includes a problem based review of the management of these problems. The obesity epidemic, as well as the proliferation of weight-loss surgery and its complications is another area which increasingly challenges our AMU resources. The article by Fiona Maggs provides some practical advice on how to address these issues. I hope you enjoy this edition, and the summer months ahead...