A Retrospective Review of the Use and Safety of Droperidol in a Large, High-risk, Inner-city Emergency Department Patient Population

Droperidol (DROP) is used in the emergency department (ED) for sedation, analgesia, and its antiemetic effect. Its ED safety profile has not yet been reported in patients (pts). OBJECTIVES: To document the use of DROP in high-risk pts (those with head injury, alcohol or cocaine intoxication, and/or remote or recent seizures), and to determine the number of serious and minor adverse events (AEs)-seizures, hypotension, extrapyramidal side effects (EPSEs)-after DROP. METHODS: The ED database (EmSTAT) was queried to determine who received intramuscular or intravenous DROP in the ED in 1998; further chart review was done if the patient was considered high risk for or had experienced an AE. Multiple regression analysis using a random-effects model determined the significance of each variable in the occurrence of AEs. RESULTS: 2,468 patients (aged 20 months to 98 years; 112 < or =17 years; 141 > or =66 years) received DROP for agitation (n = 1,357), pain (1,135), anxiety (99), vomiting (173), or other reasons (50). There were 945 pts considered high risk; 933 charts were reviewed (DROP mean dose 4.1 +/- 2.0 mg); of these, 50 patient visits did not meet the criteria for high risk. There were 622 pts with head trauma (401 with alcohol use), including 47 with computed tomography (CT) scans positive for brain injury, 64 with cocaine use, and 197 with recent or remote seizures (137 with alcohol use). Minor AEs such as transient hypotension occurred in 96 pts after DROP (73 with alcohol use); 20 received intravenous fluids, while an additional 28 pts (8 with alcohol use) received rescue medications for EPSEs. Six possible serious AEs occurred in pts with serious comorbidities; 2 cases of respiratory depression, 3 post-DROP seizures, and 1 cardiac arrest (resuscitated) 11 hours after DROP in a cocaine-intoxicated pt (normal QT interval). There was no significant difference among high-risk groups in the occurrence of AEs. CONCLUSIONS: The vast majority of pts who received DROP in the ED did not experience an AE. A few serious AEs were noted following DROP in patients with serious comorbidities; it is not clear that DROP was causative.     

The burden of brain diseases in Europe.

The burden [as defined by the World Health Organisation (WHO)] of brain diseases (neurological, neurosurgical and psychiatric diseases together) is very high and yet resources spent on these diseases are not necessarily commensurate with the extent of this burden. However, hard data on the burden of brain diseases in Europe have not previously been easily accessible. The Global Burden of Disease (GBD) 1990 study conducted jointly by the WHO, Harvard University and the World Bank provided new measures that are now becoming universally accepted and have been used also in a repeat study: The GBD 2000. The key parameter of the study is disability adjusted life years (DALY), which is the sum of years of life lost (YLL) caused by premature death and years of life lived with disability (YLD). In the present report, data from the GBD 2000 study and from the World Health Report 2001 on brain diseases is extracted for the territory of Europe. This territory corresponds roughly to the membership countries of the European Federation of Neurological Societies. The WHO's Report has a category called neuropsychiatric diseases, which comprises the majority but not all the brain diseases. In order to gather all brain diseases, stroke, meningitis, half of the burden of injuries and half of the burden of congenital abnormalities are added. Throughout Europe, 23% of the years of healthy life is lost and 50% of YLD are caused by brain diseases. Regarding the key summary measure of lost health, DALY, 35% are because of brain diseases. The fact that approximately one-third of all burden of disease is caused by brain diseases should have an impact on resource allocation to teaching, reasearch, health care and prevention. Although other factors are also of importance, it seems reasonable that one-third of the curriculum at medical school should deal with the brain and that one-third of life science funding should go to basic and clinical neuroscience. In addition, resource allocation to prevention, diagnosis and treatment of brain diseases should be increased to approach, at least, one-third of health care expenditure. With the present data on hand, neurologists, neurosurgeons, psychiatrists, patient organizations and basic neuroscientists have a better possibility to increase the focus on the brain.     

The lateral chest X-ray: Is it necessary for emergency department patients?

To determine the utility of the lateral view of the chest in emergency department patients, records of all patients who had had 2-view chest x-rays ordered in the emergency department were reviewed retrospectively. A study radiologist recorded a reading of the posteroanterior (PA) radiograph alone. The lateral radiograph was then provided, along with the PA view, and a second reading was recorded. A comparison was then made between the first and second readings.A total of 417 sets of x-rays were included. The PA view alone successfully diagnosed or suspected 92% of pulmonary nodules, 95% of effusions, 97% of cases of emphysema, 98% of pneumonias, and 100% of cases of cardiomegaly, pulmonary edema, interstitial pulmonary disease, and atelectasis.In the emergency department patient population, lateral views of the chest have minimal diagnostic yield and therefore may be used selectively to safely decrease the amount of breast radiation exposure to young women.     

Predictors of Repeat Emergency Department Visits by Elders

Objective: To determine which characteristics of older patients who use a hospital ED are associated with repeat visits during the 90 days following the index visit.
Methods: The study was conducted in the ED of a 400-bed university-affiliated acute care community hospital in Montreal. Patients aged ≥75 years who visited the ED between 08:00 and and 16:00 on a convenience sample of days over an 8-week period (July and August 1994) were assessed using a questionnaire, physical and cognitive status instruments, and a functional problem checklist. The hospital's administrative database was used to identify repeat visits during the 90 days following the ED visit. The representativeness of the sample was assessed by analyses of ED visits made by 4,466 persons aged ≥65 years during a 12-month period (September 1993 to August 1994) using the hospital's administrative database.
Results: 256 patients aged ≥75 years visited the ED during the study period and 167 were assessed. Of these, 54 (32%) were admitted to the hospital. Among the 113 patients released from the ED, 27 (24%) made repeat visits during the next 90 days. In univariate analyses, repeat visits were significantly associated with the number of functional problems, cognitive impairment, and previous ED visits. In multiple logistic regression, male gender, living alone, and number of functional problems were independent predictors of repeat visits. In the administrative data analyses, nighttime arrival to the ED for the index visit was significantly associated with repeat visits.
Conclusions: Self-reported risk factors can help to identify a group of elders likely to make repeated ED visits; the development of a screening instrument incorporating questions on these problems and implementation of appropriate interventions might improve these patients' quality of life and reduce the demand for further ED care in this age group.     

End-tidal Carbon Dioxide Monitoring during Procedural Sedation

OBJECTIVE: To prospectively determine whether end-tidal carbon dioxide (ETCO2) monitors can detect respiratory depression (RD) and the level of sedation in emergency department (ED) patients undergoing procedural sedation (PS). METHODS: This was a prospective observational study conducted in an urban county hospital of adult patients undergoing PS. Patients were monitored for vital signs, depth of sedation per the physician by the Observer's Assessment of Alertness/Sedation scale (OAA/S), pulse oximetry, and nasal-sample ETCO2 during PS. Respiratory depression was defined as an oxygen saturation <90%, an ETCO2 >50 mm Hg, or an absent ETCO2 waveform at any time during the procedure. The physician also determined whether protective airway reflexes were lost during the procedure and assisted ventilation was required, or whether there were any other complications. Rates of RD were compared with the physician assessment of airway loss and between agents using chi-square statistics. Spearman's rho analysis was used to determine whether there was a correlation between ETCO2 and the OAA/S score. RESULTS: Seventy-four patients were enrolled in the study. Forty (54.1%) received methohexital, 21 (28.4%) received propofol, ten (13.5%) received fentanyl and midazolam, and three (4.1%) received etomidate. Respiratory depression was seen in 33 (44.6%) patients, including 47.5% of patients receiving methohexital, 19% receiving propofol (p = 0.008), 80% receiving fentanyl and midazolam, and 66.6% receiving etomidate. No correlation between OAA/S and ETCO2 was detected. Eleven (14.9%) patients required assisted ventilation at some point during the procedure, all of whom met the criteria for RD. Pulse oximetry detected 11 of the 33 patients with RD. Post-hoc analysis revealed that all patients with RD had an ETCO2 >50 mm Hg, an absent waveform, or an absolute change from baseline in ETCO2 >10 mm Hg. CONCLUSIONS: There was no correlation between ETCO2 and the OAA/S score. Using the criteria of an ETCO2 >50 mm Hg, an absolute change >10 mm Hg, or an absent waveform may detect subclinical RD not detected by pulse oximetry alone. The ETCO2 may add to the safety of PS by quickly detecting hypoventilation during PS in the ED.     

脑外科手术后发生正常灌注压突破的发病机制及超微病理基础

目的:探讨脑外科手术后部分患者病变邻近脑组织发生正常灌注压突破并发症的发病机制及其超微病理基础.材料和方法:对68例脑内血管畸形病变邻近的脑组织进行电子显微镜观察.结果:病灶邻近脑组织内部分毛细血管外周的星形细胞足突缺失或出现血管基膜疏松、分层等发育不良的情况,甚至有些血管壁组织结构破损.结论:电子显微镜检查证实,在血管畸形病灶周围的脑组织内可见病理性血管.该血管的基膜发生病变,血管周围的星形细胞足突明显减少或破坏.当血液灌注压力突然变化时,这种病变的血管就可能发生液体外渗及破裂.这就是在神经外科手术中或手术后发生正常灌注压突破并发症的超微病理基础.     

1515例精神科住院患者医院感染调查与分析

目的：了解精神科住院患者医院感染情况，以利采取切实可行的预防控制措施，降低感染率。方法：对我院两年半间住院患者进行有关医院感染的调查，逐份查阅原始记录，填写统一表格，将所得资料进行相关分析。结果：医院感染72例，感染率为4．75％；感染多发生在20～29岁和30—39岁组：精神分裂症为医院感染例数最多的病种(占68．06％)；皮肤及软组织和下呼吸道感染为主要感染部位，分别为23．61％和22．22％；男女两性在年龄和病程方面差异均无显著性。结论：预防及控制精神病患者的医院感染应从病人初入院时即开始；在积极控制精神症状的同时，采取多方面措施，尽可能去除医院感染的易感因素；合理规范使用抗生素，增强患者体质等，这些均有助于预防及控制医院感染。     

远隔性小脑出血

远隔性小脑出血极为罕见，可见于多种类型的神经外科手术，一般出现在手术远隔部位，多分布于单侧或双侧小脑沟、蚓部，小脑上部出血也较为多见。远隔性小脑出血总体预后良好，病死率约为10％～15％。     

CT定位及多靶点组合治疗强迫症临床研究

目的 研究多靶点组合对强迫症的治疗作用.方法 采用立体定向方法,运用CT定位和多靶点组合,射频热凝治疗强迫症例.采用Yale-Brown强迫症量表、Hamilton抑郁、焦虑量表对照评估.结果 42例强迫症中显效 25 例,进步 12 例.结论 双侧扣带回 双侧内囊前肢多靶点组合治疗难治性精神病的强迫症有明显的治疗作用.     

妇科腹腔镜手术患者的整体护理

目的：探讨妇科腹腔镜手术前后的护理方法。方法：回顾性分析我院应用腹腔镜行妇科手术52例患者的临床护理过程。结果：本组52例妇科腹腔镜手术患者全部康复出院，对护士的精心护理感到非常满意。结论：妇科患者腹腔镜手术通过适当的整体护理措施能够使其早日康复。