We read with interest the article by Shamini et al[1], in which he
suggested that primary care services should be more responsive to needs of
the older adolescent age. Here we intend to introduce some new policies
recently implemented in hospitals in Beijing, China.
Beijing has begun implementing its public hospital reform programs
since July 1, 2012 [2]. Patients are charged a medical care service fee
which va...
We read with interest the article by Shamini et al[1], in which he
suggested that primary care services should be more responsive to needs of
the older adolescent age. Here we intend to introduce some new policies
recently implemented in hospitals in Beijing, China.
Beijing has begun implementing its public hospital reform programs
since July 1, 2012 [2]. Patients are charged a medical care service fee
which varies according to doctor's seniority while the 15 percent
pharmaceutical markup is eliminated, aiming at reducing hospitals'
dependency on profits from drug prescriptions and fine-tuning the
structure of hospitals' incomes.
Under the policy, the consultation fee varies from 42, 60, 80 to 100
yuan, based on a doctor's qualifications. For emergency care services, 62
yuan are discharged. Patients under the medical care insurance system are
reimbursed 70 percent of prescription medicine fees and they only have to
pay 2 yuan to see a general practitioner. Statistics from Beijing Chao-
yang Hospital shown that the average medical cost has been decreasing[3].
Moreover, patients can make appointments via online registration platform
or by telephone, which makes it easier for them to see a top specialist.
The new medical care service fee better represents the value of and
pays respect to physicians' work. It helps doctors boost incomes and lower
incentives to prescribe unnecessary and expensive drugs. Moreover, it is
beneficial to improve quality of medical services and better utilize
limited medical resources.
However, stemming the flow of complaints from patients is not easy.
Loopholes still remain. For patients without insurance, especially those
with minor ailments, they have to pay more for registrations than before.
In addition, the uneven distribution of medical resources and the huge
pressure of extra work-load of medical personnel[4] remain as problems
urgently needed to be tackled.
We welcome the government's efforts to boom health care
expenditure[5] and improve people's well-beings. But more work is still
required to establish a reasonable, effective, and optimized medical
service system in China.
We declare that we have no conflicts of interest.
References
1 Gnani S, McDonald H, Islam S, et al. Patterns of healthcare use
among adolescents attending an urban general-practitioner-led urgent care
centre. Emerg Med J Published Online First, doi:10.1136/emermed-2012-
202017.
2 Wang QY. Hospital to stop selling medicine at markup. China Daily
Jun 28, 2012.
http://www.chinadaily.com.cn/china/2012-
06/28/content_15533323.htm(accessed Jun 16, 2013)
3 Wang. Public hospital reform proves effective. CRI English Nov 13,
2012. http://english.cri.cn/7146/2012/11/13/2361s732309.htm (accessed Jun
16, 2013)
4 Wang W. How to make it easier to see doctors in Beijing. CRI
English Jan 2, 2013. http://english.cri.cn/7146/2013/01/02/2361s741648.htm
(accessed Jun 16, 2013)
5 Liu J. Health care expenditure booms in China: report. China Daily
Aug 29, 2012. http://www.chinadaily.com.cn/business/2012-
08/29/content_15717138.htm (accessed Jun 16, 2013)
We have read with great interest the article by Rickard et al. [1]
concerning with the management of raised intracranial pressure in course
of traumatic brain injury. More in detail, the sugar alcohol mannitol,
derived from fructose hydrogenation (sorbitol isomer), is a hyperosmolar
diuretic agent. Clinically, mannitol can be administered through a central
or peripheral venous catheter in the treatment of raised intracran...
We have read with great interest the article by Rickard et al. [1]
concerning with the management of raised intracranial pressure in course
of traumatic brain injury. More in detail, the sugar alcohol mannitol,
derived from fructose hydrogenation (sorbitol isomer), is a hyperosmolar
diuretic agent. Clinically, mannitol can be administered through a central
or peripheral venous catheter in the treatment of raised intracranial /
intraocular pressure or during surgical and anesthetic procedures [2] at
risk for intracranial / intraocular pressure raising. It is well known
that high doses of mannitol (more than 200 g/day) can cause acute renal
failure and hyperglycemic state, occasionally accompanied by seizures,
stupor and coma. The administration of mannitol is therefore to be avoided
in uremic and diabetic patients. Recently, our risk management and
research group for anaphylaxis has reported the sentinel event of an
intraoperative anaphylactic death due to mannitol infusion in an atopic
patient with specific IgE against carbohydrate cross-reactive determinants
(CCDs) [3]. The administration of mannitol should be avoided in
multiallergic patients (e.g. graminaceae, canine grass, peanuts) with
specific IgE against CCDs [4-5]. In these patients, especially in life-
threatening conditions with the need for intravenous delivery, the
administration of hypertonic sodium solution is to be preferred, in order
to prevent anaphylactic reactions.
REFERENCES
1) Rickard AC, Smith JE, Newell P, Bailey A, Kehoe A, Mann C. Salt or
sugar for your injured brain? A meta-analysis of randomised controlled
trials of mannitol versus hypertonic sodium solutions to manage raised
intracranial pressure in traumatic brain injury. Emerg Med J. Published
Online First: 28 June 2013. doi: 10.1136/emermed-2013-202679
2) Schmid P, Wuthrich B. Peranaesthetic anaphylactoid shock due to
mannitol. Allergy 1992;47:61-2.
3) Roncati L, Barbolini G, Scacchetti AT, Busani S, Maiorana A.
Unexpected death: anaphylactic intraoperative death due to Thymoglobulin
carbohydrate excipient. Forensic Sci Int 2013;228:28-32.
4) Hegde VL, Venkatesh YP. Anaphylaxis to excipient mannitol:
evidence for an immunoglobulin E-mediated mechanism. Clin Exp Allergy
2004;34:1602-9.
5) Commins SP, Platts-Mills TA. Anaphylaxis syndromes related to a
new mammalian cross-reactive carbohydrate determinant. J Allergy Clin
Immunol 2009;124:652-7.
The article by Gill et al1 provides further evidence that a log-roll
is not useful for major trauma patients in the primary survey. Even with
a GCS 15 and no influence from alcohol or opiates only 60% of patients
with thoraco-lumbar fractures had tenderness on log-roll. The authors did
not examine how many false negatives were found by examination or the
impact of a distracting injury.
The article by Gill et al1 provides further evidence that a log-roll
is not useful for major trauma patients in the primary survey. Even with
a GCS 15 and no influence from alcohol or opiates only 60% of patients
with thoraco-lumbar fractures had tenderness on log-roll. The authors did
not examine how many false negatives were found by examination or the
impact of a distracting injury.
Log-rolling a polytrauma patient in the primary survey is potentially
life-threatening if the patient has a site of internal haemorrhage as this
movement may lead to clot disruption and irretrievable exsanguination. The
log-roll causes pain in the presence of injury and provokes anxiety which
may worsen the patient's physiological state. For blunt trauma there is no
evidence that injuries missed by inspection of the back will lead to the
patients demise (although all penetrating trauma will require examination
of the back for occult wounds). Studies have also shown that the log-roll
may induce spinal movement which may be damaging in the presence of
fractures.2,3
As clinicians at the 3 adult Major Trauma Centres in the West
Midlands we advocate no log roll during the primary survey for a blunt
trauma patient with a mechanism of injury triggering a local major trauma
triage tool. The patient should instead be transferred supine using a
suitable device, such as an orthopaedic scoop stretcher onto a vacuum
mattress or Wolverson transfer mattress. Whilst clinical examination in
the primary survey is important, an immediate CT (from head to pelvis
under the supervision of the trauma team) can rapidly and reliably exclude
life-threatening injuries without examination of the back.
When a senior decision has been made that the patient does not
require a CT scan (or a CT scan has been reported as showing no internal
haemorrhage, visceral injury or pelvic fracture) it is then appropriate to
log-roll the patient to assess the back for further injury.
1. Gill DS, et al. Can initial clinical assessment exclude
thoracolumbar vertebral injury?Emerg Med J 2013;30:679-682
2. Suter RE, Tighe TV, Sartori J, et al. Thoraco-lumbar instability
during variations of the log roll maneuver. Prehospital Disaster Med
1992;7:133-8.
3. MacGuire RA, Neville S, Green BA, Watts C. Spinal instability and
the log-rolling maneuver. J Trauma 1987;27:525-31.
I have been teaching first aid to the public for the last six years.
My personal experience is that many members of the public are worried
about becoming involved in emergency situations due to fears around
litigation and "doing things wrong".
Almost every first aid course I teach I answer questions regarding
the legal situation...
I have been teaching first aid to the public for the last six years.
My personal experience is that many members of the public are worried
about becoming involved in emergency situations due to fears around
litigation and "doing things wrong".
Almost every first aid course I teach I answer questions regarding
the legal situation around first aid and the risk of being sued or
investigated. I personally feel our blame culture and the rise of 'no win,
no fee' claim services is the cause of this.
I strongly believe first aid is much more than just rehearsing
practical skills. A first aider is required to step up in an emergency
situation, to get involved and make potentially life saving decisions.
First aid syllabuses need to recognise this rather than focusing on
mundane practical skills such as the 101 uses of a triangular bandage.
I hope this pilot study sparks interest and leads to further research
into the content and delivery of first aid courses.
Yours sincerely,
Chris Jefferies
Conflict of Interest:
I am a first aid trainer for the British Red Cross
We read the article Optimal position for external chest compression
during cardiopulmonary resuscitation: an analysis based on chest CT in
patients resuscitated from cardiac arrest by Kyoung Chul Cha et al with
interest. This article has added a new concept in CPR.
Cardiopulmonary resuscitation (CPR) is a life saving emergency procedure
and it should be done as per protocol. ACC/AHA guideline2010 suggest that
effective c...
We read the article Optimal position for external chest compression
during cardiopulmonary resuscitation: an analysis based on chest CT in
patients resuscitated from cardiac arrest by Kyoung Chul Cha et al with
interest. This article has added a new concept in CPR.
Cardiopulmonary resuscitation (CPR) is a life saving emergency procedure
and it should be done as per protocol. ACC/AHA guideline2010 suggest that
effective cardiopulmonary resuscitation should include chest compression
at a rate of ?100/min with a depth of chest compression of ?5cm. The
effective site of chest compression suggested is lower half of the sternum
[1,2]. This cardiopulmonary resuscitation concept has been questioned in
some of the recent studies. Chest compression rate of >120/min can
compromise the effective chest recoil which in turn will reduce the
preload and cardiac output. High rate of chest compression will also
decrease the passive air inhalation during cardiopulmonary resuscitation
which is so vital in hand only CPR [3]. There are also differences of
opinion regarding the site of chest compression. A recent study has shown
that optimal hand position for external chest compression is at the level
of sterno xiphoid junction. When chest compression is checked with CT
images displayed at the window width of 400 HU and a window level of 40
HU, it has confirmed that compression at this level covers the widest
total heart, total ventricular and left ventricular area. Therefore it is
suggested that the level of sterno xiphoid junction should be the point of
chest compression during CPR [4]. Further studies are needed to amend the
chest compression protocol.
References
1.Sayre MR, Koster RW, Botha M, et al. Part 5: Adult basic life
support: 2010International consensus on cardiopulmonary resuscitation and
emergency cardiovascular care science with treatment
recommendations.Circulation2010;122:S298e324.
2.Berg RA, Hemphill R, Abella BS, et al. Part 5: Adult basic life
support: 2010American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care.Circulation2010;122(18
Suppl. 3):S685e705.
3.Koster RW, Baubin MA, Bossaert LL, et al. European Resuscitation
Council guidelines for resuscitation 2010. Section 2. Adult basic life
support and use of automated externaldefibrillators.Resuscitation2010;
81:1277e92.
4.Does the quality of chest compression deteriorate when the chest
compression rate is above 120/min? Soo Hoon Lee, Kyuseok Kim, Jae Hyuk Lee
et al Emerg Med J Published Online First: 23 May 2013 doi:10.1136/emermed-
2013-202682
5.Optimal position for external chest compression during
cardiopulmonary resuscitation: an analysis based on chest CT in patients
resuscitated from cardiac arrest. Kyoung Chul Cha, Yeong Jun Kim, Hyung
Jin Shin et al Emerg Med J 2013;30:8 615-619.
Proposed response
Dear Editor,
We thank the writers for their interest in our work and for the most part
agree with them. (1)(2) We fully agree that bronchiolitis is a clinical
diagnosis; it is because the viral aetiology cannot be determined
clinically that testing is contemplated. We also agree that specific
treatment is not yet available; although RSV specific drugs are being
developed and it behooves emergency depart...
Proposed response
Dear Editor,
We thank the writers for their interest in our work and for the most part
agree with them. (1)(2) We fully agree that bronchiolitis is a clinical
diagnosis; it is because the viral aetiology cannot be determined
clinically that testing is contemplated. We also agree that specific
treatment is not yet available; although RSV specific drugs are being
developed and it behooves emergency departments to at least start
considering how they will respond when these treatments do become
available.
Cohorting is actually a controversial topic. Because different strains of
respiratory syncytial virus (RSV) circulate during the same season, and
dual infection with different viruses does occur, antigen testing to
cohort patients risks re-infecting infants with a different RSV strain or
another virus. We recognize that such limitations are unavoidable in some
settings, but felt that such discussion was beyond the scope of our
manuscript.
In presenting a single positive and negative predictive value Beattie et
al (1) allude to a key point of our paper. Prevalence is dynamic because
both RSV and bronchiolitis are seasonal and sometimes have more than a
single peak. Predictive values provide this information but are
susceptible to prevalence which is dynamic. For example, a patient using
an assay with the characteristics described in the letter writers' 2011
paper(3) who tested positive when RSV prevalence is 10% would have only a
35% chance of actually having RSV. Our modeling addresses the dynamic
nature of RSV prevalence in a way that a static average measure cannot.
Such contextual interpretation maximizes the value of testing, including
when such testing is being used for cohorting in the manner Beattie et al
describe.
It also seems reasonable to assume that some antigen tests may perform
better than others. However study methodology may also affect results. The
writers' own paper (using PCR) appears to have evaluated the antigen test
over a four month period in infants whom either senior nurses or doctors
anticipated hospital admission. This is a legitimate clinical practice,
but as a research design it diminishes both the external validity and
generalizability. When measuring a test's diagnostic performance it is
generally best to include a broad range of disease severity over a number
of seasons (to address potential problems of antigenic drift affecting
test performance (4)).
Although confidence intervals were not presented in the letter writers'
2011 paper they can be calculated and for sensitivity overlap with ours.
The sensitivity 83.4% (95% CI 78.9%, 87.3%) was not different from ours
(79.4%, 95% CI 73.9%, 84.2%). Our measurements of specificity 83.1% (95%
CI 77.9%, 87.5%) compared with 67.1% (95% CI 61.9%, 72%) do differ. This
likely reflects the differences in inclusion criteria between our two
studies. The letter writers' additional unreferenced set of test
characteristics does not include enough information to allow their
evaluation.
We had to be selective in the references we cited because of space
limitations; this does not diminish the value of cohorting papers that
were not cited, rather it reflects the focused nature of the research
question we addressed and (an unrequited) desire to avoid tangential
controversies.
Yours sincerely,
Paul Walsh, Christina Overmyer, Christine Hancock, Jacquelyn Heffner,
Nicholas Walker, Thienphuc Nguyen, Lucas Shanholtzer, Enrique Caldera,
James Pusavat, Eli Mordechai, Martin E Adelson, Kathryn T Iacono
(1) Beattie TF, McLellan K, Templeton K. Near-patient testing for RSV in
the emergency department. Emerg Med J 2013, Rapid Response available at
http://emj.bmj.com/content/early/2013/08/20/emermed-2013-
202729.full/reply#emermed_el_16338
(2) Walsh P, Overmyer C, Hancock C, Heffner J, Walker N, Nguyen T, et al.
Is the interpretation of rapid antigen testing for respiratory syncytial
virus as simple as positive or negative? Emerg Med J 2013 (20 August 2013,
10.1136/emermed-2013-202767)
(3) Mills JM, Harper J, Broomfield D, Templeton KE. Rapid testing for
respiratory syncytial virus in a paediatric emergency department: benefits
for infection control and bed management. J Hosp Infect 2011 Mar;77(3):248
-251.
(4) Anonymous. Evaluation of 11 commercially available rapid influenza
diagnostic tests - United States, 2011-2012. Morb Mortal Wkly Rep, 2012
(61) 873-876.
We note the paper on near-patient testing (NPT) for respiratory
syncytial virus (RSV) in cases of bronchiolitis by Walsh et al (1). It is
an interesting paper but we suggest it fails to acknowledge one of the
main uses of this particular test methodology. The test analysed also has
a poorer performance than the one we use.
Bronchiolitis is a common respiratory disease in early childhood and
infancy. The diagnos...
We note the paper on near-patient testing (NPT) for respiratory
syncytial virus (RSV) in cases of bronchiolitis by Walsh et al (1). It is
an interesting paper but we suggest it fails to acknowledge one of the
main uses of this particular test methodology. The test analysed also has
a poorer performance than the one we use.
Bronchiolitis is a common respiratory disease in early childhood and
infancy. The diagnosis is a clinical one, and should never rely on a
diagnostic test for one particular virus. RSV is the main organism
responsible for causing bronchiolitis in infancy, but other organisms have
been described (2). As there is no specific treatment directed against
RSV, or any of the other viral causes, accurate viral diagnosis is not a
pre-requisite.
We have used NPT for RSV for many years. Our current NPT is BinaxNOW
(R) RSV test kit (Inverness medical, UK) and we have demonstrated
different results to Walsh et al using polymerase chain reaction (PCR) in
the laboratory as the gold standard for comparison. Our results for
comparison are:
Sensitivity 90
Specificity 91
Positive predictive value 86
Negative predictive value 93
We believe the real value, however, is in allowing decisions to be
made about cohorting children in times of peak bronchiolitis outbreaks,
which happen every winter. This is not an issue if every child has
guaranteed admission to a cubicle, with maximum isolation and reduction in
cross-infection.
However in many areas this is simply not feasible. In these
situations NPT for RSV is invaluable in sorting children into cohorts
which maximise bed usage (3). It allows a reasonable and clinically
relevant estimate of which child has RSV. Children with positive RSV test
on NPT can be nursed and cared-for in an area with other children with
RSV. Those that are negative can be isolated until a formal laboratory PCR
test either confirms RSV - when the child can be moved to a cohort area -
or otherwise when isolation can be continued. This is a better use of
laboratory time and resources and which has been discussed recently (4,5).
Using this approach for many years we have successfully reduced cross
-infection significantly, with better usage of scarce cubicle space (6).
We do not believe that the paper as published emphasises this point, and
we would like to highlight this important benefit.
Tom Beattie Kirsty McLellan. Kate Templeton.
References:
(1) Walsh P, Overmyer C, Hancock C, Heffner J, Walker N, Nguyen T, et
al. Is the interpretation of rapid antigen testing for respiratory
syncytial virus as simple as positive or negative? Emerg Med J 2013 (20
August 2013, 10.1136/emermed-2013-202767).
(2) American Academy of Pediatrics Subcommittee on Diagnosis and
Management of,Bronchiolitis. Pediatrics 2006 Oct;118(4):1774-1793.
(3) Mackenzie A, Hallam N, Mitchell E, Beattie T. Near patient testing for
respiratory syncytial virus in paediatric accident and emergency:
prospective pilot study. BMJ 1999 Jul 31;319(7205):289-290.
(4) Moore C. Journal of Hospital Infection 2013;85:1 - 7.
(5) Hallam N, Hesketh L. Paediatric viral respiratory polymerase chain
reaction testing: more sensitive but less rapid and with infection control
implications. J Hosp Infect 2011 Apr;77(4):367.
(6) Mills JM, Harper J, Broomfield D, Templeton KE. Rapid testing for
respiratory syncytial virus in a paediatric emergency department: benefits
for infection control and bed management. J Hosp Infect 2011 Mar;77(3):248
-251.
Conflict of Interest:
Previous publications on near-patient testing for RSV in Emergency Departments
Recently, Cattermole et al. discussed our work as well as the work of
others in a paper describing the proportion of children for whom the
Broselow tape (BT) is not applicable.[1] As the authors point out,
studies that have examined the accuracy of the BT tend to omit from
inclusion, or exclude from analysis, children whose length exceeds the
bounds of the tape. While these studies in effect overestimate the
utility of...
Recently, Cattermole et al. discussed our work as well as the work of
others in a paper describing the proportion of children for whom the
Broselow tape (BT) is not applicable.[1] As the authors point out,
studies that have examined the accuracy of the BT tend to omit from
inclusion, or exclude from analysis, children whose length exceeds the
bounds of the tape. While these studies in effect overestimate the
utility of the BT, children that are too tall for the device are
relatively easy to identify. Consequently, clinical decision makers are
immediately sensitized to the fact that the weight estimate may suffer
from inaccuracies. What may go unidentified by the clinician caring for
the "height-appropriate" child is the fact that the BT is increasingly
less reliable with increasing body mass.[2] This can pose serious
consequences for the medical management of children at the extremes of
weight. When we examined the children from our original NHANES cohort
(n=19,266) that could be classified as overweight/obese per CDC definition
(i.e. 2+ yrs, BMI>85th percentile) (n=4,587),[3] and restricted
evaluation to children who met the length criteria for application of the
BT (n=1,916), we found that the BT predicted only 100 to within 10% of
their actual weight (Table). The BT predicted a comparably small fraction
of obese children to within 20% of their actual weight. By contrast, the
Mercy weight estimation method that incorporates length and MUAC with no
restrictions estimated 81% of overweight children and 74% of obese
children to within 10% of their actual weight.[3] Cattermole et al. state
"it is clear that the accuracy of the BT is only applicable to those whom
it fits," and the proportion of children for whom the BT proves to be a
good "fit" continues to diminish as the waistlines of our pediatric
population expand. We concur that the "most promising options for weight
estimation" will likely include estimates of habitus and believe that
weight estimation methods which are less restrictive, more accurate, and
as user friendly as the BT are critically needed.
Cumulative Percent Overweight Predicted by BT within:
10% of actual weight-11%, 20% of actual weight-85%,
30% of actual weight-99%, 40% of actual weight-100%.
Cumulative Percent Obese Predicted by BT within:
10% of actual weight-0%, 20% of actual weight-18%, 30% of actual weight-
62%, 40% of actual weight-89%,
50% of actual weight-98.5%, 60% of actual weight-99.7%, 70% of actual
weight-100%.
References
1. Cattermole GN, Leung PYM, Graham CA, Rainer TH. To tall for the
tape: the weight of school children who do not fit the Broselow tape.
Emerg Med J 2013 Apr 13. [Epub ahead of print]
2. Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell
FW. A rapid method for estimating weight and resuscitation drug dosages
from length in the pediatric age group. Ann Emerg Med 1988;17(6):576-81.
3. Abdel-Rahman SM, Ridge AL. An improved pediatric weight estimation
strategy. Open Med Devices J 2012;4:87-97.
Conflict of Interest:
Children's Mercy Hospital owns the rights to IP referenced in this letter. This IP is intended to be made freely available in resource restricted settings
The article by Mellon et al highlights one of the lesser researched
areas in stroke.[1] Only 27% of the patients presenting for stroke
services at a tertiary level hospital in India were aware they had a
stroke.[2] Lack of awareness about stroke among general masses is often an
underestimated cause of prehospital delays. Less dramatic nature of
symptoms in acute ischemic stroke as compared to myocardial infarction or
sta...
The article by Mellon et al highlights one of the lesser researched
areas in stroke.[1] Only 27% of the patients presenting for stroke
services at a tertiary level hospital in India were aware they had a
stroke.[2] Lack of awareness about stroke among general masses is often an
underestimated cause of prehospital delays. Less dramatic nature of
symptoms in acute ischemic stroke as compared to myocardial infarction or
status asthamaticus could probably be one of the reasons.
Infomercials, print ads, marathons, radio announcements, street
plays, social networking websites, stroke survivor's club, roadside
banners are some of the ways which can help spread awareness. World Stroke
Campaign is one such initiative which aims at creating public awareness
about stroke and many celebrities have volunteered in the past to be a
part of it. Million Hearts is an initiative launched by the United States
government to prevent 1 million heart attacks and strokes by 2017. A
similar campaign is Healthy People 2020.
It is disheartening to know that while United Nations observes World
Blood Donor Day, World Pneumonia Day and many others, it does not formally
observe World Stroke Day, which is celebrated on October 29 by the World
Stroke Organization, despite the fact that someone dies of a stroke every
4 minutes.[3]
National/international campaigns are important but a local approach
might achieve better results. This calls for enhanced interest of
clinicians/researchers in developing novel and scientifically validated
methods of stroke awareness with which we can achieve sustained levels of
public education.
References:
[1] Mellon L, Hickey A, Doyle F et al. Can a media campaign change
health service use in a population with stroke symptoms? Examination of
the first Irish stroke awareness campaign. Emerg Med J. 2013 Jul 26. doi:
10.1136/emermed-2012-202280. [Epub ahead of print]
[2] Pandian J, Kalra G, Jaison A et al. Knowledge of stroke among
stroke patients and their relatives in Northwest India. Neurol India
2006;54(2):152-156.
[3] Murray CJ, Vos T, Lozano R et al. Disability-adjusted life years
(DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a
systematic analysis for the Global Burden of Disease Study 2010. Lancet
2012;380(9859):2197-223.
We read with great interest the article by A. Ross Naylor et al ; the
face arm speech test: does it encourage rapid recognition of important
stroke warning symptoms? This study helps in generating awareness of the
early stroke symptoms in the population. Similar studies were done in the
past like Cincinnati prehospital stroke scale (CPSS) which had a positive
predictive value between 72%-85%.1 Los Angeles Prehospital stro...
We read with great interest the article by A. Ross Naylor et al ; the
face arm speech test: does it encourage rapid recognition of important
stroke warning symptoms? This study helps in generating awareness of the
early stroke symptoms in the population. Similar studies were done in the
past like Cincinnati prehospital stroke scale (CPSS) which had a positive
predictive value between 72%-85%.1 Los Angeles Prehospital stroke screen
and ABCD2 score are other studies with a good positive predictive
value.2,3
Despite these milestone studies and various awareness programs conducted
we are miles away in getting the desired results. Since the Food and Drug
association has approved the thrombolytic therapy for acute ischemic
stroke only less than 5% have received this therapy. This was mainly
because of the unawareness of early stroke symptoms in majority of the
patients which landed them out of the therapeutic window period of three
hours.4
An early non contrast CT scan of the head, to rule out haemorrhage along
with a normal blood sugar is required to start thrombolytic therapy. In up
to 35%-53% patients of acute stroke of less than 3hrs duration subtle CT
findings like hyper dense MCA, obscuration of lenticular nucleus and loss
of grey white interface can be observed. However these findings are not
mandatory to start thrombolytic therapy.5,6
Population awareness programs regarding identification of early symptoms
of stroke, effective ambulance services, smooth transition, coordination
between emergency physician, neurologist and neuroradiologist is
indispensible for early treatment to reduce mortality, morbidity and
disability.
References
1. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. "Cincinnati
Prehospital Stroke Scale: reproducibility and validity." Ann Emerg Med
1999 Apr;33(4):373-8
2. Prospective validation of the Los Angeles prehospital stroke
screen (LAPSS)." Stroke 2000 Jan; Kidwell CS, Starkman S, Eckstein M,
Weems K, Saver JL. "Identifying stroke in the field. 31(1):71-6.
3. Johnston SC, Rothwell PM, Huynh-Huynh MN, Giles MF, Elkins JS, Sidney
S, "Validation and refinement of scores to predict very early stroke risk
after transient ischemic attack," Lancet. 2007; 369:283-292.
4. O'Connor RE, McGraw P, Edelsohn L. Thrombolytic therapy for acute
ischemic stroke: why the majority of patients remain ineligible for
treatment. Ann Emerg Med. 1999;33:9 -1
5. Keith W. Muir et al. imaging of acute stroke. Lancet Neurology.
2006; 5:755-766.
6. Gyanendra Kumar et al. Penumbra, the bas of neuroimaging in acute
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We read with interest the article by Shamini et al[1], in which he suggested that primary care services should be more responsive to needs of the older adolescent age. Here we intend to introduce some new policies recently implemented in hospitals in Beijing, China.
Beijing has begun implementing its public hospital reform programs since July 1, 2012 [2]. Patients are charged a medical care service fee which va...
We have read with great interest the article by Rickard et al. [1] concerning with the management of raised intracranial pressure in course of traumatic brain injury. More in detail, the sugar alcohol mannitol, derived from fructose hydrogenation (sorbitol isomer), is a hyperosmolar diuretic agent. Clinically, mannitol can be administered through a central or peripheral venous catheter in the treatment of raised intracran...
The article by Gill et al1 provides further evidence that a log-roll is not useful for major trauma patients in the primary survey. Even with a GCS 15 and no influence from alcohol or opiates only 60% of patients with thoraco-lumbar fractures had tenderness on log-roll. The authors did not examine how many false negatives were found by examination or the impact of a distracting injury.
Log-rolling a polytrauma...
Dear authors,
Thank you for conducting this interesting study.
I have been teaching first aid to the public for the last six years. My personal experience is that many members of the public are worried about becoming involved in emergency situations due to fears around litigation and "doing things wrong".
Almost every first aid course I teach I answer questions regarding the legal situation...
We read the article Optimal position for external chest compression during cardiopulmonary resuscitation: an analysis based on chest CT in patients resuscitated from cardiac arrest by Kyoung Chul Cha et al with interest. This article has added a new concept in CPR. Cardiopulmonary resuscitation (CPR) is a life saving emergency procedure and it should be done as per protocol. ACC/AHA guideline2010 suggest that effective c...
Proposed response Dear Editor, We thank the writers for their interest in our work and for the most part agree with them. (1)(2) We fully agree that bronchiolitis is a clinical diagnosis; it is because the viral aetiology cannot be determined clinically that testing is contemplated. We also agree that specific treatment is not yet available; although RSV specific drugs are being developed and it behooves emergency depart...
We note the paper on near-patient testing (NPT) for respiratory syncytial virus (RSV) in cases of bronchiolitis by Walsh et al (1). It is an interesting paper but we suggest it fails to acknowledge one of the main uses of this particular test methodology. The test analysed also has a poorer performance than the one we use.
Bronchiolitis is a common respiratory disease in early childhood and infancy. The diagnos...
Recently, Cattermole et al. discussed our work as well as the work of others in a paper describing the proportion of children for whom the Broselow tape (BT) is not applicable.[1] As the authors point out, studies that have examined the accuracy of the BT tend to omit from inclusion, or exclude from analysis, children whose length exceeds the bounds of the tape. While these studies in effect overestimate the utility of...
The article by Mellon et al highlights one of the lesser researched areas in stroke.[1] Only 27% of the patients presenting for stroke services at a tertiary level hospital in India were aware they had a stroke.[2] Lack of awareness about stroke among general masses is often an underestimated cause of prehospital delays. Less dramatic nature of symptoms in acute ischemic stroke as compared to myocardial infarction or sta...
We read with great interest the article by A. Ross Naylor et al ; the face arm speech test: does it encourage rapid recognition of important stroke warning symptoms? This study helps in generating awareness of the early stroke symptoms in the population. Similar studies were done in the past like Cincinnati prehospital stroke scale (CPSS) which had a positive predictive value between 72%-85%.1 Los Angeles Prehospital stro...
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