Ultrasound in Emergency Medicine EMERGENCY BILIARY SONOGRAPHY: UTILITY OF COMMON BILE DUCT MEASUREMENT IN THE DIAGNOSIS OF CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

, Abstract-Background: Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers. Objective: To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound. Methods: We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis. Results: Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0-0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0-2.7%) with an otherwise negative ultrasound and normal laboratory values. Conclusion: The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values. Ó 2013 Elsevier Inc

Sexual orientation and cognition in aging populations: Results from the Canadian Longitudinal Study on Aging

The current study utilized the Canadian Longitudinal Study on Aging (CLSA) data to investigate the relationship between sexual orientation and cognitive health of the aging population. Cognitive flexibility and verbal fluency were examined as outcome variables in the study. A total of 45,993 respondents were included in the analyses. Each model had social support or social participation as a mediator. A series of mediation analysis, stratified by gender, revealed that aging gay men performed better in cognitive tasks related to cognitive flexibility when compared to their heterosexual counterparts. The results also indicated that social support is a protective factor for cognitive health in aging lesbian women. This study provides an opportunity to consider how clinical and social services can strategize to build inclusive environments for the aging sexual minority population

Walking and Automobile Traffic Near Schools: Data to SUpport An Evaluation Of School Pedestrian Safety Programs

Pedestrian accidents among children are an important transportation issue. Several recent policy initiatives have focused on reducing childhood pedestrian accident in the United States, yet those efforts exist within a context of limited and often insufficient data. This paper describes new data that can give much more detailed information on the determinants of pedestrian safety near schools. The data were developed to support an ongoing evaluation of a major childhood pedestrian safety program - the California Safe Routes to School construction program

Trauma Center-Based Surveillance of Nontraffic Pedestrian Injury among California Children

Introduction: Every year in the United States, thousands of young children are injured by passengervehicles in driveways or parking areas. Little is known about risk factors, and incidence rates aredifficult to estimate because ascertainment using police collision reports or media sources isincomplete. This study used surveillance at trauma centers to identify incidents and parent interviewsto obtain detailed information on incidents, vehicles, and children.Methods: Eight California trauma centers conducted surveillance of nontraffic pedestrian collisioninjury to children aged 14 years or younger from January 2005 to July 2007. Three of these centersconducted follow-up interviews with family members.Results: Ninety-four injured children were identified. Nine children (10%) suffered fatal injury. Seventychildren (74%) were 4 years old or younger. Family members of 21 victims from this study (23%)completed an interview. Of these 21 interviewed victims, 17 (81%) were male and 13 (62%) were 1 or 2years old. In 13 cases (62%), the child was backed over, and the driver was the mother or father in 11cases (52%). Fifteen cases (71%) involved a sport utility vehicle, pickup truck, or van. Most collisionsoccurred in a residential driveway.Conclusion: Trauma center surveillance can be used for case ascertainment and for collectinginformation on circumstances of nontraffic pedestrian injuries. Adoption of a specific external cause-ofinjurycode would allow passive surveillance of these injuries. Research is needed to understand thecontributions of family, vehicular, and environmental characteristics and injury risk to inform preventionefforts

Use of Physician-in-Triage Model in the Management of Abdominal Pain in an Emergency Department Observation Unit

Introduction With a nationwide increase in Emergency Department (ED) visits it is of paramount importance for hospitals to find efficient ways to manage patient flow.  The purpose of this study is to determine whether there is a significant difference in hospital admission rates, length of stay (LOS), and other demographic factors in two cohorts of patients admitted directly to an emergency department observation unit (EDOU) under an abdominal pain protocol by a physician-in-triage (bypassing the main ED) versus those admitted via the traditional pathway (evaluated and treated in the main ED prior to EDOU admission). Methods This was a retrospective cohort study of patients admitted to a protocol driven EDOU with a diagnosis of abdominal pain in a single university hospital center ED.    Compiled data was obtained for all patients admitted to the EDOU with a diagnosis of abdominal pain that met EDOU protocol admission criteria. Data for each cohort was then divided into age, gender, payer status, and LOS.  This data was then analyzed to assess any significant differences between the cohorts. Results There were 327 total patients eligible for this study (85 physician-in-triage group, 242 traditional ED group).  The total success rate (defined as discharge home) was 90.8% (n=297) and failure rate (defined as admission or transfer) was 9.2% (n= 30).   There were no significant differences observed in success rates between those dispositioned to the EDOU by physicians-in-triage (90.6%) versus via the traditional route (90.5 % p) = 0.98.  There was also a significant difference found between the two groups regarding total LOS with significantly shorter main ED times and EDOU times amongst patients sent to the EDOU by the physician-in- triage group (p<.001). Conclusion There were no significant differences in EDOU disposition outcomes in patients admitted to an EDOU by a physician-in-triage or via the traditional route.  Also, there were statistically significant shorter LOSs in patients admitted to the EDOU by triage physicians.   The data from this study supports the implementation of a physician-in-triage model in combination with the EDOU in improving efficiency in the treatment of abdominal pain.     This knowledge may act to cut healthcare costs, and improve patient flow and timely decision making in hospitals with EDOUs

Influence of time to achieve target systolic blood pressure on outcome after intracerebral hemorrhage: the Blood Pressure in Acute Stroke Collaboration (BASC)

OBJECTIVE: To investigate whether an earlier time to achieving and maintaining systolic blood pressure (SBP) at 120 to 140 mm Hg is associated with favorable outcomes in a cohort of patients with acute intracerebral hemorrhage. METHODS: We pooled individual patient data from randomized controlled trials registered in the Blood Pressure in Acute Stroke Collaboration. Time was defined as time form symptom onset plus the time (hour) to first achieve and subsequently maintain SBP at 120 to 140 mm Hg over 24 hours. The primary outcome was functional status measured by the modified Rankin Scale at 90 to 180 days. A generalized linear mixed models was used, with adjustment for covariables and trial as a random effect. RESULTS: A total of 5761 patients (mean age, 64.0 [SD, 13.0], 2120 [36.8%] females) were included in analyses. Earlier SBP control was associated with better functional outcomes (modified Rankin Scale score, 3–6; odds ratio, 0.98 [95% CI, 0.97–0.99]) and a significant lower risk of hematoma expansion (0.98, 0.96–1.00). This association was stronger in patients with bigger baseline hematoma volume (>10 mL) compared with those with baseline hematoma volume ≤10 mL (0.006 for interaction). Earlier SBP control was not associated with cardiac or renal adverse events. CONCLUSIONS: Our study confirms a clear time relation between early versus later SBP control (120–140 mm Hg) and outcomes in the one-third of patients with intracerebral hemorrhage who attained sustained SBP levels within this range. These data provide further support for the value of early recognition, rapid transport, and prompt initiation of treatment of patients with intracerebral hemorrhage