Unresolved Symptoms Research Articles

Vitamin D status in patients attending a Danish migrant health clinic: a clinical retrospective study.

Non-western migrants and ethnic minority populations in western countries are particularly at risk of vitamin D deficiency due to darker skin color and low sun exposure. The aim of this study was to examine levels of 25-OH vitamin D in patients attending a Danish health clinic for migrants. Patients attending the clinic represent a distinct group of migrants with longstanding, unresolved symptoms and often multiple illnesses. In this retrospective study, data on patient demographics and vitamin D levels were extracted from the medical records of 156 patients attending a Migrant Health Clinic in 2008-2011 who were considered at-risk for low vitamin D, mainly due to symptoms of diffuse pain in the muscles, bones or joints. Over the follow-up period of 1 year, the number of patients with vitamin D below 50 nmol/L decreased from 80 to 56%. The median vitamin D level increased from 27 nmol/L [(interquartile ranges (IQR 14.5-45.0)] at baseline to 45 nmol/L (IQR 26.5-64.5) at follow-up. Patient consultations with a holistic approach and close follow-up can help patients with complex symptoms and language barriers to overcome barriers to treatment and adherence, thus leading to improved levels of vitamin D.

Supervising the Tearful Trainee: Opportunities for Professional Growth and Learning

Trainees in psychiatry sometimes become tearful during supervision, and this presents the supervisor with significant challenges and also opportunities for the development of professionalism. This paper describes two major anxieties of trainees: first, that they will be unable to control their feelings during their clinical work and that this will derail the fulfillment of their duties; second, that that their feelings stem from an identification with some aspect of the patient or the patient's circumstances and may fear that this exposes them to the stigma of mental illness. The author describes how the trainee's potential for shame can be greatly mitigated by supervisory interventions that treat this as a 'teachable' moment and opportunity for growth in professionalism. The author outlines effective interventions including didactic instruction and education, role modeling of empathic connection in the context of a boundaried relationship, and sensitive referral to mental health services for unresolved emotional issues or psychiatric symptoms. Suggestions of specific wording of interventions are provided throughout.

Comparing Unmet Needs between Community-Based Palliative Care Patients with Heart Failure and Patients with Cancer

As the role of palliative care (PC) has yet to be clearly defined in patients with heart failure (HF), such patients may face barriers regarding PC referral. In order to maximally meet the needs of HF patients, it is necessary to understand how they compare to the classic PC population: patients with cancer. To characterize the unresolved symptom and treatment needs with which patients with HF and those with cancer present to PC. We used data from the Palliative Care Research Registry (PCRR), a repository of quality improvement data from three community-based PC organizations. We abstracted first PC visit data from the PCRR for patients with primary diagnoses of HF or cancer seen between 2008 and 2012. We assessed the association of primary diagnosis (i.e., HF or cancer) on three outcomes: unresolved symptoms, treatment gaps, and a composite indicator of symptom control and quality of life. Analyses included descriptive statistics and multivariate Poisson regression. Our analytic sample comprised 334 patients with HF and 697 patients with cancer, the majority of whom were white and male. Compared to patients with cancer, patients with HF presented with fewer unresolved symptoms, both overall and at moderate/severe distress levels. Patients with HF more commonly reported moderately/severely distressful dyspnea (25% versus 18%, p=0.02), and more commonly experienced dyspnea-related treatment gaps (17% versus 8%, p<0.001). Patients with HF possess care needs that are squarely within the purview of PC. Future work is needed to delineate how PC referral policies should be refined to optimize PC access for patients with HF.

How do Australian palliative care nurses address existential and spiritual concerns? Facilitators, barriers and strategies.

To investigate the facilitators, barriers and strategies that Australian palliative care nurses identify in providing existential and spiritual care for patients with life-limiting illnesses. Palliative care aims to be holistic, incorporating all domains of personhood, but spiritual/existential domain issues are often undertreated. Lack of time and skills and concerns for what you may uncover hamper care provision. A qualitative study through semistructured interviews. We interviewed 20 palliative care nurses from a cross section of area of work, place of work, years of experience, spiritual beliefs and importance of those beliefs within their lives. Questions focused on their current practices of existential and spiritual care, identification of facilitators of, barriers to and strategies for provision of that care. Their responses were transcribed and subjected to thematic analysis. The nurses' interviews yielded several themes including development of the nurse-patient relationship (14/20 nurses), good communication skills and examples of questions they use to 'create openings' to facilitate care. Barriers were identified as follows: lack of time (11/20 nurses), skills, privacy and fear of what you may uncover, unresolved symptoms and differences in culture or belief. Novel to our study, the nurses offered strategies that included the following: undertaking further education in this area, being self-aware and ensuring the setting is conducive to in-depth conversations and interactions and documentation and/or interdisciplinary sharing for continuity of care. Palliative care nurses are well placed to provide existential and spiritual care to patients with the primary facilitator being the nurse-patient relationship, the primary barrier being lack of time and the primary strategy being undertaking further education in this area. These findings could be used for nurse-support programmes, undergraduate or graduate studies or communication workshop for nurses.

Encountering Women Veterans With Military Sexual Trauma

As women veterans (WVs) are returning from Operation Iraqi Freedom and Operation Enduring Freedom with military sexual trauma (MST), the purpose of this article is twofold. First, important exploratory questions that can assist with a thorough assessment and history are presented as well as the applicable treatment for any new, recurrent, or unresolved symptoms that involve MST. Review of multiple literary materials, as well as a clinical situation. WVs will be encountered in a variety of military or civilian primary and community care healthcare settings. Every woman (and man) in the civilian sector should be asked, "Have you ever served in the military?" Recognition, acknowledgment, and applicable interventions for MST and associated comorbidities, especially post-traumatic stress disorder, are presented as currently 80-90% of MST experiences have gone unreported. Immediate treatment and follow-up are critical for the well-being of the WVs.

The million dollar question: When should an athlete retire after concussion?

Management of acute concussions is guided by consensus statement, and the return-to-play process begins when an athlete's symptoms and examination return to baseline. This process may be relatively clear if symptoms resolve within the normal time frame following a first or second concussion. This decision-making process is more complicated in an athlete with prolonged unresolved symptoms, multiple concussions both with and without prolonged recovery, or a structural brain injury. In these situations, determining when to retire an athlete after concussion is a complex decision, without available evidence-based guidelines. This article will discuss absolute and relative contraindications to returning an athlete to contact sport following a concussion in three separate scenarios: following potentially life-threatening brain injury, persistent clinical symptoms or signs of prolonged postconcussion syndrome, and multiple concussions but without residual symptoms or signs.

Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study

Objective To document whether elements of a structured history and examination predict adverse outcome of acute sore throat.Design Prospective clinical cohort.Setting Primary care.Participants 14 610 adults with acute sore throat...

Long-term Cumulative Depressive Symptom Burden and Risk of Cognitive Decline and Dementia Among Very Old Women

Depressive symptoms and cognitive outcomes are strongly interrelated. Despite that rates of depressive symptoms fluctuate during late life, little is known about the impact of long-term cumulative depressive symptom burden on cognitive decline and dementia in older adults. This study examines the association of nearly 20 years of cumulative depressive symptoms with cognitive outcomes in a cohort of older women. We assessed depressive symptoms in 7,240 women using the Geriatric Depression scale (GDS) at serial visits. We used a Poisson model with random slopes to estimate GDS trajectories for each participant from baseline to death or end of follow-up, and then characterized depressive symptom burden by quartile of the area under the curve. We assessed cognitive outcomes using repeated measures of the Mini-Mental State Examination (MMSE) and Trails B score over 20 years, Year-20 neuropsychological test battery, and adjudicated dementia and mild cognitive impairment (MCI). Adjusting for potential confounders, compared with women in the lowest quartile of cumulative depressive symptoms burden, women in the highest quartile had 21% more MMSE errors over time (95% CI = 17%, 26%), 20% worse Trails B score over time (95% CI = 17%, 23%), worse scores on most of the Year-20 cognitive tests, and a twofold greater likelihood of developing dementia or MCI (95% CI = 1.48, 3.11). Long-term cumulative depressive symptom burden was associated with cognitive decline and risk of dementia or MCI. Older adults with a history of depression should be closely monitored for recurrent episodes or unresolved depressive symptoms as well as any cognitive deficits.

Symptomatic Esophageal Granular Cell Tumor in a Young Female

Introduction: Granular cell tumors (GCTs) are rare forms of submucosal tumors that are infrequently found in the gastrointestinal tract (10% cases). However, in the gastrointestinal tract, the esophagus is the most commonly involved site (65% cases). Most GCTs are benign, asymptomatic, and less than 5 mm in size. Larger lesions are more likely symptomatic and have a higher malignant potential. We present the case of a young female with unresolving epigastric symptoms and weight loss caused by esophageal GCT which was diagnosed on endoscopic biopsy. Case Description: A 28-year-old, Caucasian, non-smoking female with no significant medical or family history was referred due to epigastric discomfort for 6 months. This was associated with a burning sensation and 15 pounds weight loss. She denied dysphagia, nausea, vomiting, blood in the stool, changes in her appetite or bowel habit. She had regular menses. Prior to presentation the patient was empirically treated with maximal doses of proton pump inhibitors, H 2 blockers and for Helicobacter pylori with no relief of symptoms. At current presentation, physical exam was unremarkable. All laboratory results including blood counts, amylase, lipase, and routine chemistries were within normal limits. In view of her history of significant weight loss and unresolving symptoms, endoscopy was performed. This revealed a 5 mm, whitish, submucosal nodule in the distal esophagus with positive biomarker staining (Figure 1a and 1b) suggestive of GCT. Subsequently, she underwent endoscopic mucosal resection of the lesion that resulted in complete resolution of symptoms.FigureDiscussion: GCTs are more frequent in males with a mean age at diagnosis of 45 years. They are often benign, asymptomatic, and usually less than 5 mm in size. They are most commonly found incidentally on endoscopy with an estimated incidence of 0.033%, representing about 1% of benign esophageal tumors. Although considered to be benign, GCTs have a malignant potential. The symptoms, if any, are often mild and include dysphagia, nausea, and burning sensation. Endoscopic mucosal resection is the recommended treatment especially if the lesions are >1 cm. There has been no described recurrence and prognosis is excellent. Although rare, it is important to consider GCT as a differential, especially in young patients presenting with mild, non-specific symptoms.

Risk Factors for 30 Day Hospital Readmission in Patients Undergoing Treatment for Peripheral Artery Disease

Early hospital readmission among vascular surgery patients is a focus of Medicare's new reimbursement structure. We aim to identify factors associated with 30-day readmission after lower extremity interventions to treat peripheral artery disease (PAD). Retrospective analysis of 174 consecutive patients discharged from the vascular surgery service between January 1, 2011, and July 31, 2012, after procedures for lower extremity PAD was performed. Of 174 patients, 37 were readmitted within 30 days of discharge. There were no significant differences in baseline characteristics between the readmitted and the nonreadmitted groups. In a multivariate logistic regression model, urgent operation and advanced chronic kidney disease (CKD) were associated with increased risk of 30-day readmission. The most common reasons for readmission were infection of the surgical site or index limb (18 of 37), followed by unresolved limb symptoms (13 of 37). The 30-day readmission is frequent after lower extremity interventions to treat PAD. Urgent operative intervention and advanced CKD appear to be risk factors for early hospital readmission.

Su1337 Sphincter of Oddi Manometry in Patients With Chronic Right Upper Quadrant Pain and Idiopathic Acute Pancreatitis: Role of Repeat Manometry in Patients With Recurrent or Persistent Symptoms

Chronic right upper quadrant (RUQ) pain affects 5% of patients following Cholecystectomy. A significant percentage of these patients will have Sphincter of Oddi dysfunction (SOD) following extensive studies. Similarly, patients with acute idiopathic pancreatitis are found to have sphincter dysfunction as an etiologic cause. Manometry of the biliary and/or pancreatic sphincter can reliably establish the diagnosis in these 2 groups of patients. A sublet of patients present with recurrent symptoms after initial response to endotherapy while others present with unresolved symptoms.

Unresolved problems with distress screening

Centre for Psycho-Oncology Research and Training, School of Public Health, The University of Hong Kong, 5/f,WMW Mong Building, 21, Sassoon Road, Pokfulam, Hong Kong, ChinaSir,The critique of Coyne, 2013 of the Carlson et al, 2012 paper andresponse by Carlson et al, 2013 raise important issues regardingscreening patients for cancer-related distress that have concernedus for some time. Relevant to the debate are the following:(1) The comment by Coyne, 2013 regarding declines in distressover time following cancer diagnosis and treatment is widelybelieved, but incorrect. Distress trajectories based on group meanvalues are problematic. The problem is, if in a study 50% of thesample score 10 out of 10 on a notional distress scale declining to 0out of 10 over time, whereas the other 50% score 0 out of 10increasing to 10 out of 10 over the same period, the observed groupmean will remain at 5 out of 10 and the conclusion would be thereis no change in distress. This of course is the wrong conclusion.Analyses using Mixture Growth modelling, a method thatdecomposes samples into distinct trajectories, reveal patterns ofdistress distinctly different to the accepted wisdom of a steadydecline over time (Helgeson et al, 2004; Deshields et al, 2006,Henselmans et al, 2010; Lam et al, 2010, 2011, 2012a, 2012b).These studies consistently show that a broad majority of cancerpatients, around 60% are resilient, experiencing persistently lowdistress with only marginal and transient peaks throughout thecancer trajectory. A second subset of patients who have low distressearly in the cancer trajectory report gradually increasing distresslevels that peak around the end of treatment and quickly declinethereafter. A third set follow the classic pattern mentioned byCoyne, 2013, with high levels early in the trajectory declining overtime thereafter. Finally, a fourth group, 5–20%, show stable levelsof high distress persisting over the duration of the cancertrajectory. (Henselmans et al, 2010; Lam et al, 2010, 2011, 2012a,2012b) Patterns of distress in the first year following diagnosispredict distress outcomes up to 6 years following diagnosis(Helgeson et al, 2004; Lam et al, 2011, 2012a). These patternsbroadly mirror the resilience model of response to trauma(Bonanno et al, 2011).(2) Evidence increasingly points to unresolved symptoms asbeing a major predictor of cancer-related distress trajectories (Lamet al 2010; 2012b). This suggests that more effective symptommanagement would be a more cost-effective approach to cancer-related distress. However, there are always going to be patients whoneed distress-support services and such patients need to beidentified. In particular, there is a pressing need to differentiate andidentify the chronic distress patients who would benefit most fromsupportive interventions from those with transient distress.(3) Given the above, the timing of any programme for distressscreening in cancer patients will give quite different resultsdepending on when screening is performed. Currently, evidencesuggests that the greatest proportion of patients (B80%)experience some signs of distress at around 1 month followingprimary treatment. Mostly, this distress is transient, and patientsand their families cope well with it; for some it is part of a longerdecline from an earlier peak, for others it is increasing, only todecline later. Only about 1 in 6 to 1 in 8 of those positivelyscreened as distressed would have chronic distress that is unlikelyto remit on its own. Any one point estimate will not tell you towhich group a screened distressed patient belongs and hencewhether they would, or would not benefit from additionalintervention: this is relevant to Coyne’s point about outcomes.Coyne suggests the effects reported by Carlson et al, 2012are due to recognised declines in distress over time. Of greaterconcern to us is that most patients show very little distress for mostof the cancer trajectory, although they might get picked up ifrepeatedly screened, during a fleeting peak of distress, probably atcritical points in the cancer trajectory (diagnosis, treatmentcessation, recurrence). Hence, including them in any randomisedcontrolled trial is unlikely to confer much benefit and, potentially,both dilute any group-intervention effects and increase dropout, aphenomena clearly evidenced in Carlson et al’s cohort wherearound one out of three patients dropped out. This is misleading,as for the chronically distressed group the benefits of supportiveinterventions may be more substantial than published studiessuggest.(4) It is well recognised that uptake and completion ofinterventions tends to be much greater in randomised controlledtrials than in everyday clinical practice. This is likely to be the casefor therapeutic interventions targeting cancer-related distress. Ineveryday practice, most people cope with cancer. The challenge isto identify and help those who don’t.(5) Frankly put, it seems that most cancer patients are resilientand it is not cost-effective to include them in distress-supportprogrammes, because they will simply not attend or drop out.Identifying the approximately one in eight distressed patients who

Treatment of resistant insomnia and major depression.

Daily rhythms regulate everiday life and sleep/wake alternation is the best expression of this. Disruptions in biological rhythms is strongly associated with mood disorders, often being the major feature of this, major depressive disorder first of all. Although stabilization of rhythms produced by treatments have important outcome on therapeutic efficacy, insomnia often remains an unresolved symptom when major depression has otherwise been successfully treated with antidepressant. We review scientific literature in order to better clarify how to better approach insomnia as a clinical aspect to investigate and to early treat while treating other psychiatric conditions, major depression in particular. Insomnia is associated with impaired quality of life. It can be resolved with adequate diagnosis and treatment: it should be considered a comorbid condition and should be early identificated and treated in a multidisciplinary way, so that the ideal of treatment for patients with treatment resistant insomnia in major depression is an integration of non-pharmacologic measures, along with judicious use of medication, often used as an adjunctive therapy.

Management of unresolved, recurrent, and/or contralateral neurogenic symptoms in patients following first rib resection and scalenectomy

Surgical treatment for neurogenic thoracic outlet syndrome does not always yield successful outcomes. The purpose of this study was to describe patients with unresolved, recurrent, and/or contralateral symptoms following first rib resection and scalenectomy (FRRS) and to determine therapies for improving their outcomes. Data on 161 neurogenic thoracic outlet syndrome patients (182 FRRS procedures) were prospectively collected from 2003 to 2011 and retrospectively reviewed for evidence of unresolved, recurrent, and/or contralateral neurogenic symptoms following FRRS. Demographic and clinical characteristics, interventions, and outcomes were compared between these patients and those with a successful result. Twenty-three patients (24 FRRS) had unresolved symptoms at a mean of 16.1 ± 14.7 postoperative months. Compared with successes, these patients were older (mean age, 45 vs 38 years; P = .002) and active smokers (33% vs 13%; P = .031), with a longer duration of symptoms (90 vs 48 months; P = .005). They had higher rates of chronic pain syndromes (67% vs 14%; P < .001), neck and/or shoulder comorbidities (58% vs 22%; P < .001), preoperative opioid use (67% vs 31%; P = .001), and preoperative Botox injections (46% vs 20%; P = .009) with less relief (18% vs 64%; P = .014). Sixteen patients had recurrent symptoms at a mean of 12.1 ± 9.7 postoperative months. These patients had more chronic pain syndromes (38%; P = .028) and neck and/or shoulder comorbidities (50%; P = .027), with recurrence secondary to scar tissue (69%; P < .001) and reinjury (31%; P = .002). Postoperative treatments for both groups included physical therapy and local injections, where six unresolved (26%) and 13 recurrent (81%) patients achieved freedom from opioids at the end of the follow-up period. Twenty-one patients had contralateral symptoms and underwent secondary FRRS at a mean of 15.0 months (range, 7-30 months) following primary FRRS. The first operation was successful in 90% of cases. Patients with unresolved symptoms are older, active smokers with more comorbid pain syndromes, neck and/or shoulder disease, and a longer symptom duration. These patients face a more difficult recovery, whereas patients with recurrent symptoms are well managed with physical therapy and Botox injections. Patients with contralateral symptoms at >1 year are effectively treated with secondary FRRS. Patients must be followed closely after FRRS to determine if additional interventions are necessary to ensure successful results.

Revision to an adjustable non-siphon control valve in low pressure hydrocephalus: Therapeutic siphoning and a new perspective on NPH: Series of 3 cases and review of the literature

IntroductionHigh intracranial compliance states requiring negative pressure drainage, otherwise known as low-pressure hydrocephalus syndromes, are rare conditions. The use of siphoning, enabled by revision to an adjustable shunt without an anti-siphon device, has been largely unexplored in low-pressure hydrocephalus. MethodsThree patients with presumed normal pressure hydrocephalus (NPH) presented with unresolved symptoms, including urinary incontinence, disturbed gait, and cognitive dysfunction. Each was inadequately treated despite confirmed functioning Strata II valves (with built-in siphon control device) calibrated to the lowest pressure setting for maximum drainage. Surgical revision to Strata non-siphon control (NSC) valves was performed to allow for additional drainage via siphoning. ResultsFollowing revision to a shunt with a “siphoning” device, each patient achieved improved neurological function. Each differential pressure valve was initially set to a higher setting than with the Strata II valve. One of our patients experienced the formation of a subdural hematoma after shunt revision; resolution following adjustment of the valve to a higher setting suggests that siphoning may be of less importance to overdrainage syndromes when compared with valve opening pressure. ConclusionOur findings indicate that intermittent intracranial hypotension achieved by siphoning is effective in the treatment of a subset of patients presenting clinically with NPH. Direct conversion to a shunt system without an anti-siphon device allows reduction of ventricular size without the risk associated with external ventricular drainage (EVD). With conversion to the Strata NSC valve, our patients had sustained clinical improvement, even at higher valve settings.

SYMPTOM PROFILES OF DSM-IV-DEFINED REMISSION, RECOVERY, RELAPSE, AND RECURRENCE OF DEPRESSION: THE ROLE OF THE CORE SYMPTOMS

Depression outcomes in research and clinical practice are commonly defined by the concepts of remission, recovery, relapse, and recurrence. Despite their widespread use, there has been little empirical examination of these concepts. Therefore, we investigated profiles of individual symptoms during each of these phases of depression. In a 3-year prospective study of 267 depressed primary care patients, we established the presence or absence of the individual DSM-IV depressive symptoms week-by-week during DSM-IV-defined remissions, recoveries, relapses, and recurrences. We measured symptoms in 12 quarterly assessments using the Composite International Diagnostic Interview. Remissions were characterized by double the proportion of time that the core symptoms were present compared to the initial phase of recoveries after a major depressive episode (MDE; 59 versus 32%; Z = -3.03; P = .002). Before a relapse, remissions again showed elevated levels of core symptoms in comparison to the final phase of recoveries before a recurrence (58 versus 26%; Z = -2.99; P = .003). Compared with the initial and final phases of recoveries, remissions showed a consistently higher level of core symptoms. Clinically, this means that unresolved core symptoms in the direct aftermath of a MDE seem to constitute a risk for relapse and should be the target of preventive or augmented interventions.

Depression in Premenopausal Women With HSDD

Hypoactive sexual desire disorder (HSDD) is a multifactorial disorder that is affected by, and may affect, mental health. Data are from the HSDD Registry for Women, a large multicenter observational study of US women with clinically diagnosed generalized, acquired HSDD. We analyzed complete baseline data from 1088 premenopausal women. Validated measures of sexual function and distress, physical and mental health, and depression symptoms were obtained from participant and clinician questionnaires. Depression was defined as having a current diagnosis, symptoms (by Patient Health Questionnaire), or use of antidepressant (AD) medication. Thirty-four percent met criteria for current depression, of whom 56% took AD medication. Depressed women were less happy with their relationship, had greater difficulty forming or maintaining relationships, and decreased partnered sex compared with nondepressed HSDD patients. Sexual function was significantly lower in women with current depression (p < .001) versus nondepressed women. Among AD users, those with inadequately treated depression had increased severity of HSDD (p = .02) and reduced sexual desire (p = .04) compared with women in remission. Otherwise, AD use was not associated with sexual function differences among women with HSDD and diagnosed depression. About one third of premenopausal women with HSDD presented with current symptoms or a diagnosis of depression. Women with HSDD and depression reported poorer relationships and sexual function compared with women with HSDD and no depression. AD use was associated with sexual dysfunction only among women with unresolved symptoms of depression, and conversely, current symptoms of depression were associated with more severe HSDD among AD users.

Management of Unresolved, Recurrent, and/or Contralateral Neurogenic Symptoms in Patients Following First Rib Resection and Scalenectomy

Management of Unresolved, Recurrent, and/or Contralateral Neurogenic Symptoms in Patients Following First Rib Resection and Scalenectomy

Unique predisposing factors for male urinary tract infections

AbstractPurpose: While naturally occurring male host defense mechanisms prevent many urinary tract infections (UTI), this article describes two purposeful forms of urethral play (UP) that could be unique predisposing factors to increased UTI susceptibility.Data sources: Medical literature has documented unconventional penile and urethral activities since the mid 1700s. In a recent web‐based study, Rinard et al. report 74 comments from national and international respondents performing UP: various websites also validate UP practice.Conclusions: Respondents reported inserting liquids and foreign objects into the urethra. Inserted liquids included water, hot candle wax, baby oil, after‐shave lotions, and dental gel. Foreign objects frequently mentioned were the insertion of smooth stainless steel surgical dilators often used in surgical urological procedures; the respondents and the websites call this “urethral sounding.” These practices were used to “aid erections and sexual experimentation, enlarge the urethra, and stimulate their partner.” Other respondents discussed catheter insertion. Other objects such as cotton‐tipped swabs, spoons, and pencils, were also inserted. UTIs have been reported as a result of UP.Implications for practice: Nurse practitioners' knowledge of these seemingly unconventional urethral activities requires a thorough assessment and history for pediatric and adult males presenting with new, recurrent, or unresolved UTI symptoms, as well as applicable health education.

Efficacy of metered‐dose inhalers for children with acute asthma exacerbations

To compare the effectiveness of the administration of inhaled beta-agonists delivered via a metered-dose inhaler (MDI) with spacers--as part of an evidence-based asthma pathway developed to manage acute asthma exacerbations in children at the emergency room level and in inpatient management--against administration via nebulization. Case with historical control. KK Women's and Children's Hospital (Singapore). A total of 19,951 children (infants to older children) aged 18 years and younger who attended the emergency room for asthma exacerbations. Average length of stay, proportion admitted to high dependency or intensive care, proportion readmitted for unresolved symptoms within 72 hr, cost per patient and overall. There was no increase in the mean proportion of emergency room attendances admitted to inpatient care with use of an MDI (mean difference 0.97%, 95% CI: -1.6-3.5%, P = 0.447), nor of children admitted to intensive care (0.21 vs. 0.20 pre- and post-pathway, P = 0.827) or to high dependency units (2.21 vs. 1.37 pre- and post-pathway, P = 0.200) but a significant reduction in the within 72 hr re-attendance rate (mean difference 1.4%, 95% CI: 0.78-2.0%, P < 0.001) with use of an MDI. The average length and cost per patient for an inpatient stay for acute asthma exacerbations was reduced with use of an MDI. The use of an MDI with spacer as part of an evidence-based asthma pathway was effective in the management of acute asthma exacerbations in the emergency room setting and for inpatient management.