A patient under the influence of alcohol under acute care in the emergency department

The authors of this paper paid special attention to the problem of treatment patients being under influence of drink, which was very often left out in the past. Investigation shows the cases contains patients treated in Clinic of Traumatology CM UJ in years 1990-1994 and pays attention to difference between these patients to the others. The authors included difficulties, that physicians usually meet in process of diagnosis and treatment. Data was analysed under sort of injuries and their causes. Complement data is lawful, toxicological and economical aspect of the question. This work means to make easier taking the decision about diagnosis and treatment for the physicians, who meet such kind of patients during emergency service.     

High-pressure injection injuries to the hand

Despite their appearance for over 20 years, high-pressure injection injuries to the hand are often grossly undertreated or mistreated, resulting in usually avoidable permanent impairment--often with amputation. Primary care physicians, and especially emergency room physicians, must be aware of the serious nature of this usually innocuous-appearing injury and immediately refer such patients for definitive emergency surgery.     

"Through-glass" injuries

This prospective trial collected all cases where injuries had resulted from the hand passing through or striking glass and had been referred to a hand injury service during 1 year. Eighty-seven cases were referred and the factors relating to these injuries were examined. A record was made of the structures damaged, the surgery performed and prevailing socioeconomic factors. These injuries were very costly in terms of morbidity, surgical effort and time, with significant resource implications. The study appears to confirm other reports that current legislation on glazing safety was too long delayed and is inadequate now that it is in place.     

Value of echography for diagnosis and follow-up of perforating eye injuries

The introduction of vitreous surgery with its multiple capabilities of intraocular manipulations makes it possible to operate on cases which had been considered as hopeless up to now. With these techniques the importance of ultrasonic examination increased especially in cases with severe perforating injuries and their follow-up, to detect the onset of intravitreal fibrosis and early traction detachment, when no fundus view is possible. An other indication for ultrasonic examination is the exact localization of foreign bodies. Out of 484 perforating injuries which were examined and treated in our clinic during the last 10 years, ultrasonographic diagnosis was helpful in 18% and had further therapeutic consequences: In 24% a detachment operation or vitreous surgery was necessary, in 30% ultrasonography showed severe damage and surgery was considered to be ineffective. 42% were follow-up examinations of the posterior segment.     

Fireworks-caused injuries in Denmark

The number and type of fireworks injuries occurring around New Year's Eve as well as type of fireworks used was investigated with the aim of guiding future prophylactic efforts. All patient contacts to emergency rooms throughout Denmark that were due to fireworks were prospectively registered for twenty-four hours before and after New Year's Eve 1995/1996 and 1996/1997. The number of fireworks injuries increased by 13.9% from 381 to 433, and the number of serious injuries increased by 50.8%. In 1996/1997 50% of the injuries were hand injuries, 19% were eye injuries, 8% were injuries to the head and neck, and the remaining 23% were hearing injuries and miscellaneous injuries. Seventy percent of the serious injuries were hand injuries, leading to some form of amputation in a third of cases. Sixty-one percent of the admissions were due to illegal fireworks. It is concluded that the number of serious fireworks injuries is on the increase, and that the main part of these injuries are hand injuries. Over half of the the serious injuries were due to illegal fireworks. Prophylactic efforts should be aimed against hand-held and illegal fireworks.     

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.     

Preliminary experience with transluminal laser-induced intrahepatic portacaval shunts

This article outlines the objectives for a resident rotation on a pediatric emergency medicine service that is geographically separate from adult-oriented facilities. In this setting, pediatric emergency department care is considered an off service. However, these objectives incorporate key pediatric knowledge and techniques in a practical format for emergency medicine trainees who have no separate pediatric emergency department experience. The content of the pediatric emergency department educational exposure can be attained in a concentrated 2-month exposure at a pediatric facility or extracted throughout the course of multiple pediatric encounters at a general emergency department. These objectives are a part of a continuing series on the goals and objectives to direct emergency medicine resident training on off-service rotations.     

Attempted suicide--a challenge for the trauma surgeon?]

The data from 767 patients after a suicide attempt or suicide were analyzed retrospectively. Skeletal damage was present in 52% of the patients. This was also the highest percentage in the breakdown of the injury patterns, followed by damage of the central nervous system (26.6%). Injuries to parenchymatous organs (20.1%) took third place. Extensive soft tissue injuries were diagnosed in 18.1% and relevant vascular lesions in 16% of suicide cases. At the same time, the high percentage of multiple trauma patients (22.9%) reflects the severity and the extent of injuries suffered in the application of "violent methods". Injuries of suicide cases involving violence often resemble those of serious road traffic accidents. In contrast to unselected patients, the injury pattern of suicide cases with multiple trauma is dominated by jumps from a great height and being run over by a train. However, when unusual suicide techniques are used, the surgeon's experience may soon become insufficient. To our knowledge, special traumatology wards provide the best available diagnosis and emergency care for these patients unless they have suffered purely trivial injuries.     

The health and welfare system for elderly in France

Dichotomy is the main characteristic of the Health and Welfare system in France. This system lies on two distinct fields, the medical field which is managed by the National Government, and the social field managed by the Local Government. The French home care policy for the elderly has developed a large number of services to assist in activities of daily living, to provide nursing and medical care at home, to improve living conditions, to maintain social relationships, and to postpone institutionalization and hospitalization, respectively. The main home care service is represented by "home helpers" who provide maid Notiniralics services. The second widely used service is the "home care service" performed by a team of nurses, assistant-nurses, psychologists, physiotherapists. This team provides nursing care and assistance in activities of daily living. As for institutions for the elderly, they are divided into welfare and medical institutions. The welfare institutions include social establishments like shelter homes and nursing homes. The medical institutions are mostly represented by long-term care hospitals. One of the main goals of the aging policy is to create medical wards in welfare institutions in response to the increased dependency of the institutionalized elderly. Recent experimental and innovative concepts have been established, such as "shelter homes for dependent elderly" for physically or cognitively impaired elderly.     

Breast implants. Evaluation of breast implants using magnetic resonance imaging (MRI)

Ureteral injury is a potential complication of any abdominal or pelvic surgery. Gynecological surgery has traditionally accounted for most injuries. In the last decade, there have been major advances in endoscopic surgery including ureteroscopy and laparoscopy, both of which may cause ureteral injury. Increased use of these procedures change the nature of ureteral injuries. From 1988 to 1997, 22 patients with 24 ureteral injuries were identified. The causes, diagnostic methods and treatments were reviewed. Ureteral injury was defined as any laceration, transection or ligation of the ureter that required an unexpected procedure for repair, stent or drainage. In 24 ureteral injuries, there were 20 unilateral cases and 2 bilateral cases eight men (33%) were 15 to 43 years old (mean age 30), and 14 women including 2 case of bilateral lesion (67%) were 30 to 75 years old (mean age of 46). The injuries were on the right side in 11 cases (46%), left side 13 cases (54%), and in the upper, and lower third of the ureter in 7 (29%) and 17 cases (71%), respectively. Bilateral injuries were all in the lower ureter and another 2 cases of lower ureteral injuries were combined with bladder injuries. In the cases of ureteral injuries, iatrogenic injuries accounted for 19 cases (79%). Of these, urological surgery, laparoscopic surgery, ureteroscopic procedures and gynecological surgery accounted for 1 (4%), 2(8%), 5(21%) and 11 cases (46%) respectively. Between 1988 and 1992, there were 7 cases, and after 1993, there were 17 cases of ureteral injuries. The injuries caused by trauma and gynecological surgery remained stable in the 2 period. The recent increases were caused by endoscopic procedures including ureteroscopy and laparoscopy. Of the 24 cases, 13 cases (54%) were managed by ureteroneocystostomy, 5 cases (21%) by nephrectomy, 4 cases (17%) by ureteroureterotomy, 1 case by PCN and 1 case by double-J catheter stenting only. The early recognition and repair at injury allow for better results with fewer complications. Delayed finding or commitant infection may lead to failure of reconstructive procedure and lead to nephrectomy.     

Appropriateness of admission and the last 24 hours of hospital care in medical wards in an east London teaching group hospital

OBJECTIVE: To assess the rates of inappropriateness of admission and last day of care on adult medical wards in an east London hospital, to identify associations with any inappropriateness and to assess what services need to be improved or provided if patients assessed as "inappropriate" are to be more appropriately placed in the future. DESIGN: From the patients' medical notes, nursing notes and ward charts, a trained reviewer with nursing and university qualifications collected concurrent information about each patient's first 24 hours as an in-patient and about the last 24 hours of care preceding discharge. Patients were also interviewed before discharge and 7-10 days after discharge, and their health status and level of satisfaction about the discharge process assessed. SETTING: The three adult medical wards at the Homerton Hospital in Hackney, east London. This hospital is within the St Bartholomew's Hospital Teaching Hospital Group. SUBJECTS: The case-notes of a random sample of 625 adult in-patients were reviewed. END POINTS: Appropriateness of admission and last day of care. MAIN OUTCOME MEASURES: The main instrument used was the Appropriateness Evaluation Protocol (AEP). This is an instrument devised to assess the appropriateness of adult patient admission to, and specific days of care in, acute hospital beds through case-note review against a structured set of criteria. RESULTS: The study presented here reported that 31% of in-patient admissions to adult medical wards in an east London hospital were inappropriate, and also that 66% of the last days of stay were inappropriate. CONCLUSIONS: There is clearly considerable room for improvement in relation to cooperation between service providers in order to maximise efficient bed use. Delays due to waiting for medications from pharmacy, and the combination of more "inappropriate" cases wanting help from social services after discharge with the fact that many of them were still in hospital because they were waiting for these services to be organized, suggest that inappropriateness could be reduced through increased efficiency or increased provision in these areas. The study reported here is unique in its inclusion of patient interview data.     

Obstetric cholestasis

The field of orthopaedic surgery has changed rapidly in the last ten years, increasing the demand for a readily available supply of allograft. Historically, bone was first grafted in 1668. The first clinical allograft was performed in 1820 by Phillips von Walter who reconstructed part of a skull. Clinical use of allograft has developed steadily during this century, making it now an essential requirement in orthopaedic surgery. Nationally, there is a shortage of available allograft for orthopaedic procedures. Allograft bone can be used in spinal fusion, filling of bone cysts, non-union of fractures and, most commonly, in revision joint replacements. In the last twenty years joint replacement surgery has become common practice and the number of patients requiring revision joint surgery has also increased. This expansion will continue owing to the growing demands made on our health service by our increasingly elderly population. We can expect an increase in demand for allograft.     

Attitudes of consultant anaesthetists to the Calman proposals: a questionnaire survey

We undertook a postal survey to determine the views of all consultant anaesthetists within the North West (Mersey) Regional Health Authority on the Calman proposals for a consultant-based service; replies were received from 110 (84%). Fifty (45%) indicated that they would not resume emergency residential duties, 32 (29%) indicated that they would withdraw from the emergency duty rota, 12 (11%) said they would withdraw/retire from the NHS and 27 (25%) would change hospital under these circumstances. Most consultants had experience in the major anaesthetic sub-specialties within the preceding 5 years (obstetrics 67%, ITU 81%, major trauma 91%). Consequently the need for retraining amongst consultant anaesthetists prior to resuming residential emergency duties would be low. When questioned about the impact on anaesthetic services, 67 (61%) felt the proposals would be detrimental whilst 23 (21%) felt there would be beneficial effects. Most consultants remain antagonistic toward the Calman proposals, with a reluctance to return to residential duties.     

Association of allele polymorphism of dopamine d2 receptors with schizophrenic and affective disorders]

This article examines the effect of the proposed limitation of funds for family planning direct services by the Texas Department of Health (TDH). A plan was unveiled by the TDH that called for cuts from Title V (Maternal and Child Health) to phase out family planning direct service delivery and increase population-based services. This proposal would mean that by 2000 at least 28,500 low-income women would have difficulty in receiving family planning services and obstetrical and gynecological services. During the 1998 Scripps Howard Texas poll, it was shown that majority of Texans support addition in public funding of family planning services for poor women, but it would result to a more expensive tax increase. Advocates of family planning were apprehensive on the effect of inaccessible family planning services among young and poor women. On the other hand, promoters of the Title V cuts claimed that family planning service is like any other clinical service that would be ineffective unless it takes into account the community and prevention dynamics.     

Microsurgery for the treatment of windshield injuries

During the last few years, eye injuries caused by fragments of shattered windscreen have increased enormously in the Federal Republic of Germany and in West Berlin. About 1000 people per year suffer severe eye- and eyelid injuries due to traffic accidents. Microsurgery of ocular injuries allows particular attention to be paid to each part of the eye and restoration of its functions. Although the prognosis of such injuries has been improved by a more developed surgery technique using microscopes, the eye specialist as well as legislation should make every possible effort to diminish eye injuries and their serious consequences for the patients.     

Survey of changes in the provision of vascular surgical services in the Oxford Region over 5 years

AIM: This study aimed to examine changes in the provision of vascular services in the Oxford region over 5 years. METHODS: A questionnaire was sent to all general surgeons in the region asking of their involvement in vascular surgery. Data were obtained from the Department of Health concerning vascular procedures and inpatient codes for each district in the Oxford Region from 1990-1991 to 1994-1995. Office of Population Censuses and Surveys (OPCS) data for abdominal aortic aneurysm repair and femoral artery reconstruction were validated against data collected prospectively for West Berkshire. RESULTS: Eighteen of 45 surgeons who replied to the questionnaire carried out elective and emergency arterial work. All were members of the Vascular Surgical Society of Great Britain and Ireland (VSS). All but one took part in the general surgical rota. Eight surgeons carried out emergency arterial surgery only; only two of these were members of the VSS. Of 19 surgeons undertaking no arterial surgery, 15 operated on primary and 11 on recurrent varicose veins. The number of arterial reconstructions rose from 20.8 per 100000 population to 28 per 100000 throughout the study. The greatest increase occurred in districts where a new vascular consultant had been appointed. Similar results were obtained with endovascular procedures. The number of major amputations remained fairly constant at approximately 11 per 100000 population. The number of inpatient episodes for arterial disease also rose, from 35.7 to 47.6 per 100000. In validating OPCS codes against prospectively collected data, discrepancies for individual years were noted but the annual trend was reflected fairly accurately by the codes. CONCLUSION: There has been an increase in vascular activity in the region, but variations still exist between different districts.     

Cantharidin production in a blister beetle

A case-control study was carried out in Nottingham Health District, to establish whether children under five years of age admitted to hospital after a accidental injury were more likely to have previously attended the accident and emergency (A & E) department than community controls. The subjects were 342 case-control pairs matched on sex and date of birth, consisting of children under five years resident in the Health District, and the main exposure measures were attendance at the A & E department before the case's first admission, type of injury and number of earlier attendances. It was found that, after adjusting for social deprivation score and proximity to hospital, children who had been admitted after an accidental injury were twice as likely to have attended the A & E department than community controls, and were more likely to have had more than one earlier attendance. Odds ratios were significantly raised for soft-tissue injuries and lacerations. It is concluded that accidental injuries in pre-school children that require attendance at the A & E department predict accidental injuries requiring admission. Making attendances at A & E departments notifiable to health visitors would facilitate the undertaking of accident prevention work.     

De novo mutations of the growth hormone gene: an important cause of congenital isolated growth hormone deficiency?

OBJECTIVES: To determine the epidemiological features of injuries associated with fireworks. DESIGN: A retrospective study of reported cases. SUBJECTS: Subjects were those who attended selected Victorian hospital emergency departments (n = 17) and those admitted for firework related injuries (n = 16). RESULTS: The mean (SD) age of attenders at emergency department between January 1988 and June 1996, was 8.9 (6.2) years and most (88%) were under 18 years of age. Males accounted for 71% of the cases. The most common anatomical sites and types of injury were head (47%) and burns (88%), respectively. About 53% of the injuries were caused by firecrackers, the remainder by sparklers and penny bangers. Among those admitted to hospital between July 1987 and June 1996, the mean (SD) age was 22.9 (14.8) years and 50% were under 18 years of age. Males accounted for 87% of the cases. There was a significant difference in mean age between those admitted and not admitted to hospital, the former being significantly older. CONCLUSIONS: Although relatively rare, injuries from fireworks still occur in Victoria after legislative restrictions on their sale in 1985. Consequently, there is a potential risk for injuries among children, particularly from firecrackers. More enforcement of the regulations, education, and parental supervision are needed to prevent injuries from fireworks.     

Review of a general practice attachment for accident and emergency training

The changes occurring in the health care delivery system afford ideal opportunities for call centers to expand their essential functions. Two obvious and timely services that can be adapted to the call center are outcomes management and disease management. These services benefit from the central role that telephonic nurses can play in clinical assessment and data collection and analysis. Other new services, such as gate-keeping functions, may also be relevant to call centers. The information and technology specialization of expert clinicians who practice "sightless" nursing make call centers the new clinical epicenter in the service capabilities of health care networks.     

Hand injuries due to fireworks explosion

Two different series of patients with burst injuries of the hand were retrospectively reviewed: one series included 23 men, 15-55 years old, referred to the emergency department for the first-instance assessment of injuries of the right hand (13 patients) and left hand (10 patients). The other series included 44 patients (42 men and 2 women, aged 7-61 years) referred to our department for second-instance examinations: the latter patients had burst injuries involving only the hands in 43 cases and both the hand and the foot in one case. We report the radiologic patterns of traumatic bone injuries (fractures and amputations) and of musculotendinous and cutaneous injuries and discuss their mechanisms and pathogenesis. The two series were compared and the results follow: in both series the right hand was more frequently involved, metacarpal bones were most often fractured and phalanges most often amputated. In the first series, in the right hand the carpal bones were involved in one patient only, the 2nd and 3rd metacarpal bones were most frequently fractured and the 2nd finger was most frequently involved. In the left hand, the carpal bones were never affected, the 1st metacarpal bone was most often amputated and the 5th metacarpal bone most often fractured; the 2nd finger was most frequently involved. In the second series, in the right hand, the 1st metacarpal bone was most frequently fractured and the 2nd metacarpal bone most often amputated; the 2nd finger was most frequently involved. In the left hand, the 4th metacarpal bone was most frequently fractured and the 5th metacarpal bone most often amputated. The severity of the above injuries and the extent of tissue damage depend on several factors, including firecracker speed, shape, size, weight and characteristics. Radiologic exams are very useful for the accurate study of these traumatic injuries, providing indirect information about musculotendinous and cutaneous involvement. Prompted by the relative lack of information on the management of these injuries, we suggest that radiologic exams be quickly performed to help choose the most appropriate surgical approach for best cosmetic and functional results.