Corewell Health Butterworth Hospital

OBJECTIVE: To evaluate the effect of cartoon illustrations on patient comprehension of and compliance with ED release instructions. METHODS: A prospective, randomized, controlled study of consecutive patients who presented to the ED of a community teaching hospital with lacerations necessitating wound repair during a three-month study period. At ED release, the patients were randomly assigned to receive wound care instructions with or without cartoon illustrations. Three days later, the patients were followed up by telephone. A blinded investigator asked a series of questions designed to test the patient's recall of, understanding of, and compliance with wound care instructions. RESULTS: A total of 234 patients were successfully contacted by telephone; 105 (45%) had been given ED release instructions with cartoons, 129 (55%), without cartoons. There was no significant difference in age, gender, level of education, or satisfaction with the ED visit between the two groups. The patients given cartoon instructions were more likely to have read the instructions (98% vs 79%, p < 0.001), were more likely to answer all wound care questions correctly (46% vs 6%, p < 0.001), and were more compliant with daily wound care (77% vs 54%, p < 0.01). Subset analysis of those patients who had less than a high school education (n = 57) demonstrated even larger differences between the two treatment groups in terms of comprehension of and compliance with ED release instructions. CONCLUSION: Cartoon illustrations are an effective strategy for conveying information and may improve patient compliance with ED release instructions.

Theory of human relatedness addresses a pervasive human concern, establishing and maintaining relatedness to others, objects, environments, society and self. This theory, derived from a series of inductive and deductive strategies, views relatedness as a functional, behavioral system rooted in early attachment behaviors. Individuals move through different states of relatedness including connectedness, disconnectedness, parallelism and enmeshment. Social processes that contribute to this movement are sense of belonging, reciprocity, mutuality and synchrony. Disruptions in clients' relatedness contribute to biological, psychological, and social disturbances.

In a prospective, randomized, double-blind clinical trial, intravenous prochlorperazine edisylate (Compazine Edisylate) was compared with a placebo in the treatment of severe headaches. Eighty-two adult patients with vascular or tension-type headaches were identified at the time of presentation to one of three participating emergency departments. After the patient gave informed consent, a 2-mL intravenous injection of sterile saline solution or prochlorperazine edisylate (10 mg) was given to each patient at the time of randomization. The treatment groups were similar with regard to age, sex, and type and duration of headache. Within 60 minutes after injection, 74% (31/42) of those who received prochlorperazine had complete relief; 14% (6/42) of the patients had partial relief. Overall, there was complete or partial relief of pain in 88% (37/42) of the drug group and in 45% (18/40) of the placebo group. This difference was statistically significant using chi 2 analysis. Adverse effects were minimal; one patient experienced asymptomatic orthostatic hypotension. These results suggest that intravenous prochlorperazine is an effective treatment for patients with severe vascular or tension headaches who present to the emergency department.

BACKGROUND: Using a model of traumatic brain injury (TBI) in the rat, this study was undertaken to characterize the short-term biochemical changes of IL-1beta, IL-10, and tumor necrosis factor TNF-alpha to determine whether injury in the brain elicits a systemic cytokine response. METHODS: Sprague-Dawley rats were subjected to a TBI using a weight-drop model and then killed at various time points after injury. Samples of blood, brain, and liver were recovered and analyzed for concentrations of IL-1beta, IL-10, and TNF-alpha as well as IL-1beta and IL-10 mRNA expression in liver and brain. RESULTS: In brain, IL-1beta increased in the first hour after injury, peaked at 8 hours, and declined during the final 16 hours. IL-10 quickly increased during the first 4 hours and then gradually rose over the last 20 hours. Analysis of liver showed no upregulation of these markers and plasma IL-1beta and IL-10 were unchanged compared with controls. Although not upregulated in brain, TNF-alpha showed a statistically significant (p < 0.05) rise in plasma from 14 +/- 16 pg/mL at 20 minutes to 91 +/- 28 pg/mL at 24 hours. CONCLUSION: Using a model of TBI, we have demonstrated that there is a rise in both IL-1beta and IL-10 in the injured rat brain within the first 24 hours after injury without a corresponding rise in either plasma or liver. Therefore, it appears as if two strong indicators of brain injury severity are expressed and possibly carry out their actions solely in the brain.

We describe 13 unrelated children with abnormalities of somatic growth, face, brain, and connective tissue including vasculature. Although the condition in these children falls under the general group of disorders known as cutis marmorata telangiectatica congenita (CMTC), the constellation of abnormalities appears to constitute a distinct and easily recognizable phenotype within this general group. In contrast to most children reported with CMTC, children in this subgroup have a high risk for neurologic abnormalities, including developmental delay, mental retardation, megalencephaly, and hydrocephalus. Early recognition of this condition is important for appropriate surveillance for known complications and parental counseling.

From October 1985 through June 1986, 31 children in a single pediatric practice were treated for perianal signs and symptoms associated with growth of group A beta-hemolytic streptococci from perianal cultures. Signs and symptoms included perianal dermatitis (90%), perianal itching (78%), rectal pain (52%), and blood-streaked stools (35%). Ages ranged from 7 months to 8 years mean 4.25 +/- 1.8 years). There were 24 boys (77%) and seven girls (23%). The 31 cases occurred in 19 families. Intrafamily spread was only to siblings and occurred in 50% of the possible situations. Direct perianal antigen studies had a sensitivity of 89% for predicting positive cultures. Four different T types of group A streptococci were isolated from these cases, but the T type within each family outbreak was identical except in one case. When group A streptococci were found in the pharynx (64% of patients), the T type of the pharyngeal and perianal isolates were identical. Treatment was usually with oral penicillin. Relapses occurred in 39%. Signs of cellulitis were absent in all 31 cases and, therefore, we suggest that the nomenclature for this entity be changed from streptococcal perianal cellulitis to streptococcal perianal disease.

Infection associated with the use of triple lumen catheters in hospitals is a frequent and serious complication. The prevailing hypothesis for the origin of catheter-related infection (CRI) is bacterial colonization and subsequent infection of the skin insertion site and catheter interface. The recently released ARROWgard catheter contains a bonded synergistic combination of silver sulfadiazine and chlorhexidine, which is thought to render the catheter resistant to bacterial colonization and subsequent sepsis. The purpose of this study is to compare the incidence of CRI and catheter-related sepsis (CRS) between a standard triple lumen catheter and ARROWgard antiseptic coated catheter in patients receiving total parenteral nutrition (TPN). A randomized, prospective clinical trial was conducted at a community referral center from January 1993 through April 1994. One-hundred-ninety-one patients with need for TPN were randomized to receive either the ARROWgard or a standard triple lumen catheter placed under a strict sterile protocol. CRI was defined as >/= 15 colony forming units by semiquantitative culture technique of the catheter tip or intracutaneous segment. CRS was defined as growth of the same organism on the catheter and at least one peripheral blood culture. All catheters were cultured. Ninety-two patients received the ARROWgard catheter, and 99 patients received the standard catheter. There were no differences between the average age, sex, length of hospital stay, days on TPN, number of catheters/patient, indications for TPN, primary diagnoses, or duration of the central line between the two groups. The overall rate of CRI was 11.5 per cent, and CRS was 8.4 per cent in this study. The rate of CRI for the ARROWgard was 10.9 per cent, compared with 12.9 per cent for the standard catheter (P = NS). The rate of CRS for the ARROWgard was 8.7 per cent, compared with 8.1 per cent for the standard catheter (P = NS). The coating of central venous catheters with silver sulfadiazine and chlorhexidine does not reduce the rate CRI or CRS when compared with standard central venous catheters in patients receiving TPN.

OBJECTIVE: Approximately 50% of patients with alcohol dependence experience alcohol withdrawal. Severe alcohol withdrawal is characterized by seizures and/or delirium tremens, often refractory to standard doses of benzodiazepines, and requires aggressive treatment. This review aims to summarize the literature pertaining to the pharmacotherapy of severe alcohol withdrawal. DATA SOURCES: PubMed (January 1960 to October 2015) was searched using the search termsalcohol withdrawal, delirium tremens, intensive care, andrefractory Supplemental references were generated through review of identified literature citations. STUDY SELECTION AND DATA EXTRACTION: Available English language articles assessing pharmacotherapy options for adult patients with severe alcohol withdrawal were included. DATA SYNTHESIS: A PubMed search yielded 739 articles for evaluation, of which 27 were included. The number of randomized controlled trials was limited, so many of these are retrospective analyses and case reports. Benzodiazepines remain the treatment of choice, with diazepam having the most favorable pharmacokinetic profile. Protocolized escalation of benzodiazepines as an alternative to a symptom-triggered approach may decrease the need for mechanical ventilation and intensive care unit (ICU) length of stay. Propofol is appropriate for patients refractory to benzodiazepines; however, the roles of phenobarbital, dexmedetomidine, and ketamine remain unclear. CONCLUSIONS: Severe alcohol withdrawal is not clearly defined, and limited data regarding management are available. Protocolized administration of benzodiazepines, in combination with phenobarbital, may reduce the need for mechanical ventilation and lead to shorter ICU stays. Propofol is a viable alternative for patients refractory to benzodiazepines; however, the role of other agents remains unclear. Randomized, prospective studies are needed to clearly define effective treatment strategies.

OBJECTIVE: To describe the process and outcomes of nursing home (NH) residents transferred to hospital EDs. METHODS: This was a prospective, observational study conducted at 2 Midwestern community teaching hospitals during a 12-month period. All elder patients (> 64 years of age) transferred to hospital EDs from regional NHs were eligible for the study. Hospital records were used to abstract relevant descriptive and clinical data. Need for ambulance use was graded prospectively using 3 categories of urgency developed in other studies. Transfers were considered "appropriate" based on outcome measures or if the problem necessitated diagnostic and/or therapeutic procedures not available in the NH. Transfer documentation was evaluated using a standardized 18-item checklist. RESULTS: A total of 709 consecutive NH patients made 1,012 ED visits. Their mean age was 83.4 years (range 65-100); 76% were female. The majority of patients (94%) were transferred by ambulance. Ambulance transfer was classified as emergent (16% of patients), urgent (45%), or routine (39%). There were 319 (45%) patients subsequently admitted to the hospital. Approximately 77% (546/709) of the NH transfers were considered appropriate by the emergency physician (EP). Sixty-seven patients (10%) were transferred without any documentation. For those patients with transfer documentation, 6 common discrepancies were identified. CONCLUSION: Although the majority of NH transfers in this population were appropriate, many patients were transferred without adequate documentation for the EP.

Encephalopathy developed in 3 patients after transurethral prostatic resection. Each patient had blood ammonia levels more than 10 times the upper limit of normal. Data supportive of a metabolic cause for encephalopathy subsequently were obtained in a prospective study of patients undergoing transurethral prostatic resection with glycine irrigation. It is suggested that a distinct subpopulation of patients experiencing transurethral prostatic resection syndrome can be identified. These patients exhibit encephalopathic symptoms and have concurrent marked elevation of blood ammonia levels.

Enzymes play an important role in the production of radicals and their metabolism. Techniques to measure pro-oxidant conditions that generate radicals and end-products are described in various chapters throughout this book. The major defense enzymes are superoxide dismutase (SOD), which converts the superoxide radical to hydrogen peroxide: (H2O2), catalase (CAT), selenium (SE)-dependent glutathione peroxidase (GSHPx), and leukocytic myeloperoxidase, which degrade inorganic and lipid hydroperoxides formed by interaction with reactive oxygen species and glutathione-S-transferase (GST; which also has peroxidase activity, but is selenium-independent) (1). The activity of GSHPx is coupled to glutathione reductase (GSSG-R), which maintains reduced glutathione (GSH) levels (2). Enzyme activity can be decreased by negative feedback from excess substrate or from damage by oxidative modification (3).

The clinical, histopathologic, immunohistochemical, and electron microscopic findings of two cases of melanocytic schwannoma are reported. One case, which occurred in the parotid gland, is believed to be the first reported in this location. The other case was located in the sacral spinal region. A review of the clinical and pathologic features of 32 previously reported cases is presented. The recurrence rate was 24%. Those tumors that were incompletely excised and/or located in the cranial nerves had the worst prognosis.

Efficiency and productivity are important factors in managing programs and human resources and in determining resource allocation. Absence of practice productivity and efficiency data leads to inappropriate decisions and actions resulting in detrimental outcomes. It is critical that nurse executives and managers have effective measures by which to analyze productivity and to evaluate empirically the effects of management actions and decisions for any proposed or implemented change. The authors describe a work sampling methodology that can be used to establish a data base for evaluating programmatic, staff mix, role redesign, or care delivery model changes.

Three unrelated infants presented with radiographic punctate calcifications, nasal hypoplasia, and abnormalities of the spine. Additional anomalies included cupped ears in 2 patients and one each with Dandy-Walker malformation with hydrocephaly, congenital cataracts, and peripheral pulmonary artery stenosis. The mothers of these 3 patients had chronic conditions associated with intestinal malabsorption requiring total parenteral nutrition for varying periods of time. The underlying causes of malabsorption were celiac disease, short bowel syndrome secondary to surgical resection, and jejuno-ileal bypass, respectively. Bleeding diathesis occurred in one mother requiring vitamin K supplementation during the second and third trimesters of pregnancy. We speculate that the chondrodysplasia punctata and other abnormalities in these children were caused by an acquired maternal vitamin K deficiency manifested during early pregnancy. However, the involvement of other vitamin deficiencies cannot be excluded. Thus, vitamin K deficiency of the embryo secondary to maternal malabsorption appears to be a third vitamin K-related mechanism leading to chondrodysplasia punctata in addition to warfarin embryopathy and epoxide reductase deficiency (pseudo-warfarin embryopathy).

In 1988, there were seven conditions which could be considered distinct oral-facial-digital syndromes (OFDS). Currently there are at least nine, as well as different classification systems in use. This paper provides an update on recently described OFDS, and discusses alternative classification systems.

OBJECTIVES: To compare the characteristics of sexual assault in pubertal girls (<18 years old) and adults in a community-based population of women presenting to an urban sexual assault clinic. METHODS: This case-series analysis evaluated consecutive female patients presenting to a sexual assault clinic during a three-year study period. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medicolegal examinations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Data from the two patient groups (adolescents vs. women > or =18 years of age) were analyzed using chi-square test and t-test. RESULTS: A total of 766 cases were identified: 43% of the victims were 13 to 17 years old (mean 15.0 years old), and 57% were older than 17 years old (mean 30.8 years old). Adolescents were more likely to be assaulted by an acquaintance or relative (84% vs. 50%, p < 0.001) and to delay medical evaluation (17 hours vs. 12 hours, p < 0.001) than were older women. Adolescent sexual assault was less likely to involve weapons or physical coercion (29% versus 57%, p < 0.001) and was associated with fewer nongenital injuries (33% vs. 55%, p < 0.001). Adolescents had a greater frequency of anogenital injuries (83% vs. 64%, p < 0.001), however, compared with older women. Common sites of injury in adolescents were posterior, including the fossa navicularis, hymen, fourchette, and labia minora. The injuries showed consistent topologic features, varying with the site and nature of tissue. Adult victims of sexual assault had a less consistent pattern of anogenital injuries with fewer hymenal injuries, greater injury to the perianal area, and widespread erythema. CONCLUSIONS: Of women presenting to an urban sexual assault clinic, 43% were adolescents. The epidemiology of sexual trauma and the pattern of anogenital trauma in this age group are unique and may pose special challenges to emergency health care providers.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS: The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS: Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.

Described is a technique that has evolved from the challenges of closure of larger cleft palate defects and that we are now using in preference over other techniques to repair a wide variety of clefts. Soft-palate closure and muscular sling reconstruction are accomplished using a modified Furlow technique. An associated cleft of the hard palate and the gaps produced by posterior displacement of the reconstructed soft palate are closed by adding tissue, buccal flaps, rather than by closure under tension or leaving residual raw surfaces. Palate lengthening is achieved both by the Z-plasty effect and by the interposition of buccal flaps between the hard and soft palate. Seventy-six palates have been repaired using this procedure. There were three postoperative fistulas.

We report on a boy with congenital scalp and limb defects, consistent with a diagnosis of Adams-Oliver syndrome (aplasia cutis congenita with terminal transverse limb defects). An additional finding present in this child and in his mother was cutis marmorata telangiectatica congenita. Although this boy fits the diagnostic criteria for Adams-Oliver syndrome, his mother does not. We discuss whether this condition is highly variable, or heterogeneous.

Small intestinal tumors are relatively rare, notoriously difficult to diagnose, and often advanced at the time of definitive treatment. The purpose of this study is to compare the differences between benign and malignant tumors of the small intestine and between symptomatic and asymptomatic tumors with respect to their clinical presentation, efficacy of diagnostic procedures, and surgical management with correlation to pathologic findings. Forty-nine patients with primary small intestinal tumors between 1981-1993 had 17 benign and 32 malignant tumors. Benign tumors more commonly presented with acute gastrointestinal hemorrhage (29% versus 6%, P < 0.05), and were often asymptomatic (47% versus 6%, P < 0.05). Malignant tumors more commonly presented with abdominal pain (63% versus 24%, P < 0.05) and weight loss (38% versus 0%, P < 0.05). The total number of diagnostic tests/patient averaged 2.3 +/- 0.3, and the average time from onset of symptoms to resection was 30.2 +/- 6.6 weeks. Upper endoscopy, angiography, and upper gastrointestinal contrast studies had the most useful sensitivity rates. Surgical treatment of tumors included biopsy/excision, limited bowel resection, segmental resection with regional lymphadenectomy, or a bypass procedure. The most common types of benign and malignant tumors were leiomyoma (41%) and adenocarcinoma (53%), respectively. Histologically, tumors were evenly distributed throughout the small intestine. Small intestinal tumors remain difficult to diagnose because of an atypical presentation and renew the need for appropriate suspicion when treating patients with vague abdominal symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)