The emergency department evaluation and outcomes of elderly fallers

BACKGROUND: Approximately one-third of community dwelling elderly people (age ≥65 years) falls each year contributing to over 2 million elderly emergency department (ED) visits for falls annually. The cost of care for fatal falls by elderly patients in the US was $179 million in 2000, and was$19 billion for non-fatal falls. The risk of falling increases with various risk factors including advancing age. Despite the frequency and costs associated with elderly falls, it is not clear what evaluation elderly fallers receive in the ED, after the ED, and the outcomes of the care provided. OBJECTIVES: We sought to examine the ED and post-ED workup of elderly fallers, and to compare this evaluation to that recommended by published ED fall evaluation and treatment guidelines. We also examined the disposition of these patients and the rate of adverse events which occurred within 1 year of discharge. METHODS: This study was a retrospective chart review of elderly ED fall patients from one urban teaching hospital with >90,000 visits per year. Patients aged ≥65 years who had an ED visit in 2012 with fall related ICD-9 codes E880-886, E888 and who had been seen by a primary care physician (PCP) within our hospital network during the past 3 years were included. We excluded patients who were transferred to our hospital and subsequent visits related to the original fall. We randomly selected 350 eligible patients for chart review. We adapted our data collection instrument from published fall evaluation recommendations including the American Geriatric Society. Categorical data were presented as percentages and continuous data were recorded as mean with standard deviation (SD) if normally distributed or medians with inter-quartile ranges (IQR) if non-normally distributed. RESULTS: A random sample of 450 charts were taken, 100 were subsequently excluded for erroneous identification. The average age was 80 (SD±9) years; 124 (35%) were male, with an average Charlson comorbidity index of 7.6 (SD 2.9). In terms of history, 251/350 (72%) took 5 or more medications, 144/350 (41%) had their visual acuity checked in the past 12 months, and 34/350 (10%) had fallen two or more times in the past 3 months. In the physical exam, only 43/350 (12%) had orthostatics done. 168/350 (48%) patients had their extremity strength recorded, of these 16/168 (10%) had decreased muscle strength. Only 128/350 (37%) patients had their gait recorded, of which 108/128 (84%) were noted to have an abnormal gait. Basic chemistry laboratory tests and hematology were sent on 199/350 (57%) of patients in the ED. X-rays were taken of 275/350 (79%) patients, and CTs were taken of 184/350 (53%) patients in the ED. 277/350 (79%) patients were discharged to their place of preadmission residence from the ED, ED observation unit, or hospital while 70/350 (20%) were discharged to a skilled rehab facility, all after being admitted to the hospital. 196/350 (56%) patients returned to the ED for any reason within 1 year of discharge, averaging 2.4 ± 1.9 visits. 161/350 (46%) patients were hospitalized within 1 year after discharge, averaging 2 ± 1.4 hospital admissions. 23 (7%) of patients died within 1 year after discharge. CONCLUSION: The comprehensive evaluation of falls for well-established risk factors and causes appears to be poor in this academic medical center ED. While results may not be generalizable to other EDs, the results suggest that standardized evaluation and treatment guidelines are needed

Role of contrast-enhanced ultrasound (CEUS) in paediatric practice: an EFSUMB position statement

The use of contrast-enhanced ultrasound (CEUS) in adults is well established in many different areas, with a number of current applications deemed off-label, but the use supported by clinical experience and evidence. Paediatric CEUS is also an off-label application until recently with approval specifically for assessment of focal liver lesions. Nevertheless there is mounting evidence of the usefulness of CEUS in children in many areas, primarily as an imaging technique that reduces exposure to radiation, iodinated contrast medium and the patient-friendly circumstances of ultrasonography. This position statement of the European Federation of Societies in Ultrasound and Medicine (EFSUMB) assesses the current status of CEUS applications in children and makes suggestions for further development of this technique

Experiences With Surgical Treatment of Chronic Lower Limb Ulcers at a Tertiary Hospital in Northwestern Tanzania: A Prospective Review of 300 Cases.

Chronic lower limb ulcers constitute a major public health problem of great important all over the world and contribute significantly to high morbidity and long-term disabilities. There is paucity of information regarding chronic lower limb ulcers in our setting; therefore it was necessary to conduct this study to establish the patterns and outcome of chronic lower limb ulcers and to identify predictors of outcome in our local setting. This was a descriptive prospective study of patients with chronic lower limb ulcers conducted at Bugando Medical Centre between November 2010 and April 2012. Ethical approval to conduct the study was sought from relevant authorities. Statistical data analysis was done using SPSS version 17.0 and STATA version 11.0. A total of 300 patients were studied. Their ages ranged from 3 months to 85 years (median 32 years). The male to female ratio was 2:1. The median duration of illness was 44 days. Traumatic ulcer was the most frequent type of ulcer accounting for 60.3% of patients. The median duration of illness was 44 days. The leg was commonly affected in 33.7% of cases and the right side (48.7%) was frequently involved. Out of 300 patients, 212 (70.7%) had positive aerobic bacterial growth within 48 hours of incubation. Pseudomonas aeruginosa (25.5%) was the most frequent gram negative bacteria isolated, whereas gram positive bacteria commonly isolated was Staphylococcus aureus (13.7%). Twenty (6.7%) patients were HIV positive with a median CD4+ count of 350 cells/μl. Mycological investigation was not performed. Bony involvement was radiologically reported in 83.0% of cases. Histopathological examination performed in 56 patients revealed malignancy in 20 (35.7%) patients, of which malignant melanoma (45.0%) was the most common histopathological type. The vast majority of patients, 270 (90.0%) were treated surgically, and surgical debridement was the most common surgical procedure performed in 24.1% of cases. Limb amputation rate was 8.7%. Postoperative complication rate was 58.3% of which surgical site infection (77.5%) was the most common post-operative complications. The median length of hospital stay was 23 days. Mortality rate was 4.3%. Out of the two hundred and eighty-seven (95.7%) survivors, 253 (91.6%) were treated successfully and discharged well (healed). After discharge, only 35.5% of cases were available for follow up at the end of study period. Chronic lower limb ulcers remain a major public health problem in this part of Tanzania. The majority of patients in our environment present late when the disease is already in advanced stages. Early recognition and aggressive treatment of the acute phase of chronic lower limb ulcers at the peripheral hospitals and close follow-up are urgently needed to improve outcomes of these patients in our environment

Addressing Traumatic Stress in the Acute Traumatically Injured Patient

Psychological injuries after an acute traumatic event are commonly overlooked. Currently within United States, there is no consistently utilized screening process that addresses traumatic stress within the acute trauma population. Roy\u27s Adaptation Model guided this project, focusing on the idea that bedside nurses are at the frontline of providing early identification through nursing assessment. The purpose of this pilot study was to evaluate whether the implementation of the Primary Care-Posttraumatic Stress Disorder (PC-PTSD) screening tool by bedside nurses would result in identifying more patients at risk for traumatic stress after an acute trauma as compared with the use of no screening method. This descriptive survey study took place over a 6-week period at a Midwest Level 1 trauma hospital. The results revealed that the tool did not increase the number of health psychology consults when compared with the same 6-week period a year prior when no tool was used. Nonetheless, use of the PC-PTSD tool did trigger 28% of the patients to receive a health psychology consult. Forty-five percent of patients who received a health psychology consult were recommended outpatient therapy. Utilization of this tool by bedside nurses did not adversely increase a number of inappropriate health psychology consults. These results agree with the literature and further suggest that there are a clinically significant number of acute trauma patients who are at risk for traumatic stress. With this screening tool, nurses accurately assessed patients and connected them with timely psychological treatment

Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis.

Background:Recombinant factor VIIa (rFVIIa) has been used off-label as an adjunct in the reversal of warfarin therapy and management of hemorrhage after trauma. Only a handful of these reports are rigorous studies, from which results regarding safety and effectiveness have been mixed. There remains no clear consensus as to the role of rFVIIa in traumatic brain injury (TBI). Methods:Eleven level 1 trauma centers provided clinical data and head CT scans of patients with a Glasgow Coma Scale (GCS) score of ≤13 and radiographic evidence of TBI. A propensity score (PS) to receive rFVIIa in those surviving ≥2 days was calculated for each patient based on patient demographics, comorbidities, physiology, Injury Severity Score, admission GCS score, and treatment center. Patients receiving rFVIIa within 24 hours of admission were matched to patients who did not receive rFVIIa for outcomes assessment. Subgroup analysis evaluated patients with primary head injury with PS matching. Results:There were 4284 patient observations; 129 received rFVIIa. Groups were comparable after matching. No differences in mortality or morbidity were found. Improvement in GCS score from admission to discharge was less among those receiving rFVIIa (5.5 vs. 2.4; P value 0.001); however, there was no difference in average GCS score at discharge. No significant differences in outcomes were identified in patients with isolated TBI receiving rFVIIa. Discussion:rFVIIa in early management of TBI is not associated with a decreased risk of mortality or morbidity, and may negatively impact recovery and functional status at discharge in the severely injured patient with polytrauma. Level of evidence:Level III. Study type:Therapeutic/care management

Disrupting the Path from Childhood Trauma to Juvenile Justice: An Upstream Health and Justice Approach

A groundbreaking public health study funded by the U.S. Centers for Disease Control and Prevention (CDC) and the Kaiser Foundation found astoundingly high rates of childhood trauma, including experiences like abuse, neglect, parental substance abuse, mental illness, and incarceration. Hundreds of follow-up studies have revealed that multiple traumatic adverse childhood experiences (or “ACEs”) make it far more likely that a person will have poor mental health outcomes in adulthood, such as higher rates of depression, anxiety, suicide attempts, and substance abuse. Interestingly, the original ACE Study examined a largely middle-class adult population living in San Diego, but subsequent follow-up studies have examined the prevalence of ACEs and its impact on mental health in other populations, including among people involved in the juvenile and criminal justice systems. Unsurprisingly, individuals entangled in those systems are more likely to have experienced higher numbers of these traumatic events, despite a frequent lack of access to critical mental health treatment, including the treatment necessary to address past childhood trauma. The ACEs framework for understanding health and mental health outcomes resulting from childhood trauma has received a high level of attention recently following an in-depth, multi-part series on these issues by National Public Radio (NPR) and other media. Because the ACEs public health research shows us that events in childhood can cause “toxic stress” and have a lasting impact on the mental health of a child well into adulthood, this framework provides us with an opportunity to consider how to more effectively intervene to stop the pathway from ACEs to juvenile justice system involvement and address the related health, mental health, developmental, and legal needs of children and their families. Before a child becomes an adult facing a mental health crisis or incarceration, attorneys, doctors, and other professionals can collaborate to disrupt that fate. This Article argues for a more upstream approach to address mental health using a medical-legal collaboration, based on the experiences of the authors, a law professor and medical school professor who work together to try to improve outcomes for children who have experienced trauma and their families. In Part I, we begin by examining the groundbreaking ACE studies, exploring the toxic stress and health and mental health outcomes that are associated with high rates of ACEs in childhood. Next, in Part II, we analyze the research revealing high rates of trauma and ACEs among populations involved in the juvenile justice system. Finally, we conclude in Part III by arguing for a more upstream public health and justice approach. We examine a particular problem in the city of Albuquerque, the largest urban area in New Mexico: children who have a particular ACE right from birth in the form of substance abuse by a household member. These infants are born with prenatal drug exposure and many experience symptoms of withdrawal in their first weeks of life, often quickly followed by an accumulation of additional forms of early childhood trauma. We discuss an approach through which the authors work to address those issues and disrupt the path from that childhood trauma to poor outcomes and juvenile justice system involvement. This approach engages attorneys with doctors and other health and developmental professionals to address ACEs among young children ages zero to three and their siblings, parents, and other caregivers. We advocate for an early, holistic, multi-generational, multi-disciplinary public health and justice approach to address ACEs early and improve the trajectory for children who have experienced childhood trauma

Economic Analysis of Children's Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis.

BackgroundUnderstanding the economic value of health interventions is essential for policy makers to make informed resource allocation decisions. The objective of this systematic review was to summarize available information on the economic impact of children's surgical care in low- and middle-income countries (LMICs).MethodsWe searched MEDLINE (Pubmed), Embase, and Web of Science for relevant articles published between Jan. 1996 and Jan. 2015. We summarized reported cost information for individual interventions by country, including all costs, disability weights, health outcome measurements (most commonly disability-adjusted life years [DALYs] averted) and cost-effectiveness ratios (CERs). We calculated median CER as well as societal economic benefits (using a human capital approach) by procedure group across all studies. The methodological quality of each article was assessed using the Drummond checklist and the overall quality of evidence was summarized using a scale adapted from the Agency for Healthcare Research and Quality.FindingsWe identified 86 articles that met inclusion criteria, spanning 36 groups of surgical interventions. The procedure group with the lowest median CER was inguinal hernia repair ($15/DALY). The procedure group with the highest median societal economic benefit was neurosurgical procedures ($58,977). We found a wide range of study quality, with only 35% of studies having a Drummond score ≥ 7.InterpretationOur findings show that many areas of children's surgical care are extremely cost-effective in LMICs, provide substantial societal benefits, and are an appropriate target for enhanced investment. Several areas, including inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital heart surgery and orthopedic procedures, should be considered "Essential Pediatric Surgical Procedures" as they offer considerable economic value. However, there are major gaps in existing research quality and methodology which limit our current understanding of the economic value of surgical care

Animal-Related Injuries in a Resource-Limited Setting: Experiences from a Tertiary Health Institution in Northwestern Tanzania.

Animal related injuries are a major but neglected emerging public health problem and contribute significantly to high morbidity and mortality worldwide. No prospective studies have been done on animal related injuries in our setting. This study was conducted to determine the management patterns and outcome of animal related injuries and their social impact on public health policy in the region. This was a descriptive prospective study of animal related injury patients that presented to Bugando Medical Centre between September 2007 and August 2011. Statistical data analysis was done using SPSS computer software version 17.0. A total of 452 (8.3%) animal-related injury patients were studied. The modal age group was 21-30 years. The male to female ratio was 2.1:1. Dog-bites (61.1%) were the most common injuries. Musculoskeletal (71.7%) region was the most frequent body region injured. Soft tissue injuries (92.5%) and fractures (49.1%) were the most common type of injuries sustained. Only 140 (31.0%) patients were hospitalized and most of them (97.1%) were treated surgically. Wound debridement was the most common procedure performed in 91.2% of patients. Postoperative complication rate was 15.9%, the commonest being surgical site infections (SSI) in 55.1% of patients. SSI was significantly associated with late presentation and open fractures (P < 0.001). The overall median duration of hospitalization was 16 days. Patients who had severe injuries, long bone fractures and those with hemiplegia stayed longer in the hospital (P < 0.001). Mortality rate was 10.2% and was significantly high in patients with severe injuries, severe head injury, tetanus and admission SBP < 90 mmHg (P < 0.001). The follow up of patients was poor. Animal related injuries constitute a major public health problem in our setting and commonly affect the young adult male in their economically productive age-group. Measures towards prevention and proper treatment and follow up are important in order to reduce morbidity and mortality resulting from this form of trauma