Charles K. Brown

Discharge Instructions: Do Illustrations Help Our Patients Understand Them?

STUDY OBJECTIVE To determine whether the addition of illustrations to discharge instructions improves patient comprehension. DESIGN Randomized, blinded, prospective study. A blinded investigator asked a series of questions designed to test the participants comprehension of the discharge instructions. There were 10 possible correct responses. SETTING Emergency department of a rural Level I trauma center. PARTICIPANTS Convenience sample of 101 patients discharged with the diagnosis of laceration. INTERVENTIONS Patients were randomly assigned to receive discharge instructions with (n = 54) or without (n = 47) illustrations. RESULTS The median number of correct responses was five. Patients with illustrations were 1.5 times more likely to choose five or more correct responses than those without illustrations (65% versus 43%; P = .033). The effect of illustrations varied by demographic group. Among nonwhites (n = 51), patients with illustrations were more than twice as likely to choose five or more correct responses (P = .032). Among patients with no more than a high school education (n = 71), patients with illustrations were 1.8 times more likely to choose five or more correct responses (P = .038). Among women (n = 48), patients with illustrations were 1.7 times more likely to chose five or more correct responses (P = .006). CONCLUSION The addition of illustrations to discharge instructions for patients who have sustained lacerations improves patient comprehension. There is a large effect among patients who are nonwhite, female, or have no more than a high school education.

Subcuticular Sutures and the Rate of Inflammation in Noncontaminated Wounds

STUDY OBJECTIVE To determine whether buried, absorbable, subcuticular sutures increase the degree of inflammation in noncontaminated wounds. DESIGN Randomized, blinded, prospective trial. SETTING Laboratory. PARTICIPANTS Eleven Sprague-Dawley rats weighing 300 to 325 g. INTERVENTIONS Four wounds were made on each rat. Two wounds on each were closed with three interrupted buried, absorbable, subcuticular sutures 6-0 polyglactin 910 and running 5-0 nylon skin sutures. The other two wounds were closed with running 5-0 nylon skin sutures alone. RESULTS Fourteen days after the sutures were placed, the animals were killed, and histologic preparations were made from each wound. Each sample was scored on a scale of 0 to 3 for the presence of inflammatory infiltrates, fibroplasia and capillary proliferation, necrosis, exudates, giant cells, and edema. We determined a total wound score by adding the scores from each category. The mean total wound score was 4.46 +/- 2.92 for those closed with buried, absorbable, subcuticular sutures and 4.91 +/- 2.56 for those closed without buried, absorbable, subcuticular sutures. Using the Wilcoxon rank-sum test, we found no statistically significant difference in mean total wound score of wounds closed with and without buried, absorbable, subcuticular sutures (alpha = .01). The probability of detecting a twofold difference in total wound scores was 60% (beta = .40). CONCLUSION Buried, absorbable, subcuticular sutures do not significantly increase the degree of inflammation in noncontaminated wounds.

Retained foreign body: a fingernail fragment?

A 19-year-old female presented four and one-half months after an occupational injury from a punch-type machine. Exploration revealed a large fragment of her fingernail embedded in the fingerpad. Foreign bodies are commonly encountered in the practice of emergency medicine and failure to localize and remove them can result in significant morbidity. We present a case of a fingernail as a foreign body. Foreign bodies may be difficult to detect despite sophisticated imaging techniques. Although not visualized often, a radiolucent foreign body may be inferred from boney changes. A thorough history regarding mechanism of injury and resultant wound exploration are required. When an adequate wound examination using digital tourniquet control and proper precautions is performed, the majority of foreign bodies will be detected.

Can clinical prediction rules used in acute pediatric ankle and midfoot injuries be applied to an adult population

BACKGROUND Almost every patient who comes to an emergency department (ED) with the chief complaint of ankle or foot pain will receive a radiograph, but less than 15% will have a finding positive for ankle or midfoot fracture. In an effort to reduce the number of radiographs performed, clinicians have attempted to derive a set of maximally sensitive clinical prediction rules. Dayan et al (Acad Emerg Med. 2004;11(7):736-745) in 2004 derived a set of such rules for children. These rules have not yet been evaluated in the adult population. OBJECTIVE The objective of this study is to apply the existing clinical prediction rules used to identify children with fractures after twisting injuries of the ankle to a population that includes adults. METHODS This was a prospective observational study using convenience sampling. Patients older than 2 years presenting to the ED or associated urgent care center with the chief complaint of an ankle or foot injury were considered eligible for enrollment into the study. After informed consent was obtained, 11 physical examination variables were assessed. Radiographs were obtained and reported, and the radiograph results were noted on the patients data sheet. Based on the radiograph results, sensitivity and specificity of each of the physical examination variables were analyzed. RESULTS Sixty-eight patients were eligible, and 29 patients were enrolled after exclusion criteria were applied (median age, 34 years). Three patients were diagnosed with a malleolar zone fracture, and 2 patients were diagnosed with a midfoot zone fracture. Five indicators were found to be 100% sensitive for ankle fracture, and 2 indicators were 100% sensitive for midfoot fracture. CONCLUSIONS The same indicators found to be predictive of high risk for fracture in a population of pediatric patients were found to be predictive in a population including adults.

Use of cranial computed tomography (CT) in elderly patients presenting after a fall: can we predict those having abnormal head CT scans.

Aims: Identify factors predictive of increased risk of intracranial injury and assess the ability of the non-age related components of the New Orleans head CT criteria (NOC) to guide decision-making. Study Design: Retrospective electronic medical record review and application of decision rule. Place and Duration of Study: Emergency Department (ED) of Vidant Medical Center, Department Original Research Article Bennett et al.; BJMMR, 6(3): 342-350, 2015; Article no.BJMMR.2015.210 343 of Emergency Medicine, Brody School of Medicine at East Carolina University; Greenville North Carolina, USA; January 2008 through December 2008 Methodology: Electronic Medical Records (EMR) of patients > 65 years of age coming to our Emergency Department during 2008 with a diagnosis of fall or traumatic injury were reviewed. Demographics, fall/injury details, risk factors, CT performance, and CT findings were recorded. Revisit within 30 days was reviewed. Non-age related NOC were applied to the population. Transfers, known intracranial injury, and multisystem trauma were excluded. Independent predictors of positive findings were sought using logistic regression. Results: We identified 783 patients with fall and traumatic injury. Ninety-six met exclusion criteria, leaving 687 for analysis. Three hundred twenty one patients received head CT; 296 met the nonage NOC for head CT. Twelve (3.1%) abnormal head CTs were identified; nine showed an acute finding. Acute findings were not predicted by any independent variable. All 12 of the abnormal head CTs (nine acute, three chronic) were identified by the non-age NOC. Forty five patients presented again within 30 days with no injuries noted. Conclusion: Age over 65 did not increase the risk for acutely abnormal head CT in the patient presenting to the ED after a fall. No single factor was predictive of acutely abnormal head CT. The use of the non-age related NOC predicted those patients having an abnormal head CT with 100% accuracy. Age may not independently necessitate head CT after a fall.

Artificial neural networks: Predicting head CT findings in elderly patients presenting with minor head injury after a fall

Objectives:: To construct an artificial neural network (ANN) model that can predict the presence of acute CT findings with both high sensitivity and high specificity when applied to the population of patients ≥ age 65 years who have incurred minor head injury after a fall. Methods:: An ANN was created in the Python programming language using a population of 514 patients ≥ age 65 years presenting to the ED with minor head injury after a fall. The patient dataset was divided into three parts: 60% for “training”, 20% for “cross validation”, and 20% for “testing”. Sensitivity, specificity, positive and negative predictive values, and accuracy were determined by comparing the models predictions to the actual correct answers for each patient. Results:: On the “cross validation” data, the model attained a sensitivity (“recall”) of 100.00%, specificity of 78.95%, PPV (“precision”) of 78.95%, NPV of 100.00%, and accuracy of 88.24% in detecting the presence of positive head CTs. On the “test” data, the model attained a sensitivity of 97.78%, specificity of 89.47%, PPV of 88.00%, NPV of 98.08%, and accuracy of 93.14% in detecting the presence of positive head CTs. Conclusions:: ANNs show great potential for predicting CT findings in the population of patients ≥ 65 years of age presenting with minor head injury after a fall. As a good first step, the ANN showed comparable sensitivity, predictive values, and accuracy, with a much higher specificity than the existing decision rules in clinical usage for predicting head CTs with acute intracranial findings.