Jane Koziol-McLain

MANAGEMENT OF ACUTE PYELONEPHRITIS IN AN EMERGENCY DEPARTMENT OBSERVATION UNIT

STUDY OBJECTIVES To determine whether moderately to severely ill patients with acute pyelonephritis can be treated successfully on an outpatient basis, and whether any aspect of history, physical examination, or initial laboratory data predicts failure of outpatient therapy and the need for hospitalization. DESIGN Retrospective chart review of all patients with a diagnosis of acute pyelonephritis seen during a three-year period. SETTING Emergency department observation unit of an urban teaching hospital serving residents of the city and county of Denver. TYPE OF PARTICIPANTS Women between the ages of 15 and 50 with symptoms, physical examination, and initial laboratory data consistent with a diagnosis of pyelonephritis. INTERVENTIONS Patients received IV antibiotics, rehydration, analgesics, and antiemetics in an observation unit for up to 12 hours, when they were either admitted to the hospital or discharged home on oral antibiotics. MEASUREMENTS AND MAIN RESULTS Sixty-three of 87 patients (72%) with acute pyelonephritis were managed successfully as outpatients, nine (22%) were hospitalized directly from the observation unit because they were considered to be too ill to go home, and five (6%) returned with persistent symptoms after ED therapy and were hospitalized. No clinical or laboratory variable predicted success or failure of ED observation unit therapy at the time of initial presentation. CONCLUSION In selected patients, the observation unit may be used to initiate therapy for acute pyelonephritis. Those with an adequate clinical response to initial treatment may be discharged on oral antibiotic therapy with appropriate follow-up.

Measuring the accuracy of the infrared tympanic thermometer: Correlation does not signify agreement

This prospective study assessed the accuracy of the infrared tympanic thermometer (ITT) compared to the rectal thermometer (RT) using statistical measures of agreement. In a convenience sample of 100 adult emergency department patients, ear examinations to assess for cerumen or otitis were followed by temperature measurements using the First Temp 2000A thermometer in both ears and the IVAC 2000 rectally. Left and right ITT temperatures showed high correlation and agreement; therefore, only right ITT results are reported. Both the ITT and RT recorded similar mean temperatures, standard deviations, and ranges. The correlation of the ITT and RT and agreement were below the 0.8 level, indicating excellent agreement. The mean temperature difference (RT-ITT) between the two devices was 0.1 +/- 0.7 degrees C; in 10% of patients, the temperature difference was > or = 1 degree C. Among 10 patients identified as febrile by RT (RT > or = 38.5 degrees C), 6 were febrile by ITT. Significant differences occurred between the temperature measurements using the ITT and RT; these devices do not demonstrate excellent agreement.

Loss and grief reactions after spontaneous miscarriage in the emergency department

STUDY OBJECTIVE To describe the psychological and functional consequences of miscarriage in women after emergency department treatment and to identify variables that are associated with feelings of loss and grief. DESIGN A prospective telephone follow-up study. SETTING The ED of an urban teaching hospital. TYPE OF PARTICIPANTS A consecutive sample of 44 women who were treated for miscarriage. MAIN RESULTS Women were contacted a median of 17.5 days after their miscarriage. Although the pregnancy had been planned by only 12 women (28%), 30 (70%) stated they wanted the pregnancy once they knew they were pregnant. Women commonly felt a sense of loss (82%) and most experienced some limitations with daily functioning (77%). Although wanting the pregnancy was associated with a sense of loss, 40% of the women who did not want the pregnancy experienced loss. CONCLUSION Grief reactions are pervasive after spontaneous miscarriage. There is no subgroup of women who could be expected not to experience loss and grief. The ED management of the woman who miscarries should address the anticipated loss and grief.