Brian K. Nelson

Seroma formation following breast cancer surgery.

Abstract:   A seroma is the most frequent complication of breast cancer surgery, the etiology of which remains obscure. We reviewed our data to determine the factors related to the incidence of seroma formation in our patients. A retrospective analysis of the records of 359 consecutive patients (334 Hispanic; 93%) who underwent primary surgical therapy from January 1, 1996 to December 31, 2000, with either modified radical mastectomy (MRM) or wide local excision (WLE) and axillary lymph node dissection (ALND) was performed. In all cases, removal of the breast was performed using electrocoagulation, and sharp dissection was used in the axilla. One‐eighth inch closed suction round drains were used. Early arm motion was encouraged. The seroma rate was compared to the age of the patient, the presence and number of positive axillary lymph nodes, the total number of axillary lymph nodes removed, tumor size, weight of the patient, the use of neoadjuvant chemotherapy, and the type of surgery performed. The overall seroma rate was 15.8%. Seromas occurred in 19.9% of patients undergoing MRM and in 9.2% of patients undergoing breast‐conserving surgery (p = 0.01). The seroma rate was not influenced by any other tested variables. All seromas were easily managed with aspiration and pressure; this technical maneuver allowed seroma resolution in all patients except one following one to six aspirations. A seroma did not delay initiation of chemotherapy. No patient developed a capsule requiring excision. In our experience, a seroma is a “necessary evil;” it will occur unpredictably in a predictable number of patients. 

Prospective, Randomized Trial of Template-assisted Versus Undirected Written Recording of Physician Records in the Emergency Department☆☆☆★★★

STUDY OBJECTIVE To determine whether use of the T-System (Emergency Services Consultants, Irving, TX) template-generated medical documentation system (1) decreases physician evaluation time in the emergency department, (2) increases gross billing under the 1997 Health Care Financing Administration guidelines by minimizing downcoding caused by inadequate documentation, and (3) increases physician satisfaction with the documentation process, compared with the undirected written narrative format. METHODS A prospective, randomized, unblinded, controlled, convenience trial of documentation with the T-System of ED templates versus undirected written documentation was conducted in the ED of a county-owned, university-affiliated hospital. All patients seen between the hours of 7 AM and 10 PM during a 16-day period were included. The intervention was varying the method of documentation of the emergency physician. Adequacy of randomization to the 2 documentation groups was assessed by comparing ED triage classification, patient disposition, level of training of the evaluating physician, and whether ED consultation with other services occurred. Outcome measurements included emergency physician total evaluation and treatment time, professional bill, and satisfaction, as evaluated by a questionnaire completed after the study period. The 2 documentation groups were compared by an intention-to-treat analysis and by Students t test and the median test as appropriate. RESULTS A total of 1,228 patient encounters were included. Emergency physician total evaluation and treatment time with template-directed documentation was 4.6 minutes less than with undirected recording, a difference that was not significant (95% confidence interval [CI], -9.2 to 18.3). Gross billing was

Tension pneumothorax following CPR or mechanical ventilation

29. 60 more per patient (95% CI,

Pure red cell aplasia and hepatitis in a child receiving isoniazid therapy

22.20 to

Usefulness of the stool Wright's stain in the emergency department.

37.00) with the T-System, as assessed by our hospital coders. This difference was caused by a mean.50 (95% CI,.39 to.60) higher level of evaluation and management coding. Physicians preferred the T-System (P <.0005). CONCLUSION Use of template-assisted documentation in the ED was associated with higher gross billing and physician satisfaction but no significant decrease in emergency physician total evaluation time.

Faculty Triage Shortens Emergency Department Length of Stay

To the Editor: Because the patients chest has already been examined and the patient is intubated when a pneumothorax develops as a result of CPR or mechanical ventilation, traditional symptoms and signs may not be evident. Experience with four tension pneumothoraces developing during CPR and two during trauma resuscitation prompts me to suggest the following diagnostic signs and treatment. The earliest sign of this complication appears to be a decrease in compliance manifested by increasing airway pressures and difficulty delivering adequate tidal volumes with bag-valve-mask device. The observation under these circumstances is that the patient is very difficult to bag. This should prompt immediate auscultation and percussion of the chest. When an oxygen-powered breathing device is being used, however, this sign may not be evident. As intrapleural pressure increases, the involved hemithorax will cease movement with ventilation. If this sign is also ignored, eventually a soft mass will appear above the clavicle, representing billowing of the pleural dome in response to the high pressure in the pleural space. Currently the accepted initial treatment of tension pneumothorax is needle thoracostomy in the second intercostal space, midclavicular line. 1 The maneuver is recommended as an interim measure to buy time while a tube thoracostomy is placed. On three occasions, with arrests I have observed that needle thoracostomy, even with multiple large-bore needles (14-gauge), did not allow adequate venting of the pleural space. I theorize that the very high volumes of air (up to a liter) introduced with each ventilation were more than the needles could evacuate. I suggest, then, that tension pneumothorax developing during resuscitative efforts with positive pressure ventilation may be difficult to recognize, and that the immediate treatment should be entry of the pleural space with a scalpel without dissection or sterile technique. After venting the pleural space, a chest tube could be placed.

Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study

A 7-year-old boy had pure red cell aplasia and clinically significant hepatitis during isoniazid therapy. The former complication had been reported only in adults, and the latter is rare in children.

Intravenous lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: A randomized clinical trial

A prospective study was conducted to determine if a Wrights stain of stool specimen to detect fecal leukocytes was accurate in predicting the presence of a bacterial pathogen on stool culture. Entry criteria were patient age greater than or equal to 3 months and diarrhea of greater than 1 day. The patient population was drawn from an urban county hospital emergency department on the Texas-Mexican border. A total of 69 patients were evaluated by both routine stool culture and stool Wrights stain. Twenty-three were evaluated for parasitic pathogens. There were seventeen cultures positive for bacterial pathogens and twenty-three positive Wrights stains. Bacterial isolates included Shigella, Salmonella and Campylobacter. Also detected were Giardia, Shistosoma, Blastocytis and Cryptosporidium. The sensitivity of a Wrights stain positive for fecal leukocytes for the presence of a bacterial pathogen by culture was 82%, with a specificity of 83%. These were significantly correlated with a positive culture for a bacterial pathogen (P less than .01). The predictive value of a positive result was 61%, and predictive value of a negative result was 94%, for bacterial pathogens. The Wrights stain is a useful tool for the early presumptive diagnosis of infectious bacterial diarrhea in the emergency department.