A Case of Bowen’s Disease and Small-Cell Lung Carcinoma: Long-Term Consequences of Chronic Arsenic Exposure in Chinese Traditional Medicine

Chronic arsenic toxicity occurs primarily through inadvertent ingestion of contaminated water and food or occupational exposure, but it can also occur through medicinal ingestion. This case features a 53-year-old lifetime nonsmoker with chronic asthma treated for 10 years in childhood with Chinese traditional medicine containing arsenic. The patient was diagnosed with Bowen’s disease and developed extensive-stage small-cell carcinoma of the lung 10 years and 47 years, respectively, after the onset of arsenic exposure. Although it has a long history as a medicinal agent, arsenic is a carcinogen associated with many malignancies including those of skin and lung. It is more commonly associated with non–small-cell lung cancer, but the temporal association with Bowen’s disease in the absence of other chemical or occupational exposure strongly points to a causal role for arsenic in this case of small-cell lung cancer. Individuals with documented arsenic-induced Bowen’s disease should be considered for more aggressive screening for long-term complications, especially the development of subsequent malignancies

The effects of interprofessional education - Self-reported professional competence among prehospital emergency care nursing students on the point of graduation - A cross-sectional study

The aim of the study was to investigate whether interprofessional education (IPE) and interprofessional collaboration (IPC) during the educational program had an impact on prehospital emergency care nurses' (PECN) self-reported competence towards the end of the study program. A cross-sectional study using the Nurse Professional Competence (NPC) Scale was conducted. A comparison was made between PECN students from Finland who experienced IPE and IPC in the clinical setting, and PECN students from Sweden with no IPE and a low level of IPC. Forty-one students participated (Finnish n = 19, Swedish n = 22). The self-reported competence was higher among the Swedish students. A statistically significant difference was found in one competence area; legislation in nursing and safety planning (p <0.01). The Finnish students scored significantly higher on items related to interprofessional teamwork. Both the Swedish and Finnish students' self-reported professional competence was relatively low according to the NPC Scale. Increasing IPC and IPE in combination with offering a higher academic degree may be an option when developing the ambulance service and the study program for PECNs. (C) 2017 Elsevier Ltd. All rights reserved.Peer reviewe

Pre-hospital emergency nurse specialist's experiences in caring for patients with non-specific chief complaints in the ambulance - A qualitative interview study

Background: Pre-hospital emergency nurse (PEN) specialists are faced with patients presenting with non-specific chief complaints (NSC) to the emergency medical service (EMS) on a daily basis. These patients are often elderly and one in three has a serious condition and their acuity is not recognized. Objective: The aim of the current study was to explore PEN specialists' experiences in caring for patients presenting with non-specific chief complaints. Design: A qualitative study design with eleven individual interviews of PENs, between 2018 and 2020. Qualitative content analysis was used. Results: The analyses generated three categories including subcategories. The categories were "Unexplained suffering". "Systematic approach and experience enhances medical safety". "Organizational processes can be optimized". The relation between the categories compiled as 'In-depth systematic assessment is perceived to reduce suffering and increases patient safety. Conclusion: The PENs experiences in caring for patients presenting with non-specific chief complaints show that an in-depth systematic assessment may lead to a meaningful caring encounter which enables the identification of the cause of the chief complaint. Experience and a systematic approach were considered as essential to enhance medical safety. This could be strengthened through feedback on the nurse's care provided by care managers and employers. To optimize organizational processes, the development of the opportunity to convey the patient to different levels of care can be an important component.Peer reviewe

Assessing health-related quality of life (HRQoL) in survivors of out-of-hospital cardiac arrest : A systematic review of patient-reported outcome measures

Aim: High quality evidence of out-of-hospital cardiac arrest (OHCA) survivors' health-related quality of life (HRQoL) can measure the long-term impact of CA. The aim of this study was to critically appraise the evidence of psychometric quality and acceptability of measures used in the assessment of HRQoL in cardiac arrest survivors. Methods: Systematic literature searches (2004-2017) and named author searches to identify articles pertaining to the measurement of HRQoL. Data on study quality, measurement and practical properties were extracted and assessed against international standards. Results: From 356 reviewed abstracts, 69 articles were assessed in full. 25 provided evidence for 10 measures of HRQoL: one condition-specific; three generic profile measures; two generic index; and four utility measures. Although limited, evidence for measurement validity was strongest for the HUI3 and SF-36. However, evidence for reliability, content validity, responsiveness and interpretability and acceptability was generally limited or not available in the CA population for all measures. Conclusions: This review has demonstrated that a measure of quality of life specific to OHCA survivors is not available. Limited evidence of validity exists for one utility measure - the HUI3 - and a generic profile - the SF-36. Robust evidence of the quality and acceptability of HRQoL measures in OHCA was limited or not available. Future collaborative research must seek to urgently establish the relevance and acceptability of these measures to OHCA survivors, to establish robust evidence of essential measurement and practical properties over the short and long-term, and to inform future HRQoL assessment in the OHCA population. (C) 2017 Elsevier B.V. All rights reserved.Peer reviewe

Assessing the discharge instructing in the emergency department : Patient perspective

Objective: The objective of the study is to assess how well the emergency department (ED) personnel succeed in instructing the patient at discharge. Methods: In November and December 2016 at Peijas Hospital ED, Finland, a structured questionnaire was conducted during a phone interview on patients the day after discharge. Results: A total of 132 patients interviewed. Ninety percent had received discharge instructions from the ED staff, most of them (75%) about medication. Almost half of the patients (45%) were satisfied with the communication at discharge, those not satisfied (47%) felt that the staff did not know enough of their background to give discharge instructions. Of the patients, 20% thought that they did not have the opportunity to ask questions during the guidance session, and 41% thought that the session was too short and restricted. Some patients (20%) felt that the instructions were ambiguous, but 63% (83/132) felt they were able to follow them well or very well. Conclusion: The pace of care in the ED is fast and duration of the stay is short. The patients must be able to take responsibility of their self-care. Failure to follow medical discharge instructions could lead to non-compliance. Attention should be paid to enhancing the quality of discharge instructing and the instructions provided by the ED personnel, as recurring visits and inquiry calls add to the ED workload.Peer reviewe

Ethnic differences in out-of-hospital cardiac arrest among Middle Eastern Arabs and North African populations living in Qatar

Aims: There are very few studies comparing epidemiology and outcomes of out-of-hospital cardiac arrest (OHCA) in different ethnic groups. Previous ethnicity studies have mostly determined OHCA differences between African American and Caucasian populations. The aim of this study was to compare epidemiology, clinical presentation, and outcomes of OHCA between the local Middle Eastern Gulf Cooperation Council (GCC) Arab and the migrant North African populations living in Qatar. Methods: This was a retrospective cohort study of Middle Eastern GCC Arabs and migrant North African patients with presumed cardiac origin OHCA resuscitated by Emergency Medical Services (EMS) in Qatar, between June 2012 and May 2015. Results: There were 285 Middle Eastern GCC Arabs and 112 North African OHCA patients enrolled during the study period. Compared with the local GCC Arabs, univariate analysis showed that the migrant North African OHCA patients were younger and had higher odds of initial shockable rhythm, pre-hospital interventions (defibrillation and amioderone), pre-hospital scene time, and decreased odds of risk factors (hypertension, respiratory disease, and diabetes) and pre-hospital response time. The survival to hospital discharge had greater odds for North African OHCA patients which did not persist after adjustment. Multivariable logistic regression showed that North Africans were associated with lower odds of diabetes (OR 0.48, 95% CI 0.25–0.91, p = 0.03), and higher odds of initial shockable rhythm (OR 2.86, 95% CI 1.30–6.33, p = 0.01) and greater scene time (OR 1.02 95% CI 1.0–1.04, p = 0.02). Conclusions: North African migrant OHCA patients were younger, had decreased risk factors and favourable OHCA rhythm and received greater ACLS interventions with shorter pre-hospital response times and longer scene times leading to better survival.Peer reviewedFinal Accepted Versio

Comparison of emergency department time performance between a Canadian and an Australian academic tertiary hospital

Objective To compare performance and factors predicting failure to reach Ontario and Australian government time targets between a Canadian (Sunnybrook Hospital) and an Australian (Austin Health) academic tertiary-level hospitals in 2012, and to assess for change of factors and performance in 2016 between the same hospitals. Methods This was a retrospective, observational study of patient administrative data in two calendar years. The main outcome measure was reaching Ontario and Australian ED time targets for admissions, high and low urgency discharges. Secondary outcomes were factors predicting failure to reach these targets. Results Between 2012 and 2016, Sunnybrook and Austin experienced increased patient volume of 10.2% and 19.2%, respectively. Bed capacity decreased at Sunnybrook (-10.8%) but increased at the Austin (+30.3%). For both years, Austin failed to achieve the Australian time target, but succeeded for all Ontario targets except for low urgency discharges. Sunnybrook failed all targets irrespective of year. The top factors for failing Ontario ED length-of-stay targets for both hospitals in 2012 and 2016 were bed request greater than 6 h, access block greater than 1 h, use of cross-sectional imaging, consultation and waiting for the emergency physician greater than 2 h. Conclusion Austin outperformed Sunnybrook for Ontario and Australian government time targets. Both hospitals failed the Australian targets. Factors predicting failure to achieve targets were different between hospitals, but were mainly clinical resources. Sunnybrook focussed on increasing human resources. Austin focussed on increasing human resources, observation unit and hospital beds. Intrinsic hospital characteristics and infrastructure influenced target success.Peer reviewe

Effectiveness of the Chest Strap Electrocardiogram to Detect Atrial Fibrillation

Atrial fibrillation (AF) is a significant cause of cardioembolic strokes. AF is often symptomless and intermittent, making its detection challenging. The aim of this study was to assess the possibility to use a chest strap (Suunto Movesense) to detect AF both by cardiologists and automated algorithms. A single channel electrocardiogram (ECG) from a chest strap of 220 patients (107 AF and 111 sinus rhythm SR with 2 inconclusive rhythms) were analyzed by 2 cardiologists (Doc1 and Doc2) and 2 different algorithms (COSEn and AFE-vidence). A 3-lead Holter served as the gold standard ECG for rhythm analysis. Both cardiologists evaluated the quality of the chest strap ECG to be superior to the quality of the Holter ECG; pPeer reviewe

Assessment of the breath alcohol concentration in emergency care patients with different level of consciousness

BACKGROUND: Many patients seeking emergency care are under the influence of alcohol, which in many cases implies a differential diagnostic problem. For this reason early objective alcohol screening is of importance not to falsely assign the medical condition to intake of alcohol and thus secure a correct medical assessment. OBJECTIVE: At two emergency departments, demonstrate the feasibility of accurate breath alcohol testing in emergency patients with different levels of cooperation. METHOD: Assessment of the correlation and ratio between the venous blood alcohol concentration (BAC) and the breath alcohol concentration (BrAC) measured in adult emergency care patients. The BrAC was measured with a breathalyzer prototype based on infrared spectroscopy, which uses the partial pressure of carbon dioxide (pCO₂) in the exhaled air as a quality indicator. RESULT: Eighty-eight patients enrolled (mean 45 years, 53 men, 35 women) performed 201 breath tests in total. For 51% of the patients intoxication from alcohol or tablets was considered to be the main reason for seeking medical care. Twenty-seven percent of the patients were found to have a BAC of <0.04 mg/g. With use of a common conversion factor of 2100:1 between BAC and BrAC an increased agreement with BAC was found when the level of pCO₂ was used to estimate the end-expiratory BrAC (underestimation of 6%, r = 0.94), as compared to the BrAC measured in the expired breath (underestimation of 26%, r = 0.94). Performance of a forced or a non-forced expiration was not found to have a significant effect (p = 0.09) on the bias between the BAC and the BrAC estimated with use of the level of CO₂. A variation corresponding to a BAC of 0.3 mg/g was found between two sequential breath tests, which is not considered to be of clinical significance. CONCLUSION: With use of the expired pCO₂ as a quality marker the BrAC can be reliably assessed in emergency care patients regardless of their cooperation, and type and length of the expiration.Annika Kaisdotter Andersson, Josefine Kron, Maaret Castren, Asa Muntlin Athlin, Bertil Hok, and Lars Wiklun

Comparison of in-hospital and out-of-hospital cardiac arrest of trauma patients in Qatar

Background Cardiac arrests in admitted hospital patients with trauma have not been described in the literature. We defined "in-hospital cardiac arrest of a trauma" (IHCAT) patient as "cessation of circulatory activity in a trauma patient confirmed by the absence of signs of circulation or abnormal cardiac arrest rhythm inside a hospital setting, which was not cardiac re-arrest." This study aimed to compare epidemiology, clinical presentation, and outcomes between in- and out-of-hospital arrest resuscitations in trauma patients in Qatar. It was conducted as a retrospective cohort study including IHCAT and out-of-hospital trauma cardiac arrest (OHTCA) patients from January 2010 to December 2015 utilizing data from the national trauma registry, the out-of-hospital cardiac arrest registry, and the national ambulance service database. Results There were 716 traumatic cardiac arrest patients in Qatar from 2010 to 2015. A total of 410 OHTCA and 199 IHCAT patients were included for analysis. The mean annual crude incidence of IHCAT was 2.0 per 100,000 population compared to 4.0 per 100,000 population for OHTCA. The univariate comparative analysis between IHCAT and OHTCA patients showed a significant difference between ethnicities (p=0.04). With the exception of head injury, IHCAT had a significantly higher proportion of localization of injuries to anatomical regions compared to OHTCA; spinal injury (OR 3.5, 95% CI 1.5-8.3, pPeer reviewe