Burn management. Nonthermal injuries

The return to optimal function for patients who sustain chemical and electrical injuries depends on immediate emergency treatment and burn center referral for definitive care. Patients with exfoliating diseases also require care provided by a burn center. Critical care nurses, along with other members of a multidisciplinary health care team, must be dedicated to the principles of infection control, pain management, and psychosocial care to ensure positive outcomes and the return of these citizens to society.     

Treating achalasia: from whalebone to laparoscope

Reports of bile duct injuries are from tertiary care institutions and, therefore, may not report the spectrum of management that these patients receive in the care of these injuries. From June 14,1990 (the first operation) to June 30, 1995, 2654 laparoscopic cholecystectomies (LCs) were reviewed at this community hospital medical center to determine risk factors contributing to the etiology of these injuries, time and symptoms at presentation, duration of illness, and management of these injuries. None of the 13 general surgeons practicing during this time period had laparoscopic training in a general surgical residency. There were six major bile duct injuries (0.25%), of which five were available for further review. All occurred in women with cholelithiasis and chronic cholecystitis. Two operations were routine and two were associated with biliary tract anomalies. In two patients, the injuries were detected at LCs and definitive biliary-enteric anastomoses were performed immediately. Three patients presented at 2, 15, and 42 days after LC. In two patients, one or more operative procedures were performed before definitive repair and these patients were referred to tertiary care centers. One patient was managed with sequential CT-guided drainage catheters after attempted closure of the defect. The length of illness for these five patients was 8, 69, 348, 402, and 435 days with a follow-up of 245, 345, 531, 575, and 1088 days. Laparoscopic experience before injury by the operating surgeon was 3, 26, 35, 77, and 333 operations. Major biliary tract injuries occurred during routine cholecystectomy, length of illness was substantial for most patients, and biliary-enteric anastomosis was definitive for four of the five patients. The operating surgeons' "learning curve" did not seem as important as in other studies.     

Nonoperative management of liver and/or splenic injuries: effect on resident surgical experience

Changes in the management of trauma over the past few years are significantly affecting postgraduate surgical education, with the lack of operative trauma experience being a major concern in some programs. This problem is accentuated in residency programs that obtain their trauma caseload primarily from blunt injury. Our experience over the past 6 years confirms that the growing trend toward nonoperative management of blunt liver and spleen injuries in adults is likely to exacerbate this problem. Blunt trauma admissions to our Level I trauma center increased from 2888 from 1991 through 1993 (group A) to 3587 from 1994 through 1996 (group B). Liver and/or splenic injuries occurred with equal frequency in both groups. Whereas diagnostic peritoneal lavage was used in 26 per cent of group A, its use dropped to 2 per cent in group B as abdominal computerized tomography was used more frequently to evaluate these patients. Nonoperative management increased from 10 per cent of group A to 54 per cent of group B. As a result, therapeutic laparotomies dropped from 85 in group A (58% of patients with liver/splenic injuries) to 74 (35%) in group B and nontherapeutic laparotomies from 48 (33%) to 23 (11%). While the evolution in the management of blunt liver and splenic injuries has resulted in the avoidance of nontherapeutic laparotomies, the operative caseload available to surgical housestaff has been adversely affected. Although the Residency Review Committee has stressed the importance of the critical care management of these patients, the criteria used to evaluate the number of trauma cases in postgraduate surgical education may need to be revised.     

Inotropic effects of glyceryl trinitrate and spontaneous NO donors in the dog heart

Facial fractures may portend intracranial and skullbase injury and may lead to rapid compromise of the airway. Primary care physicians may provide emergency care for patients who have sustained facial trauma. After immediate resuscitation and stabilization, management of facial fractures requires knowledge of the anatomy, rapid treatment methods and identification of potential associated injuries for each type of facial fracture. Differentiation between the life-threatening aspects of these injuries and the less urgent, but more apparent, facial injuries will lessen the risk of complications such as bleeding, meningitis and asphyxia. Knowledge of the anatomy of the facial skeleton and of the potential injuries associated with each of the various types of facial fractures will facilitate effective management decisions. Consultation should be sought when functional features are involved or when the injury threatens to produce future cosmetic anomalies.     

Women and injuries--factors influencing recovery

This study focuses on female patients of working age, hospitalized due to moderate, mostly orthopaedic injuries. The aim was to highlight the medical and non-medical factors affecting outcome. Two groups of women, those who 12 months after the injury reported disability within at least three out of five possible areas (work, family, household, social life and leisure-time; n = 34), were compared with women reporting disability within two areas or less (n = 59). Four factors were predictive of outcome according to the multivariate analysis: injury severity as measured by the Abbreviated Injury Scale (AIS), self-perceived injury-related mental and physical health measured by the Visual Analogue Scale (VAS) during hospitalization and a history of three or more previous injuries requiring medical care. Sociodemographic background factors did not affect the outcome. By integrating information from AIS and VAS with the number of previous injuries, three quarters of the women were correctly classified; i.e., it was possible to detect a majority of those reporting a poorer outcome one year after the injury already during hospitalization. Simple screening instruments like these seem to be useful in the early detection of vulnerable patients. This study further suggests that more attention should be paid to non-medical factors, the importance of which may have been underestimated regarding a poorer outcome among female patients hospitalized due to injuries. Thus, psychosocial support should not only be offered to patients with major trauma or an obvious psychiatric disorder, but to all injured patients and should be considered as an integral part of medical care.     

Home-based cardiac rehabilitation and lifestyle modification: the MULTIFIT model

Managed care has changed the way health care is delivered in the United States. Simultaneously, major changes in the management of patients with coronary heart disease has led to dramatic shifts in cardiac rehabilitation. Exercise training, education, and counseling to modify coronary risk factors has clearly been shown to benefit patients with coronary disease. Moreover, intensive risk factor modification has been shown to prevent progression of coronary atherosclerosis and to lower morbidity and mortality. Newer delivery models of rehabilitation are needed to improve health outcomes in a cost-effective way. A nursing case management model (MULTIFIT), illustrates one such innovative delivery model that meets the needs of a managed care plan for comprehensive cardiovascular risk reduction and surveillance of patients.     

Spine injuries in combat troops--Panama, 1989

Operation Just Cause was until recently the largest American combat operation since Vietnam, and remains the largest nighttime parachute operation since World War II. All 252 casualties were airlifted to San Antonio, Texas, for medical treatment. Greater than 80% sustained orthopedic injuries. Sixteen patients were admitted for injuries to the back or neck. Three of the four patients with significant fractures or fracture-dislocations were paraplegic. Two of the three patients with gunshot wounds to the back required extensive reconstruction for wound management. In addition to the 252 casualties, there were 23 fatalities, among whom 7 suffered major injuries to the spine. Spine injuries represented the most significant source of long-term morbidity among those soldiers wounded in combat in Panama, and were common among the fatalities. Noteworthy in these cases was the high percentage of severe neurologic injuries in patients with significant fractures (75%), particularly fractures associated with gunshot wounds. Also of interest were the cases of major soft tissue injury associated with high-velocity gunshot wounds (66%) and the extensive soft tissue surgery needed to treat these injuries.     

Fine needle capillary cytology versus fine needle aspiration cytology--a comparison of quality between puncture techniques in the ENT area

In examining ways to improve female health care access and utilization, the magnitude of health problems must be examined before the design of solutions. Two types of barriers interfere with health care: attitudinal barriers blocking motivation to seek health care services and organizational barriers which block actual use of needed services. The major health problems of women in the United States are heart disease, cancer, stroke, lung-related diseases, intentional injuries, diabetes and HIV/AIDS. Public health has had a greater impact than high technology on the health of our nation. Balancing health care reform, changes in legislation and funding for medical education should help the United States be responsive to the challenge to move from substandard health for many women to superlative health care for all women and their family members.     

Trauma nursing: the team approach

The team approach to trauma care has demonstrated benefits for patients in terms of both quality of care and outcome. This article examines the current management and organizational strategies of trauma care and the effect these have on patient outcome. The four main roles of the nurse within the trauma team are discussed. Research has shown that during the resuscitation of patients only 26% of nurses felt confident that the care they gave was satisfactory. However, 81% of these nurses may be responsible for the care of patients with multiple injuries at least once a week (Hamilton, 1991). Although medical staff have a vital role to play within the trauma team, this article will focus predominantly on the role of the nurse.     

Longitudinal surveillance of chloroquine resistance of Plasmodium falciparum after cessation of medication in south Yunnan

Despite several large studies, the scoop and run versus field stabilization debate in prehospital trauma care continues. It is unlikely that all trauma patients are best treated by either field stabilization or scoop and run and the most effective form of prehospital care may be dependent upon the type of injuries sustained. Studies suggest that penetrating trauma involving major vascular injury may be best treated by scoop and run since advanced life support (ALS) measures serve only to delay time to definitive surgical treatment. Conversely, patients with head injuries may benefit from rapid ALS performed on scene in order to control airway and breathing problems, and reduce intracranial pressure prior to transport. Between these two groups of patients lie those with blunt trauma in whom scoop and run may be most appropriate if there is major vascular damage or those in whom field stabilization may offer the patient a greater chance of survival if blood loss is not a life-threatening problem.     

The hidden illness of endoscopy patients: mental health disorders, Part I

Because nearly half of all adults experience some mental health disorders in their lifetime, many endoscopy patients must have psychiatric problems along with their gastrointestinal (GI) illnesses. In addition, all patients undergoing an endoscopic procedure experiences some degree of apprehension and worry; anxiety itself is a major factor in most mental illnesses. Endoscopy nurses are very good at establishing rapport quickly with patients and learning about the patient's health history from all the available sources of information. These nurses spend much of their time teaching, listening, reassuring, and caring for people undergoing GI procedure, and these same skills are an important part of the care in mental health disorders. A series of case studies of GI patients in a busy endoscopy department document and summarize the mental health disorder each experienced and the pertinent care given by the GI nurse during an endoscopy or gastric laboratory procedure. Although it is inappropriate for endoscopy nurses to attempt to diagnose major psychiatric disease or provide psychiatric interventions for these patients, their nursing care and reassurance enable the patients to successfully complete their GI procedures.     

Dental care for the handicapped: general problems

In contrast to an increased oral health level in the Western countries, this improvement is not the case in age matched handicapped. The dental mutilation is generally related to periodontal problems (plaque, gingivitis, periodontitis, calculus), dental caries, traumatic injuries and self-injuring behaviour. Via a questionnaire, data from 88 institutions in Flanders were obtained. It became clear that there is a striking lack of oral health care and follow-up within institutions. There is a strong need for mouth hygiene instructions programmes for educators, parents, as well as for dentists involved in the special care of these patients.     

Acute administration of cocaine, but not amphetamine, increases the level of synaptotagmin IV mRNA in the dorsal striatum of rat

We reviewed the real and potential ocular problems in all head and neck injuries at a tertiary care and regional trauma center from April of 1994 to March of 1995. Through a retrospective study, 127 charts were reviewed, specifically looking at the mechanism of injury, types of injury, whether there was any ocular trauma noted in the chart, and whether there was a consultation to the ophthalmology department. Forty-one of these patients were seen by an ophthalmologist as the initial consultant for ocular and orbital injuries recognized by the emergency staff. In the 86 remaining patients, signs of potential ocular injury were recorded in the chart in 62 (72%) of these patients, yet an ophthalmology consultation was requested for only 23 of them (37%). This survey reveals the lack of awareness in a regional trauma center of certain ocular and periocular signs that may be indicative of more serious ocular injuries. It is the purpose of this article to highlight these concerns to the various health professionals involved with head and neck trauma patients in the hope that the patients will, in the end, benefit from a more thorough and complete assessment of the potential ocular and periocular injuries.     

It is past time: Moving psychology into primary health care.

It is past time for psychologists to expand their services into primary health care. For too long, psychological work has been limited to mental health care. Psychology also has much to offer in primary health care. One of my major initiatives during my tenure as president of the American Psychological Association (APA) was to focus on psychologists' contributions to health care in general, particularly on what psychologists are doing to help cancer patients. A great need exists for professional psychologists to expand into these areas. To illustrate the value of psychological interventions in primary health care, I focus on two major health care problems: heart disease and cancer. Both are particularly important areas for health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A coverage plan for health centres in Murewa district in Zimbabwe: an example of action research

Good access to health facilities providing good first-level health care remains problematic in many developing countries. It is a hindrance to effective and efficient functioning of the hospital, as outpatient departments become overcrowded with patients from areas without health centres. In many cases the quality of care delivered to these patients is poor because within the district health system the hospital is not the best place for the supply of comprehensive, integrated and continuous care. Eventually, high hospital involvement in first-level care can jeopardize the delivery of adequate referral care for those patients who desperately need the hospital's technology and expertise. This paper provides an account of the way this problem was investigated and managed by the district health management team in the Murewa district in north-east Zimbabwe. The design of a comprehensive 'master plan' or 'coverage plan' is presented as well as the problems and difficulties encountered. The Murewa experience highlights the relevance of a coverage plan for rational and coherent health infrastructure planning at district level. The approach followed by the Murewa team illustrates the use of action research as an integral part of the management of district health systems.     

EPR evidence for the involvement of free radicals in the iron-catalysed decomposition of qinghaosu (artemisinin) and some derivatives; antimalarial action of some polycyclic endoperoxides

The role of pharmacies that specialize in the treatment of specific chronic diseases in the alternate-site health care setting is discussed. The optimal use of medications through disease management programs can improve patient outcomes and lower overall health care costs. The increase in disease management programs has spawned the growth of disease-specific pharmacies in the home care and other alternate-site health care settings. These pharmacies usually operate from a single location or are regionalized operations that deliver pharmaceutical products to patients throughout the United States. The pharmacies employ clinicians who specialize in a particular disease. These clinicians conduct comprehensive patient education programs, drug-use review, and compliance monitoring. Disease management pharmacies focus on chronic, expensive diseases; costs related to inventory, equipment, and storage can be very high. Many disease management pharmacies are involved in preferred-distribution or closed-distribution arrangements with pharmaceutical manufacturers. Pharmacists involved in disease management programs routinely send compliance information about their patients to pharmaceutical companies, managed care organizations, or prescribing physicians. Disease management pharmacies act as advocates for patients with particular chronic diseases. Various foundations and patient advocacy and research groups have created their own disease management pharmacies. Disease management has also reached the community pharmacy practice setting. Pharmacies specializing in the treatment of specific chronic diseases in the alternate-site health care setting can improve health care and promote efficient use of health care dollars.     

Immediate surgical treatment of major renal trauma

Of the 77 cases of renal trauma treated at Oulu University Central Hospital during the years 1965--1975, 60 injuries were minor and 17 severe. 73 of these injuries were closed and 4 penetrating. The rate of operative treatment in severe renal injuries was 88% minor renal injuries being treated conservatively. Primary exploration was done in 18 of the 77 cases and in all patients with penetrating injuries. Only 7 of the 73 patients with blunt trauma and one of the 4 patients with penetrating injury required nephrectomy, including one patient with renal carcinoma. 6 of the 77 patients died, most as a result of severe associated injuries, giving a mortality of 8%. None of the surviving patients treated for renal trauma suffered from major complications. In 13 of the 18 patients operated upon, renal injury was the main indication for operation. Operation was performed in 5 of the 18 patients after immediate radiological evaluation. The advantages of immediate surgical management in severe renal injuries are early and final treatment, short hospital stay, and low incidence of complications. Qualifications for emergency surgery are access to renal angiography and familiarity with reparative renal procedures.     

Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines

OBJECTIVES: This study was designed to characterize physician practices in the management of congestive heart failure (CHF) and to determine whether these practices vary by specialty and how they relate to guideline recommendations. BACKGROUND: Congestive heart failure is responsible for considerable mortality, morbidity and health care resource utilization. Although there have been important advances in the diagnostic evaluation and treatment of CHF, little information is available on physician practices in this area. METHODS: We surveyed physicians concerning their management of patients with CHF. The results were analyzed in multivariate models to determine the relation of diagnostic and treatment approaches to physician specialty, time since training, board certification and volume of patients with CHF. Surveys were sent to a sample of 2,250 family and general practitioners (FP/GPs), internists and cardiologists. Responses were examined in relation to guidelines issued by the Agency for Health Care Policy and Research that had been released 9 months previously. RESULTS: Significant differences were found between physician groups with regard to each of the major guideline recommendations. For example, routine evaluation of left ventricular function, a point of emphasis in the guideline, is performed by 87% of cardiologists, but by only 77% of internists and 63% of FP/GPs (p < 0.001 between groups). Angiotensin-converting enzyme inhibitors were used by cardiologists, internists and FP/GPs in 80%, 71% and 60% of patients with mild to moderate CHF, respectively (p < 0.001 between groups). Larger differences were reported in the prescribed dosages of these drugs and their use in patients with renal dysfunction. CONCLUSIONS: Cardiologists report practices more in conformity with published guidelines for CHF than do internists and FP/GPs. Because of the large numbers of patients with CHF and their substantial mortality, morbidity and cost of care, these differences may have a major impact on outcomes and health care costs.