Effect of emergency department fast track on emergency department length of stay : a case-control study

Objective: To examine the effect of fast track on emergency department (ED) length of stay (LOS).Design and setting: Pair-matched case&ndash;control design in a public teaching hospital in metropolitan Melbourne, Australia.Participants: Patients treated by the ED fast track (cases) between 1 January and 31 March 2007 were compared with patients treated by the usual ED processes (controls) from 1 July to 15 November 2006 (n = 822 matched pairs).Intervention: ED fast track was established in November 2006 and focused on the management of patients with non-urgent complaints.Main outcome measures: The primary outcome measure was ED LOS for fast-track patients. Secondary outcomes were waiting times and ED LOS for other ED patients.Results: Median ED LOS for non-admitted patients was 132 minutes (interquartile range (IQR) 83&ndash;205.25) for controls and 116 minutes (IQR 75.5&ndash;159.0) for cases (p&lt;0.01). Fast-track patients had a significantly higher incidence of discharge within 2 h (53% vs 44%, p&lt;0.01) and 4 h (92% vs 84%, p&lt;0.01).Conclusions: ED fast track decreased ED LOS for non-admitted patients without compromising waiting times and ED LOS for other ED patients<br /

Characterisation of non-obese diabetic patients with marked insulin resistance identifies a novel familial partial lipodystrophy-associated PPARγ mutation (Y151C)

Familial partial lipodystrophy (FPLD) is a rare metabolic disorder with clinical features that may not be readily recognised. As FPLD patients require a specific therapeutic approach, early identification is warranted. In the present study we aimed to identify cases of FPLD among non-obese patients with type 2 diabetes mellitus and marked insulin resistance. We searched the databases of three diabetic outpatient clinics for patients with marked insulin resistance, arbitrarily defined as the use of ≥100 U insulin/day, and BMI ≤ 27 kg/m(2). In all patients, metabolic variables and anthropomorphic measurements were evaluated and DNA was sequenced for mutations in the genes encoding lamin A/C (LMNA), peroxisome proliferator-activated receptor γ (PPARγ) and cell death-inducing DFFA-like effector c (CIDEC). Out of 5,221 diabetic individuals, 24 patients fulfilled all criteria. Twelve patients were willing to participate, of whom five showed clinical features of lipodystrophy. In three of these patients the clinical diagnosis of FPLD was confirmed by the presence of mutations in LMNA or PPARG; one patient harboured a novel heterozygous mutation (Y151C) in PPARG. The Y151C mutant displayed impaired DNA-binding capacity and hence reduced transcriptional activity compared with wild-type PPARγ. Dominant-negative activity was absent. The combination of BMI ≤ 27 kg/m(2) and the use of >100 U insulin/day increases the chance of identifying lipodystrophy. Thus careful assessment of clinical features of FPLD should be considered in these patients, allowing earlier therapeutic intervention

Remodeling of Abdominal Aortic Angulation and Curvature After Endovascular Aneurysm Repair in Patients With vs Without Late Type Ia Endoleak or Endograft Migration

Purpose: To investigate aortic remodeling of the supra- and infrarenal aorta from preoperative to 1 month and midterm follow-up after endovascular aneurysm repair (EVAR) by analyzing changes in angulation and curvature in patients with vs without late type Ia endoleak or device migration. Materials and Methods: From a multicenter database, 35 patients (mean age 76 +/- 5 years; 31 men) were identified with late (>1 year) type Ia endoleak or endograft migration (>= 10 mm) and defined as the complication group. The control group consisted of 53 patients (mean age 75 +/- 7 years; 48 men) with >1-year computed tomography angiography (CTA) follow-up and no evidence of endoleaks. Suprarenal and infrarenal angles were measured on centerline reconstructions of the preoperative, 1-month, and midterm CTA scans. The value and location relative to baseline of maximum suprarenal and infrarenal curvature were determined semiautomatically using dedicated software. Changes were determined at 1 month compared with the preoperative CTA and at midterm compared with 1 month. Results: Preoperative suprarenal angulation was significantly greater in the complication group compared to the controls (34 degrees +/- 18 degrees vs 24 degrees +/- 17 degrees, p=0.008). It decreased significantly at 1 month in the complication group (29 degrees +/- 16 degrees, p=0.011) and at midterm follow-up in the controls (20 degrees +/- 19 degrees, p Conclusion: At midterm follow-up, significant differences in supra- and infrarenal angulation and curvature were observed between patients with vs without type Ia endoleak or migration. The location of the maximum curvature shifted distally in patients with complications. The aortic morphology is more stable during midterm follow-up in the patients without endoleaks

Cranial MRI beyond the Neonatal Period and Neurodevelopmental Outcomes in Neonatal Encephalopathy Due to Perinatal Asphyxia: A Systematic Review

BACKGROUND: Magnetic resonance imaging (MRI) including diffusion-weighted imaging within seven days after birth is widely used to obtain prognostic information in neonatal encephalopathy (NE) following perinatal asphyxia. Later MRI could be useful for infants without a neonatal MRI or in the case of clinical concerns during follow-up. Therefore, this review evaluates the association between cranial MRI beyond the neonatal period and neurodevelopmental outcomes following NE. METHODS: A systematic literature search was performed using PubMed and Embase on cranial MRI between 2 and 24 months after birth and neurodevelopmental outcomes following NE due to perinatal asphyxia. Two independent researchers performed the study selection and risk of bias analysis. Results were separately described for MRI before and after 18 months. RESULTS: Twelve studies were included (high-quality n = 2, moderate-quality n = 6, low-quality n = 4). All reported on MRI at 2-18 months: seven studies demonstrated a significant association between the pattern and/or severity of injury and overall neurodevelopmental outcomes and three showed a significant association with motor outcome. There were insufficient data on non-motor outcomes and the association between MRI at 18-24 months and neurodevelopmental outcomes. CONCLUSIONS: Cranial MRI performed between 2 and 18 months after birth is associated with neurodevelopmental outcomes in NE following perinatal asphyxia. However, more data on the association with non-motor outcomes are needed

The mechanics of setting up a COVID-19 response: Experiences of the COVID-19 epidemic from Groote Schuur Hospital, Cape Town, South Africa

The SARS-CoV-2 pandemic has challenged the provision of healthcare in ways that are unprecedented in our lifetime. Planning for the sheer numbers expected during the surge has required public hospitals to de-escalate all non-essential clinical services to focus on COVID-19. Western Cape Province was the initial epicentre of the COVID-19 epidemic in South Africa (SA), and the Cape Town metro was its hardest-hit geographical region. We describe how we constructed our COVID-19 hospital-wide clinical service at Groote Schuur Hospital, the University of Cape Town’s tertiary-level teaching hospital. By describing the barriers and enablers, we hope to provide guidance rather than a blueprint for hospitals elsewhere in SA and in low-resource countries that face similar challenges now or during subsequent waves

Partial Priapism Treated with Pentoxifylline

ABSTRACTMain findings:A 26-year-old man suffering from partial priapism was successfully treated with a regimen including pentoxifylline, a nonspecific phosphodiesterase inhibitor that is often used to conservatively treat Peyronie's disease.Case hypothesis:Partial priapism is an extremely rare urological condition that is characterized by thrombosis within the proximal segment of a single corpus cavernosum. There have only been 36 reported cases to date. Although several factors have been associated with this unusual disorder, such as trauma or bicycle riding, the etiology is still not completely understood. Treatment is usually conservative and consists of a non-steroidal anti-inflammatory and anti-thrombotic.Promising future implications:This case report supports the utilization of pentoxifylline in patients with partial priapism due to its anti-fibrogenic and anti-thrombotic properties

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Effect of clinician designation on emergency department fast track performance

Objective To examine the effect of clinician designation on emergency department (ED) fast track performance.Design and Setting A retrospective audit of patients managed in the fast track area of an ED in metropolitan Melbourne, Australia.Participants Patients triaged to ED fast track from 1 January 2008 to 31 December 2008 (n=8714).Main Outcome Measures Waiting times in relation to Australasian triage scale (ATS) recommendations and ED length of stay (LOS) for non-admitted patients were examined for each clinician group.Results Compliance with ATS waiting time recommendations was highest (82.5%) for emergency nurse practitioners/candidates and lowest (48.2%) for junior medical officers. Median ED LOS was less than 3 h for non-admitted patients, and 85.8% of non-admitted fast track patients (n=6278) left the ED within 4 h. Patients managed by emergency nurse practitioners/ candidates had the shortest ED LOS (median 1.7 h) and patients managed by junior medical officers and locum medical officers the longest ED LOS (median 2.7 h) (x&sup2;=498.539, df=6, p&lt;0.001).Conclusions Clinician designation does impact on waiting times and, to a lesser extent, ED LOS for patients managed in ED fast track systems. Future research should focus on obtaining a better understanding of the relationship between clinician expertise, time-based performance measures and quality of care indicators.<br /