We read with interest the work by Mills and Crawford regarding timely
medicines reconciliation. We have seen similar results in the acute
medical department.
The presence of pharmacists, pharmacy technicians and a formalised
medicines reminder system for junior doctors in acute medicine also
significantly improves the rate of medicines reconciliation in the first
24 hours of an in-patient stay.
We read with interest the work by Mills and Crawford regarding timely
medicines reconciliation. We have seen similar results in the acute
medical department.
The presence of pharmacists, pharmacy technicians and a formalised
medicines reminder system for junior doctors in acute medicine also
significantly improves the rate of medicines reconciliation in the first
24 hours of an in-patient stay.
I read with interest the Commentary by Roland and Coats with regard
to early warning scores(1). The evidence base for the use of track and
trigger systems (TTS)in the Emergency Department is not particularly
strong and I agree that using a system that is designed for hospital
inpatients will not be appropriate for our specific patient group.
The rapid emergency medicine score(REMS) is a physiological scoring
sy...
I read with interest the Commentary by Roland and Coats with regard
to early warning scores(1). The evidence base for the use of track and
trigger systems (TTS)in the Emergency Department is not particularly
strong and I agree that using a system that is designed for hospital
inpatients will not be appropriate for our specific patient group.
The rapid emergency medicine score(REMS) is a physiological scoring
system that was derived in a non-surgical ED in Sweden (2) and
subsequently validated in a study of almost 12,000 patients (3). Area
under ROC curve for in-hospital mortality was 0.852 (Standard Error of the
Mean 0.014). It has also been evaluated in a UK-based study by Goodacre et
al (4).
Clearly, TTS are here to stay and we need one which is appropriate to
our patient population and helps to identify critically ill patients when
they arrive in the ED. REMS was derived on ED patients, includes age as
part of its scoring (itself an independent predictor of mortality) and
studies involving it have much greater sample sizes than work on MEWS. It
has its limitations, in that it has only (so far) been used on medical
patients and it is a more complicated tool than MEWS. Also a recent survey
of UK EDs (conducted by the author) revealed that whilst MEWS is in
widespread use, REMS is not being used at all.
However, if we are looking for a TTS to use in ED, should we not
start with REMS, rather than modify a ward-based system?
A postal survey of 254 UK EDs was undertaken. Responses
were received from 145 departments giving a response rate
of 57%. 87% of respondents are currently using early
warning scores. Of those, 80% are using MEWS, 10% are
using the Patient at Risk Score (PARS) and none are using
REMS. 93% of respondents are in support of early warning
scores in the ED.
References:
1. Roland D, Coats TJ. An early warning? Universal risk scoring in
emergency medicine. Emerg Med J 2010;1.doi10.1136/emj.2010.106104
2. Olsson T, Lind L. Comparison of the Rapid Emergency Medicine Score
and APACHE II in nonsurgical emergency department patients. Acad Emerg Med
2003;10:1040-1048
3. Olsson T, Terent A, Lind L. Rapid emergency medicine score: a new
prognostic tool for in-hospital mortality in nonsurgical emergency
department patients. Journal of Internal Medicine 2004;255:579-587
4. Goodacre S, Turner J, Nicholl J. Prediction of mortality among
emergency medical admissions. Emerg Med J 2006;23:372-375
We congratulate Mueller et al. investigating the usefulness of serum
protein S-100B to save
cranial CT resources in the management of patients with minor head injury
[1]. Although we
definitely support their conclusions about the usefulness of protein S-
100B, two major
concerns regarding the methodology of their study ought to be considered:
Firstly, despite the well-described diagnostic time frame of S-100B...
We congratulate Mueller et al. investigating the usefulness of serum
protein S-100B to save
cranial CT resources in the management of patients with minor head injury
[1]. Although we
definitely support their conclusions about the usefulness of protein S-
100B, two major
concerns regarding the methodology of their study ought to be considered:
Firstly, despite the well-described diagnostic time frame of S-100B as a
screening tool in
minor head injury [2, 3, 4], the authors interpreted the results of two
patients false negative.
However blood sampling of both patients was 11.5 and 48 hours subsequent
to the incident
far beyond recommended time frame to rule out traumatic brain injury,
which was also
mentioned by the authors themself in their discussion section. Therefore
we completely
agree with the authors' recommendation to ensure blood sampling for S-100
B as a screening tool within a maximum of 3 hours following the incident.
If S-100B cannot be measured within 3 hours, it should not be considered
to exclude traumatic brain injury [3].
Secondly, the authors found one patient with a skull fracture not been
detected by serum S-100B. The patient was therefore interpreted as false
negative as well. However protein S- 100B is a brain-specific serum
protein to detect traumatic brain injury not skull fractures.
Compared to missed or delayed diagnosis of traumatic brain injury,
isolated asymptomatic skull fractures do not progress and rarely endanger
patients' health.
Acknowledging these circumstances, the sensitivity and the negative
predictive value of serum-S100B would be 100%. Therefore the authors'
conclusions may mislead clinicians considering the implementation of S-
100B to manage patients with minor head injury in the
emergency department. Clinicians intending serum protein S-100B as a
screening tool for decision making in adult mild traumatic brain injury in
the acute setting should be familiar with its capabilities and
limitations. If those are considered, S-100B is able to reduce the number
of cranial CT by 30% [4].
Yours sincerely,
M. Zock, Chirurgische Klinik und Poliklinik, Campus Innenstadt,
Klinikum der Universitaet
Muenchen, Germany
Dr. B.A. Leidel, MD, Interdisziplinaere Rettungsstelle und
Notfallaufnahme, Campus Benjamin
Franklin, Charite - Universitaetsmedizin Berlin, Germany
References:
1. Mueller B, Evangelopoulos DS, Bias K et al. (2010) Can S-100B
serum protein help to save cranial CT resources in a peripheral trauma
centre? A study and consensus paper. Emerg Med J.
DOI:10.1136/emj.2010.095372
2. Townend W, Dibble C, Abid K et al. (2006). Rapid elimination of
protein S-100B from serum after minor head trauma. J Neurotrauma. 23(2):
149-155
3. Jagoda AS, Bazarian JJ, Bruns JJ et al. from the American College
of Emergency Physicians and Centers for Disease Control and Prevention
(2008). Clinical Policy: Neuroimaging and decision making in adult mild
traumatic brain injury in the acute setting. Ann Emerg Med. 52: 714-748
4. Biberthaler P, Linsenmeier U, Pfeifer KJ et al. (2006). Serum S-
100B concentration provides additional information for the indication of
computed tomography in patients after minor head injury: a prospective
multicenter study. Shock. 25(5): 446-453
I was working at a A&E department in North West few years ago and had
similar questions as to why patients not taking any analgesia before
attending the department. I did a survey on this matter and this is the
result of the survey.
Objectives
To determine the percentage of patients attending the accident and
emergency department with pain but without taking any analgesia prior t...
I was working at a A&E department in North West few years ago and had
similar questions as to why patients not taking any analgesia before
attending the department. I did a survey on this matter and this is the
result of the survey.
Objectives
To determine the percentage of patients attending the accident and
emergency department with pain but without taking any analgesia prior to
attendance and to find out the reasons for not taking analgesia.
Methods
A questionnaire was filled by 122 patients attended the minor unit of
accident and emergency department.
Results
57% of patients had not taken any analgesia. Most of the patients
(61%) were less than 45 years old and 64% of them had not taken any
analgesia. Nearly 80% of patients presented with limb pain and 64% of them
had not taken any analgesia. Main reasons for not taking analgesia were
'have not thought about taking it' (51.4%), 'did not think need any'
(8.6%), 'did not have any' (7.2%) and 'did not like taking them' (5.7%).
Nearly 94% of patients who had not taken analgesia were eventually
discharged home with analgesia as the definite management. Out of 43% of
patients who had taken analgesia, paracetamol was the main choice.
Conclusion
There was high proportion of patients attending the accident and
emergency department without any analgesia. Most of these patients were
eventually discharged home with analgesia. Improvement in patients
awareness and education is recommended.
We are incredibly glad to hear that Dr. Sherren has taken an interest
in our research (1). I concur with his position on this matter. I believe
that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac
arrest patients will be solved through near future technologies such as
extracorporeal membrane oxygenators. However, if we divide cardiac arrests
broadly into in-hospital and out-of-hospital, or on-site arrests...
We are incredibly glad to hear that Dr. Sherren has taken an interest
in our research (1). I concur with his position on this matter. I believe
that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac
arrest patients will be solved through near future technologies such as
extracorporeal membrane oxygenators. However, if we divide cardiac arrests
broadly into in-hospital and out-of-hospital, or on-site arrests, we must
admit that, even in the future, on-site treatment will largely rely upon
CPR administered by other persons who are on-hand. Therefore, it is
necessary that resuscitation research on the often overlooked ergonomic
aspects of CPR be revitalized and brought to greater focus. The starting
point for an ergonomic approach to CRP research will have to begin with
the effectiveness of chest compressions. Already, in the 2005 guidelines,
the importance of chest compression was emphasized (2). Within such
emphasis, our research group is especially interested in the influence the
relative body positions of the patient in need of CPR and the rescuer have
on the quality of CPR administered. Previous research in this area
indicates that it is most effective to administer CPR from a kneeling
position (CPRKP) on a patient who is on the floor (3). If this is true,
there is a need to identify what factors cause CPR administered from a
standing position (CPRSP) on a patient who lies on the bed to be less
effective. Research such as this must look at the rescuer's changes in
body positioning, as well as other factors, from an ergonomics perspective
in order to be most effective. Under the assumption that making the
conditions of performing CPRSP more similar to those of CPRKP would reduce
the loss of effectiveness associated with CPRSP, our research team
postulated the following hypotheses: 1) that if the bed on which the
patient lies were to be lowered to the height of the rescuer's knees
during CPRSP, the rescuer would be able to perform CPR in basically the
same position as with CPRKP and 2) that rather than placing the patient on
a mattress and then a backboard, removing the mattress altogether will
improve the conditions of administering CPR. The current study that we are
presenting is the first of several studies being conducted regarding these
hypotheses. We feel that Dr. Sherren's suggestion of having the rescuer
perform CPR while kneeling on the bed itself (CPRKOB) is also a valid
hypothetical solution to solving the problem of loss of effectiveness
associated with performing CPR on patients in beds. However, this too must
undergo rigorous performance studies. While there are cases in which
CPRKOB has been performed in clinical settings, most clinical beds are not
very strong, and thus a level of instability is often a factor in such
cases. This is especially true of smaller emergency-room gurneys. Indeed,
it may be true that the simplest solution to preventing the loss of
effectiveness in CPR performed on patients in beds is to remove the beds
altogether. However, procedures such as endotracheal intubation and
vascular access, as well as various monitors attached to a patient may
make the act of removing a patient from a bed in order to perform CPR
unrealistic; extensive performance studies would have to be performed in
order to make any sort of a persuasive argument for such a procedure. As
Dr. Sherren has pointed out, mannequin-based performance studies have not
beed recognized as very important because they lack things as chest recoil
and thoracic pump effects - therefore, making them less desirable than
animal and clinical trials. However, considering that CPR is a procedure
directly performed by persons, performance studies will give us the best
evidence for the creation of guidelines for effective CPR. Again, we thank
Dr. Sherren for his attention to our research and give him our regards.
References
1. PB Sherren. Effects of bed height on the performance of chest
compressions - Clinical application of results. Emerg Med J 2010;eLetter
2. International Liaison Committee on Resuscitation. International
consensus on cardiopulmonary resuscitation and emergency cardiovascular
care science with treatment recommendations. Part 2. Adult basic life
support. Resuscitation 2005;67:187-201.
3. Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different
mattresses affect the quality of cardiopulmonary resuscitation? Intensive
Care Med 2003;29:2330-5.
We read with interest the case report by Abeysinghe and colleagues
reporting hyperinsulinaemic euglycaemic therapy (HIET) in the treatment of
a patient presenting with persistent hypotension following an overdose of
the lipophilic calcium channel blocker diltiazem.[1]
Diltiazem is extremely lipophilic with a log P value of 4.53 (a
measure of lipid solubility). Thus we consider that it would have been
amenable t...
We read with interest the case report by Abeysinghe and colleagues
reporting hyperinsulinaemic euglycaemic therapy (HIET) in the treatment of
a patient presenting with persistent hypotension following an overdose of
the lipophilic calcium channel blocker diltiazem.[1]
Diltiazem is extremely lipophilic with a log P value of 4.53 (a
measure of lipid solubility). Thus we consider that it would have been
amenable to treatment with intravenous lipid emulsion (ILE). This new and
emerging addition to the treatment arsenal of lipophilic drug overdoses is
supported by a rapidly expanding body of experimental work and clinical
cases. The effectiveness of ILE in reversing local anaesthetic induced
cardiovascular collapse has been unequivocally demonstrated in animal
studies, and recent attention has turned to non-local anaesthetic
applications.[2] The role of ILE has extended to include suppression of
the toxic effects of verapamil and recently the first case report
describing a successful outcome with the use of ILE combined with HIET for
the treatment of diltiazem overdose has been published.[3]
Abeysinghe and colleagues astutely noted that in calcium channel
blocker overdose 'myocardial extraction of free fatty acids is decreased
despite maintained plasma levels'. ILE is believed to have several
beneficial effects with enhancement of myocardial fatty acid transport
appearing to be one of the ways in which physiological and metabolic
integrity might be restored. Secondly, ILE binds lipophilic drugs within
an expanded intravascular lipid phase (the 'lipid sink' effect), thereby
reducing the amount of drug available to exert its toxic effects. Finally,
ILE may act via a direct inotropic action by increasing cardiac
intracellular calcium concentration.[2] With evidence for the
effectiveness of ILE in lipophilic drug overdoses increasing we believe it
may become a standard intervention in the treatment of calcium channel
blocker overdose either as monotherapy or possibly alongside HIET.
Dr Theophilus Luke Samuels
Dr David R Uncles
Dr Johann W Willers
Dr Aikaterini Papadopoulou
References
1 Abeysinghe N, Aston J, Polouse S. Diltiazem overdose: a role for
high-dose insulin. Emerg Med J 2010;27:802-3.
2 Cave G, Harvey M. Intravenous Lipid Emulsion as Antidote Beyond
Local Anaesthetic Toxicity: A Systematic Review. Acad Emerg Med
2009;16:815-24.
3 Montiel V, Gougnard T, Hantson P. Diltiazem poisoning treated with
hyperinsulinemic euglycemia therapy and intravenous lipid emulsion. Eur J
Emerg Med Published Online First: 17 November 2010. doi:
10.1097/MEJ.0b013e32834130ab.
We would like to thank van Veen et al. for their evaluation of the
Manchester Triage System (MTS) in children. This study was based on
simulated case scenario to investigate the repeatability of triage, with a
total compliance of nurses with the MTS. We would like to highlight that
in real life experience, strict adherence of nurses to triage protocol is
rare.
Wacher et al. (evaluating the implementation of a set of stan...
We would like to thank van Veen et al. for their evaluation of the
Manchester Triage System (MTS) in children. This study was based on
simulated case scenario to investigate the repeatability of triage, with a
total compliance of nurses with the MTS. We would like to highlight that
in real life experience, strict adherence of nurses to triage protocol is
rare.
Wacher et al. (evaluating the implementation of a set of standardized
pediatric telephone triage protocols) have found that 58% of nurses felt
confined to the protocols, and 42% admitted intentional deviation from
them, when they believed that optimal patient care mandated that they do
so .1 Correlation among dispositions determined by triage providers was
poor, despite instructions to follow protocols as closely as possible.
Although it is a basic assumption that protocols operate by
standardization, these results indicate that nurses did not reliably
choose the same protocol in a given case and did not reach the same triage
endpoint even when they followed the same protocol. As suggested by Poole
et al., nurses may decide under some circumstances to follow their
intuition rather than the recommendations. 2 Piccotti et al. evaluated the
percentage of consistency with the triage process drawn up at the level of
pediatric emergency department (ED), and concluded that they were a need
for further efforts to improve compliance with the protocol and pursue a
higher degree of uniformity in evaluation by triage personnel. 3 The
triage in ED relies on two key factors: accurate triage tools for
identifying major cases, and compliance of medical staff with the triage
protocols. The MTS must be studied rigorously in daily practice before it
can be safely disseminated for general use, as far as many bias linked
with poor adherence can make it less seducing in practice.
1. Wacher DA, Brillman JC, Lewis J, Sapien RE. Pediatric Telephone
triage protocols: standardized decisionmaking or false sense of security?
Ann Emerg Med 1999; 33: 388- 94.
2. Poole SR, Schmitt BD, Carruth T et al: After-hours telephone coverage:
The application of an area-wide telephone triage and advice system for
pediatric practices. Pediatrics 1993; 92: 670-79.
3. Picotti E, Magnani M, Tubino B et al. Assessment of the triage system
in a pediatric emergency department. A pilot study of critical codes. J
Prev Med Hyg 2008; 49: 120-23.
Ischemia modified albumin (IMA) has recently been proposed for the
early detection of myocardial ischemia without infarction [1]. We read
with interest the article of Ming-Hui Lin, who evaluated this marker as an
early negative predictor of acute coronary syndrome (ACS) in different
time to presentation groups and different cardiac risk groups [2]. The
authors asserted that IMA is a relatively new test, performed on diffe...
Ischemia modified albumin (IMA) has recently been proposed for the
early detection of myocardial ischemia without infarction [1]. We read
with interest the article of Ming-Hui Lin, who evaluated this marker as an
early negative predictor of acute coronary syndrome (ACS) in different
time to presentation groups and different cardiac risk groups [2]. The
authors asserted that IMA is a relatively new test, performed on different
instruments and with no universal standardisation, so that different
laboratories are likely to produce different test results. This is however
only partially true. In a previous study we have comprehensively addressed
this issue, highlighting that the diagnostic performances of IMA are
influenced by some analytical drawbacks. In particular, there is a
significant inverse association between IMA and serum albumin, so that the
"raw" IMA serum values in patients with extremely low or high serum
albumin levels (i.e., <20 or >55 g/L) may be unreliable and lacking
in clinically informative value. To overcome this limitation, we have
thereby proposed the use of a corrective formula, as follows: [(individual
serum albumin concentration/median albumin concentration of the
population) x IMA value] [3]. The major advantage of this equation is the
normalization of test results for the concentration of serum albumin in
the samples. We have also demonstrated that this approach is effective to
(i) substantially reduce the otherwise heterogeneous distribution of
values in heath and disease while maintaining the median IMA concentration
substantially unchanged, and (ii) overcome the bias arising from various
methods and instrumentation, thus contributing to harmonize results among
different laboratories and techniques. Although we agree that IMA might
not be a reliable negative predictor for ACS using the manufacturer cut-off, it might be advisable to re-evaluate the results of Ming-Hui Lin
normalizing results for serum albumin by using our corrective formula.
The Corresponding Author has the right to grant on behalf of all
authors and does grant on behalf of all authors, an exclusive licence (or
non exclusive for government employees) on a worldwide basis to the BMJ
Publishing Group Ltd and its Licensees to permit this article (if
accepted) to be published in EMJ editions and any other BMJPGL products
to exploit all subsidiary rights, as set out in our
licence(http://group.bmj.com/products/journals/instructions-for-
authors/licence-forms)."
Competing Interest: None to declare.
References.
1. Lippi G, Montagnana M, Salvagno GL, Guidi GC. Potential value for new
diagnostic markers in the early recognition of acute coronary syndromes.
CJEM 2006;8:27-31.
2. Lin RM, Fatovich DM, Grasko JM, Vasikaran SD. Ischaemia modified
albumin cannot be used for rapid exclusion of acute coronary syndrome.
Emerg Med J. 2010;27:668-71
3. Lippi G, Montagnana M, Salvagno GL, Guidi GC. Standardization of
ischemia-modified albumin testing: adjustment for serum albumin. Clin Chem
Lab Med 2007;45:261-2.
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven tha...
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven that nail polish effects the accuracy of pulse oximeters [1]. However, several randomized,
controlled trials with both healthy persons and critically ill patients report on the effect of nail polish on oxygen saturation measured by pulse
oximetry [2, 3, 4]. Interestingly, some of these studies have been cited by the authors themselves.
Sample size calculation prior to beginning of a trial is obligate to determine the significance of results. Unfortunately, in this trial an adequate mathematical sample size calculation was obviously waived.
Therefore, results of the present study cannot be interpreted regarding both the statistical significance and the clinical relevance.
To determine pulse oximetry accuracy, intermittent arterial blood gas analyses (ABGA) are essential [3]. However, accuracy in the present study was only determined by consecutive pulse oximeter measurements over a specific duration, which may alter pulse oximetry readings. A major limitation of the present study is that accuracy is not analyzed in the
present study although it is most important in patients who have nail polish applied, e.g. to identify hypoxia. The authors only report on mean
values (given in percent) but omit to verify their measurements, e.g. with ABGA.
Additionally, the presented results also lack standard deviation
(SD). Independently, one may assume that the presented differences (max. 1,25%) are not clinically relevant, which is in congruency to other publications [2, 3, 4].
In the present trial one may therefore speculate the differences identified might be due to slightly alternating oxygen saturation values in spontaneously breathing persons.
In conclusion, the present study does not add significant new data for nail polish to the present knowledge.
References:
[1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E, Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen saturation determined by pulse oximetry in healthy young adult females. Emerg Med J. 2010 Oct 5. [Epub ahead of print]
[2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail polish on pulse oximetry. Anesth Analg 1988;67:683
[3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation. 2007 Jan;72(1):82-91
[4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intensive Crit Care Nurs. 2007 Feb;23(1):51-5.
Muller et al report that S-100B had a specificity of 12.2% and a
sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker
for CCT triage may improve patient screening and decrease the number of
CCT scans performed. However, if we were to roll a 6-sided die and call
the number 6 negative and the numbers 1 to 5 positive we would expect to
have a test with similar parameters: 83.3% sensitivity (i.e. positiv...
Muller et al report that S-100B had a specificity of 12.2% and a
sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker
for CCT triage may improve patient screening and decrease the number of
CCT scans performed. However, if we were to roll a 6-sided die and call
the number 6 negative and the numbers 1 to 5 positive we would expect to
have a test with similar parameters: 83.3% sensitivity (i.e. positive 5/6
times in those with the disease) and 16.6% specificity (i.e. negative 1/6
times in those without the disease). This illustrates how adopting a low
threshold for positivity can produce and apparently high sensitivity at
the expense of specificity for an essentially worthless test (like rolling
a die). Reporting likelihood ratios overcomes this problem. The likelihood
ratios for a positive and negative test based on the estimates of
sensitivity and specificity reported by Muller are 0.98 and 1.11
respectively.
In fact, the performance of S-100B may not be quite as bad as their
reported estimates suggest. Based on the data reported in Table 2 the
sensitivity is indeed 86.4% (19/22) but the specificity is actually 31.8%
(67/211), giving positive and negative likelihood ratios of 1.27 and 0.43
respectively. This is still not much help for decision-making but probably
better than rolling a die.
We read with interest the work by Mills and Crawford regarding timely medicines reconciliation. We have seen similar results in the acute medical department.
The presence of pharmacists, pharmacy technicians and a formalised medicines reminder system for junior doctors in acute medicine also significantly improves the rate of medicines reconciliation in the first 24 hours of an in-patient stay.
Dr Tom...
I read with interest the Commentary by Roland and Coats with regard to early warning scores(1). The evidence base for the use of track and trigger systems (TTS)in the Emergency Department is not particularly strong and I agree that using a system that is designed for hospital inpatients will not be appropriate for our specific patient group.
The rapid emergency medicine score(REMS) is a physiological scoring sy...
Sir,
We congratulate Mueller et al. investigating the usefulness of serum protein S-100B to save cranial CT resources in the management of patients with minor head injury [1]. Although we definitely support their conclusions about the usefulness of protein S- 100B, two major concerns regarding the methodology of their study ought to be considered: Firstly, despite the well-described diagnostic time frame of S-100B...
Dear sir
I was working at a A&E department in North West few years ago and had similar questions as to why patients not taking any analgesia before attending the department. I did a survey on this matter and this is the result of the survey.
Objectives
To determine the percentage of patients attending the accident and emergency department with pain but without taking any analgesia prior t...
We are incredibly glad to hear that Dr. Sherren has taken an interest in our research (1). I concur with his position on this matter. I believe that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac arrest patients will be solved through near future technologies such as extracorporeal membrane oxygenators. However, if we divide cardiac arrests broadly into in-hospital and out-of-hospital, or on-site arrests...
We read with interest the case report by Abeysinghe and colleagues reporting hyperinsulinaemic euglycaemic therapy (HIET) in the treatment of a patient presenting with persistent hypotension following an overdose of the lipophilic calcium channel blocker diltiazem.[1]
Diltiazem is extremely lipophilic with a log P value of 4.53 (a measure of lipid solubility). Thus we consider that it would have been amenable t...
We would like to thank van Veen et al. for their evaluation of the Manchester Triage System (MTS) in children. This study was based on simulated case scenario to investigate the repeatability of triage, with a total compliance of nurses with the MTS. We would like to highlight that in real life experience, strict adherence of nurses to triage protocol is rare. Wacher et al. (evaluating the implementation of a set of stan...
Ischemia modified albumin (IMA) has recently been proposed for the early detection of myocardial ischemia without infarction [1]. We read with interest the article of Ming-Hui Lin, who evaluated this marker as an early negative predictor of acute coronary syndrome (ACS) in different time to presentation groups and different cardiac risk groups [2]. The authors asserted that IMA is a relatively new test, performed on diffe...
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven tha...
Muller et al report that S-100B had a specificity of 12.2% and a sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker for CCT triage may improve patient screening and decrease the number of CCT scans performed. However, if we were to roll a 6-sided die and call the number 6 negative and the numbers 1 to 5 positive we would expect to have a test with similar parameters: 83.3% sensitivity (i.e. positiv...
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