Thought provoking as this paper is, it doesn't take account of any
'special awareness' of the problem as percieved by the coronial &
reactive health service opinions upon which it is based.
It might not be the case that Brighton's problems are any greater
than any other similar conurbation - only that those reacting to your
questions are more specifically looking for, and willing to ident...
Thought provoking as this paper is, it doesn't take account of any
'special awareness' of the problem as percieved by the coronial &
reactive health service opinions upon which it is based.
It might not be the case that Brighton's problems are any greater
than any other similar conurbation - only that those reacting to your
questions are more specifically looking for, and willing to identify, such
apparent links than any other.
The report by De et al.[1] correctly highlights the need for an index of
suspicion of a haemorrhage into an arachnoid cyst even after minor trauma.
The majority of such cysts are incidental findings and the variety of
symptomatology may not make their consideration all too clear. It is
important therefore to consider the need for early CT scanning in new or
recent onset persistent and localised head...
The report by De et al.[1] correctly highlights the need for an index of
suspicion of a haemorrhage into an arachnoid cyst even after minor trauma.
The majority of such cysts are incidental findings and the variety of
symptomatology may not make their consideration all too clear. It is
important therefore to consider the need for early CT scanning in new or
recent onset persistent and localised headaches that may be accompanied by
falls, mild personality changes or unsteadiness, especially (but not
exclusively) in the young. The history of a recent head trauma, even
minor, may be an important clue. The need for surgical intervention for an
intracystic haemorrhage and the relief of any resultant midline shift
cannot be overemphasised; CT scanning in emergency departments should be
readily available in cases so suspected.
Equally important is the possibility of a subdural haematoma (SDH),
which must be borne in mind especially in sports related (minor or not)
trauma. SDHs are a recognised association of arachnoid cysts, mainly of
the middle fossa, but have also been the presenting feature of previously
undiagnosed arachnoid cysts. The patient’s complaints may be more vague
than in a case of intracystic haemorrhage and may build up over a longer
period of time. The injury may be much milder, such as heading a football[2]
or being hit during ball games.[3] Given that SDH may anyway occur in sports
injuries even in the absence of arachnoid cysts[4] the diagnosis of the
latter has serious implications in sports medicine. Should an arachnoid
cyst be an absolute or relative contraindication for contact/collision
sports? Should such athletes not be screened for arachnoid cysts given the
life-threatening possible complications?
References
(1) De K, Berry K, Denniston S. Haemorrhage into an arachnoid cyst: a
serious complication of minor head trauma. Emerg Med J 2002;19(4):365-6.
(2) Kawanishi A, Nakayama M, Kadota K. Heading injury precipitating subdural
hematoma associated with arachnoid cysts: two case reports. Neurol Med
Chir (Tokyo) 1999;39(3):231-3.
(3) Prabhu VC, Bailes JE. Chronic subdural hematoma complicating arachnoid
cyst secondary to soccer-related head injury: case report. Neurosurgery
2002;50(1):195-7.
(4) Keller TM, Holland MC. Chronic subdural haematoma, an unusual injury
from playing basketball. Br J Sports Med 1998;32(4):338-9.
We accept, as pointed out by Dr Campbell, that our retrospective
findings could be confounded by many factors. Nonetheless our Doctors were
on average seeing 154 less patients per six months by the end of the study
period.[1]
The concept of developing "ideal practice patterns" is an interesting one
and would in itself merit debate.
Certainly from the patient's perspective the time waiting to see a...
We accept, as pointed out by Dr Campbell, that our retrospective
findings could be confounded by many factors. Nonetheless our Doctors were
on average seeing 154 less patients per six months by the end of the study
period.[1]
The concept of developing "ideal practice patterns" is an interesting one
and would in itself merit debate.
Certainly from the patient's perspective the time waiting to see a Doctor
and the time from arrival to discharge or admission are taken as
indicatiors of efficient practice and are significantly impacted upon by
the speed with which Doctors see patients.
The questions raised with regards to the implications of a Doctor's
speediness for quality of care, education and longevity need to be
addressed independently of our study and probably using a qualitative
approach.
The fact remains that the Senior House Officers in the second half of our
5 year retrospective study were seeing fewer patients in their six months
in Accident & Emergency
than they used. In a predominantly Senior House Officer delivered service
this has implications for the future delivery of Emergency Care.
References
(1) P Gilligan, RN Illingworth, S Crane, D Hegarty. Are accident and
Emergency senior House Officers getting slower? Emerg Med J 2004; 21: 646. doi:10.1136/emj.2004.014787
I agree with the findings of the study. My common sense says that If
we have a reservoir having a capacity of 10 litres, even if we divide it
into two compartments by a shelf, its capacity will remain 10 litres.
Unless we increase the size of the reservoir we can not store more than 10
litres in to it.
I read with interest the comments regarding the Best Evidence Topic
Report (BET) entitled “Incision and drainage preferable to oral
antibiotics in acute paronychial nail infection?” and would be delighted
to provide justification for the conclusion[1]. Acute paronychia is one
of the most common infections of the hand. Far from being a simple
digital abscess, acute paronychia represents a dynamic...
I read with interest the comments regarding the Best Evidence Topic
Report (BET) entitled “Incision and drainage preferable to oral
antibiotics in acute paronychial nail infection?” and would be delighted
to provide justification for the conclusion[1]. Acute paronychia is one
of the most common infections of the hand. Far from being a simple
digital abscess, acute paronychia represents a dynamic and evolving
condition. The patient initially complains of pain and tenderness in the
paronychial fold, which appears erythematous and inflamed. If the
infection persists, a collection of pus may develop, forming an abscess
around the paronychium. Left untreated, this may spread under the nail
sulcus to the opposite side, creating a “run-around abscess”[2-4].
In clinical practice within the Emergency Department, patients
present at different stages along this continuum of infection. Although
it is widely held that acute paronychia mandates surgical management, many
paronychiae are treated conservatively by general practitioners, using
oral antibiotics. Indeed, this approach has been advocated for early
infections in the literature, as have warm-water soaks[2].
BETs are designed to summarise the best available evidence to answer
a specific and well-defined clinical problem. The BET in question
describes the clinical scenario of a patient who has neither obvious
fluctuance and abscess formation nor trivial erythema. In the experience
of the two authors, this presentation is not uncommon and presents a
dilemma for the Emergency physician. If surgical management confers no
benefit over the conservative approach, avoidance of an unpleasant and
unnecessary surgical procedure may be beneficial for the patient.
Following independent exhaustive literature searches and review at
the Manchester Royal Infirmary Emergency Medicine Journal Club, we were
unable to identify any relevant comparative trials to answer the three-part question. As such, our conclusion that there is no evidence that a
surgical approach is either better or worse than conservative treatment in
this situation is justified.
In the absence of relevant evidence in the literature we do not,
however, state that either approach is of equal benefit. We clearly state
that if pus is present in acute paronychial nail infection, our current
practice is to incise and drain the abscess. Further, we highlight an
interesting area for potential future research.
References
1. Shaw J, Body R. Incision and drainage preferable to oral
antibiotics in acute paronychial nail infection? Emergency Medicine
Journal 2005; 22: 813-814.
2. Rockwell PG. Acute and chronic paronychia. American Family
Physician 2001; 63: 1113-1116.
3. Jebson PJL. Infections of the fingertip: Paronychias and felons.
Hand Clinics 1998; 14: 547-555.
4. Canales FL, Newmeyer WL 3rd, Kilgore ES. The treatment of felons
and paronychias. Hand Clinics 1989; 5: 515-523.
I would like to thank the editors of the EMJ for their replies to the
points raised by myself and Dr Webster, however these replies have
themselves highlighted further concerns [1][2].
It is clear that considerable effort goes into producing the BETs but
as Mr Mackway-Jones states, BETs do not represent the highest level of
evidence. Might it not be better to coordinate this effort to produc...
I would like to thank the editors of the EMJ for their replies to the
points raised by myself and Dr Webster, however these replies have
themselves highlighted further concerns [1][2].
It is clear that considerable effort goes into producing the BETs but
as Mr Mackway-Jones states, BETs do not represent the highest level of
evidence. Might it not be better to coordinate this effort to produce a
much smaller number of systematic reviews. The goal of evidence based
medicine must be to change practice to that which has been shown to be
most effective. I would argue that BETs are unlikely to achieve this as it
seems only a fraction of the available evidence is ever presented to the
reader. I believe that the readership of the EMJ would be much more likely
to change their practice in response to a formal systematic review of a
subject.
If we are to assess the popularity of BETs by the number of hits on
the EMJ website perhaps this should be assessed over a longer period than
one month. The list of top ten most viewed articles in 2003 does not
include a single Best BET [3]. It of interest that half of this list
consists of review articles with the remainder being original research
papers.
I share Dr Boyle’s view, in that my overriding concern remains the
review process [4]. Mr Mackway-Jones has described this rigorous process
in detail. It would appear to include many of the steps that authors would
normally undertake in preparing a paper, such as review by colleagues,
prior to submission. Unfortunately one vital component of the review
process is missing – independence. Given the full title of this section of
the journal - “Towards evidence based emergency medicine: best BETs from
the Manchester Royal Infirmary” and the fact that many of the BETs appear
to originate from Manchester, an independent review process is vital. If
the BETs are as popular and as methodologically sound as Mr Mackway-Jones
suggests then this addition to the review process should not cause him any
undue concern.
References
(1) K Mackway-Jones. BestBETs reply from the BestBETs group Emerg Med
J 2004 21: 523.
(2) J Wardrope and P Driscoll. Good BETs? Emerg Med J 2004 21: 523.
(3) Top ten most read 2003.
(http://emj.bmjjournals.com/misc/topten.shtml)
(4) A A Boyle. Best Bets, how robust is the review process? Emerg Med
J, E-letters, June 2004.
(http://emj.bmjjournals.com/cgi/eletters/21/4/523).
Two articles appeared in consecutive issues of the EMJ last year regarding emergency oxygen therapy. The first was a comprehensive review
of emergency oxygen therapy for the COPD patient[1] and the second
comprised guidelines prepared by the North West Oxygen Group (NWOG) for
oxygen use in the breathless patient.[2] The review highlighted the
dangers of high-flow oxygen (HFO) in COPD during exacerbation...
Two articles appeared in consecutive issues of the EMJ last year regarding emergency oxygen therapy. The first was a comprehensive review
of emergency oxygen therapy for the COPD patient[1] and the second
comprised guidelines prepared by the North West Oxygen Group (NWOG) for
oxygen use in the breathless patient.[2] The review highlighted the
dangers of high-flow oxygen (HFO) in COPD during exacerbations. Evidence
was presented to show that hypercapnia resulting from HFO was strongly
associated with coma and death and that 30 % of patients become rapidly
unconscious with HFO.
This prompted us to examine the scale of the problem in our hospital.
We collected a prospective series of patients, with known COPD, over a six
-month period, from September 2001 to February 2002, presenting in type 2
respiratory failure (pH<_7.35 pacosub="pacosub"/>2>6.0 kPa) who had been given HFO
either in the ambulance or in Accident & Emergency or both.
We identified 27 episodes associated with the prescription of HFO out
of a total 175 admissions with an exacerbation of COPD. HFO was
prescribed in the ambulance in 25 episodes and in two in A&E where
controlled oxygen had been used in the ambulance. pH measurements ranged
between 7.08 and 7.30 (mean 7.21). Patients remaining on HFO when arterial
gas analysis was performed had a mean PaO2 of 20 (range 9.6-37.7) and mean
PaCO2 of 10.6 (range 7.6-13.8). Patients in whom HFO was removed, had
arterial gas analysis breathing air, with a mean PaO2 of 6.3 (range 4.0-
7.7) and mean PaCO2 of 12.4 (range 9.1-16.7)
Nine patients died. Two patients were intubated and ventilated in
ITU, one died. Eleven received non-invasive ventilation, two in HDU, and
four died. Six received doxapram and three died. One patient died in
A&E before therapy was commenced.
Fifteen patients were initially labelled as COPD, 6 as asthma and 6
as other miscellaneous diagnoses or no diagnosis. Seven patients had home
oxygen therapy, but only four of these had this recorded in the ambulance
notes.
All patients remaining on HFO had PaO2 higher than recommended or
physiologically required. This is known to be associated with increased
acidosis,[3] and although the precise mechanism remains controversial, the
association probably results from a combination of removal of hypoxic
drive, increases in physiological dead space and the Haldane effect. The
resultant type 2 respiratory failure carried high morbidity, mortality and
costs. This problem continues despite recent publications. This may in
part be due to incorrect labelling of patients by health professionals or
the patients themselves. However, in the majority of patients it is due to
the deliberate prescription of HFO to patients with COPD.
What should current practice be? Murphy et al.[1] state that
guidelines be as "evidence-based as possible" and they suggest that the
evidence that does exist supports a ‘safe’ level of hypoxia of no lower
than 50mmHg (approximately 6.6kPa or SpO2 85 %) in this group of patients.
The same authors contributed to the guidelines published in the subsequent
issue.[2] Here they advise starting with an inspired oxygen concentration
of approximately 40 % using 4-6 l/min via a medium concentration mask.
They suggest titrating the oxygen upwards to maintain arterial oxygen
saturation at 90 % and decreasing it if the patient becomes drowsy and the
saturation exceeds 93-94 %. Decreasing inspired oxygen in the face of
drowsiness resulting from hypercapnia can be hazardous. Higher alveolar
PCO2 can result in precipitous falls in alveolar PO2 when the inspired
fraction is reduced, with commensurate falls in arterial PO2 seen in some
of our patients. We feel, therefore, that this mode of delivery and
concentration of oxygen may pose unnecessary risk to those patients more
sensitive to the effects of oxygen.
We now recommend:
(1) that all ambulances should carry Venturi masks
since inspired oxygen concentration using simple face masks is highly
dependent upon the inspiratory flow of the patient;
(2) that the initial
choice of mask should deliver 28 % oxygen (the majority of patients will be
safely oxygenated and further Venturi devices may then be used, if
necessary, to titrate the inspired oxygen to achieve saturations above
85 %); and
(3) with respect to correct identification, we are providing at-
risk patients with ‘Respiratory Failure Alert’ credit cards.
While we acknowledge that our data are not part of a randomized
trial, they illustrate that type 2 respiratory failure is a major cause of
morbidity and mortality and there is indirect evidence to suggest an
association between HFO and these outcomes.[3] Until a randomized control
trial of HFO versus controlled oxygen is available, we agree with the NWOG
that guidelines need to be put in place based on current evidence. We
also agree with the recent editorial in the BMJ[4] that oxygen treatment
guidelines should be based on achieving target arterial oxygen tensions
and saturations. Based on the evidence reviewed by Murphy et al.[1] we
favour starting with 28 % Venturi oxygen mask and aiming for SpO2 of 85-90 %
in this group of patients rather than the 40 % oxygen recommended by the
NWOG.[2]
References
(1) Murphy R, Driscoll P, O'Driscoll R. Emergency oxygen therapy for
the COPD patient. Emerg Med J 2001;18:333–339.
(2) Murphy R, Mackway-Jones K, Sammy I, et al. Emergency oxygen therapy
for the breathless patient. Guidelines prepared by North West Oxygen
Group. Emerg Med J 2001;18:421–423.
(3) Plant PK, Owen JL, Elliott MV. One year period prevalence study of
respiratory acidosis in acute exacerbations of COPD: implications for the
provision of non-invasive ventilation and oxygen administration. Thorax
2000;55:550–4.
(4) Thomson AJ, Webb DJ, Maxwell SRJ, et al. Oxygen therapy in acute
medical care.
BMJ 2002;324:1406–1407.
Thanks to Dr Yen and colleagues for their interest. We agree that
the possibility of a case-mix or wound complexity change could account for
bias in this before and after study. However, knowing our case-mix we feel
this is unlikely. Most of our wounds are simple skin lacerations and
anything more complex than this goes to theatre with general or plastic
surgery. It would be unusual for a wound to requ...
Thanks to Dr Yen and colleagues for their interest. We agree that
the possibility of a case-mix or wound complexity change could account for
bias in this before and after study. However, knowing our case-mix we feel
this is unlikely. Most of our wounds are simple skin lacerations and
anything more complex than this goes to theatre with general or plastic
surgery. It would be unusual for a wound to require more than 6 stitches
in our department.
The study would be more robust if we had graded wound complexity, recorded
the number of sutures and length of operation and matched the two groups.
We cannot however at this stage go back to retrieve this data as it will
not all be recorded.
Randomization would have been useful but very difficult to perform.
Randomizing patients would require the doctors to use alternate methods (
traditional suturing v safe suturing) on each patient which is biased in
itself.
Randomizing the doctors would require half the doctors in the department
to use the safe method which creates an ethical problem for the others,
and as these staff work side by side one group would tell the other what
they were doing thus introducing bias.
Randomizing two separate hospital units would introduce case-mix and
cultural bias.
Regardless of the results of the study it was disappointing to note
that needle-handling with fingers and a slightly casual attitude to needle
-handling persisted after the training. This is a concern for us. This is
partly related to the low level of blood-borne virus in the local
population, <1% for Hep C and lower than this for Hep B and HIV. It
would be interesting to perform the study in a unit where anxiety about
blood-borne virus infection was higher and see if compliance and
perforation rates were any better.
We would like to congratulate Harvey and colleagues on their study of
upgauging peripheral venous cannulae in volume resuscitation.
In late 1980's a similar technique was brought to our attention(WDM)
by an obstetrician (Ian Page,MRCOG) who learned it from a senior
obstretrician.For a major obstetric haemorrhage -gentle manual pressure
was applied proximal to the intravenous peripheral can...
We would like to congratulate Harvey and colleagues on their study of
upgauging peripheral venous cannulae in volume resuscitation.
In late 1980's a similar technique was brought to our attention(WDM)
by an obstetrician (Ian Page,MRCOG) who learned it from a senior
obstretrician.For a major obstetric haemorrhage -gentle manual pressure
was applied proximal to the intravenous peripheral cannulae in situ and
20ml of normal saline was injected gently to distend surrounding veins.
The latter was then cannulated with a larger catheter.
Despite the trend for central venous and intraosseous access (and the
morbidity attached)we would fully endorse this technique for volume
resuscitation in most clinical situation.
Headache is a very common presentation in the neurology practice, and
one of the most prevalent consultations in the office.Thus, headache
clinics and/or sub-specialist neurologists with interest in the headache
field become more and more common.
However, in an Emergency Department, things are a lot different from
the chronic headache-suffer patient. The guidelines of the International
Headac...
Headache is a very common presentation in the neurology practice, and
one of the most prevalent consultations in the office.Thus, headache
clinics and/or sub-specialist neurologists with interest in the headache
field become more and more common.
However, in an Emergency Department, things are a lot different from
the chronic headache-suffer patient. The guidelines of the International
Headache Society, for example, do not help the doctor in an ER.
First of all, if the patient present at the ED with a novel symptom,
a headache, and he or she never suffered from this kind of pain, a signal
of alarm must ring: accurate anamnesis and clinical and neurological
examination must be performed with refinement, even in a complex and
movement place. There are also signs of danger, as fever, meningeal signs,
papilar edema, etc.
The patient with a previous history of headache, a migraine for
example, who presents a new type of pain deserve special care.
And in the emergency situation, to benefit the patient, is no shame
to a doctor to rule out organic diseases with a CT, a lumbar puncture and
so. If the results become negative and the treatment of the pain results
in a good picture that is a good thing!
Economics views of such cases, as the managed care ones, or the
simplification of the headaches, the prejudice (“is nothing”,” the patient
is creating a pain”, etc.) should be stronger avoided, especially in
regard to junior doctors and residents.
The paper here published shows interesting results, but the basic
rules must remain – we are managing people, not money.
Dear Editor
Thought provoking as this paper is, it doesn't take account of any 'special awareness' of the problem as percieved by the coronial & reactive health service opinions upon which it is based.
It might not be the case that Brighton's problems are any greater than any other similar conurbation - only that those reacting to your questions are more specifically looking for, and willing to ident...
Dear Editor
The report by De et al.[1] correctly highlights the need for an index of suspicion of a haemorrhage into an arachnoid cyst even after minor trauma. The majority of such cysts are incidental findings and the variety of symptomatology may not make their consideration all too clear. It is important therefore to consider the need for early CT scanning in new or recent onset persistent and localised head...
Dear Editor
We accept, as pointed out by Dr Campbell, that our retrospective findings could be confounded by many factors. Nonetheless our Doctors were on average seeing 154 less patients per six months by the end of the study period.[1]
The concept of developing "ideal practice patterns" is an interesting one and would in itself merit debate. Certainly from the patient's perspective the time waiting to see a...
Dear Editor,
I agree with the findings of the study. My common sense says that If we have a reservoir having a capacity of 10 litres, even if we divide it into two compartments by a shelf, its capacity will remain 10 litres. Unless we increase the size of the reservoir we can not store more than 10 litres in to it.
Dear Editor,
I read with interest the comments regarding the Best Evidence Topic Report (BET) entitled “Incision and drainage preferable to oral antibiotics in acute paronychial nail infection?” and would be delighted to provide justification for the conclusion[1]. Acute paronychia is one of the most common infections of the hand. Far from being a simple digital abscess, acute paronychia represents a dynamic...
Dear Editor
I would like to thank the editors of the EMJ for their replies to the points raised by myself and Dr Webster, however these replies have themselves highlighted further concerns [1][2].
It is clear that considerable effort goes into producing the BETs but as Mr Mackway-Jones states, BETs do not represent the highest level of evidence. Might it not be better to coordinate this effort to produc...
Dear Editor
Two articles appeared in consecutive issues of the EMJ last year regarding emergency oxygen therapy. The first was a comprehensive review of emergency oxygen therapy for the COPD patient[1] and the second comprised guidelines prepared by the North West Oxygen Group (NWOG) for oxygen use in the breathless patient.[2] The review highlighted the dangers of high-flow oxygen (HFO) in COPD during exacerbation...
Dear Editor
Thanks to Dr Yen and colleagues for their interest. We agree that the possibility of a case-mix or wound complexity change could account for bias in this before and after study. However, knowing our case-mix we feel this is unlikely. Most of our wounds are simple skin lacerations and anything more complex than this goes to theatre with general or plastic surgery. It would be unusual for a wound to requ...
Dear Editor,
We would like to congratulate Harvey and colleagues on their study of upgauging peripheral venous cannulae in volume resuscitation.
In late 1980's a similar technique was brought to our attention(WDM) by an obstetrician (Ian Page,MRCOG) who learned it from a senior obstretrician.For a major obstetric haemorrhage -gentle manual pressure was applied proximal to the intravenous peripheral can...
Dear Editor
Headache is a very common presentation in the neurology practice, and one of the most prevalent consultations in the office.Thus, headache clinics and/or sub-specialist neurologists with interest in the headache field become more and more common.
However, in an Emergency Department, things are a lot different from the chronic headache-suffer patient. The guidelines of the International Headac...
Pages