Marc Sabbe

Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department

Background Recent literature revealed that medication histories obtained by physicians and nurses are often incomplete. However, the number of patients included was often low. Study objective In this study, the authors compare medication histories obtained in the Emergency Department (ED) by pharmacists versus physicians and identify characteristics contributing to discrepancies. Methods Medication histories were acquired by the pharmacist from patients admitted to the ED, planned to be hospitalised. A structured form was used to guide the pharmacist or technician to ensure a standardised approach. Discrepancies, defined as any difference between the pharmacist-acquired medication history and that obtained by the physician, were analysed. Results 3594 medication histories were acquired by pharmacy staff. 59% (95% CI 58.2% to 59.8%) of medication histories recorded by physicians were different from those obtained by the pharmacy staff. Within these inaccurate medication histories, 5963 discrepancies were identified. The most common type of error was omission of a drug (61%; 95% CI 60.4% to 61.6%), followed by omission of dose (18%; 95% CI 17.6% to 18.4%). Drugs belonging to the class of psycholeptics, acid suppressors and beta blocking agents were related to the highest discrepancy rate. Acetylsalicylic acid, omeprazole and zolpidem were most commonly forgotten. Conclusion This large prospective study demonstrates that medication history acquisition is very often incomplete in the ED. A structured form and a standardised method is necessary. Pharmacists are especially suited to acquire and supervise accurate medication histories, as they are educated and familiar with commonly used drugs.

Screening for risk of readmission of patients aged 65 years and above after discharge from the emergency department: predictive value of four instruments

Objectives To compare the abilities of four different screening tools to predict return visits of older persons after they have been discharged from the emergency department (ED). Methods We assessed 83 short-term (discharged within 24 h) patients (aged 65 years and above) who visited the ED of the University Hospitals Leuven, Belgium, from 15 October 2005 to 24 December 2005. The Identification of Seniors at Risk (ISAR), the Triage Risk Screening Tool (TRST), the eight-item questionnaire of Runciman, and the seven-item questionnaire of Rowland were administered at admission to screen the patients for risk factors of future ED readmission. By telephone follow-up 14, 30, and 90 days after discharge from the ED, we asked the patients (or their families) whether readmission had occurred since their initial discharge from the ED. Results Readmission rates were 10%, 15.8%, and 32.5% after 14, 30, and 90 days, respectively. When using three or more positive answers as the cutoff scores, the Rowland questionnaire proved to be the most accurate predictive tool with a sensitivity of 88%, specificity of 72%, and negative predictive value of 98% at 14 days after discharge. Thirty days after discharge, the sensitivity was 73%, specificity was 75%, and negative predictive value was 92%. Conclusion Repeat visits in older persons admitted to an ED seemed to be most accurately predicted by using the Rowland questionnaire, with an acceptable number of false positives. This instrument can be easily integrated into the standard nursing assessment.

Cyanide poisoning by fire smoke inhalation: a European expert consensus

Smoke inhalation is a common cause of cyanide poisoning during fires, resulting in injury and even death. In many cases of smoke inhalation, cyanide has increasingly been recognized as a significant toxicant. The diagnosis of cyanide poisoning remains very difficult, and failure to recognize it may result in inadequate or inappropriate treatment. Findings suggesting cyanide toxicity include the following: (a) a history of enclosed-space fire; (b) any alteration in the level of consciousness; (c) any cardiovascular changes (particularly inexplicable hypotension); and (d) elevated plasma lactate. The feasibility and safety of empiric treatment with hydroxocobalamin for fire smoke victims have been reported in the literature. On the basis of a literature review and a panel discussion, a group of European experts has proposed emergency management protocols for cyanide toxicity in fire smoke victims.

Muscle paralysis by rocuronium during halothane, enflurane, isoflurane, and total intravenous anesthesia

We determined the dose-response relationship, the onset time, the duration, and the recovery time of a rocuronium neuromuscular block under four anesthesia techniques. Patients were equally randomized to four different groups (n = 20) receiving 0.5%–l% halothane, 1.5%–2% enflurane, 1.2%–1.8% isoflurane end-tidal concentration in 34%/66% O2/N2O, or 6.0 mg-kg−1 h−1 propofol without N2O for anesthesia and alfentanil for analgesia. Strength of thumb adduction in response to single and train-of-four stimulation of the ulnar nerve was quantitated. Rocuronium 0.15, 0.2, 0.25, and 0.3 mg/kg were given intravenously. When maximal depression of twitch tension occurred, supplemental doses up to a total of 0.5 mg/kg were given. If required, additional doses of 0.15 mg/kg were given at 25% recovery of control twitch tension. Standard hemodynamics, end-tidal CO2, and anesthetic gas concentrations were monitored continuously. The mean ED50 (SD) was 0.133 (±0.009) mg/kg for the halothane group, 0.118 (±0.012) mg/kg for the enflurane group, 0.069 (±0.026) mg/kg for the isoflurane group, and 0.167 (±0.007) mg/kg for the total intravenous anesthesia (TIVA) group, respectively. There was a statistically significant difference between the halothane and TIVA, and between the enflurane and TIVA groups (P < 0.05). Rocuronium has a short onset time and an intermediate duration of action. The neuromuscular blocking potency and pharmacodynamic profile are moderately influenced by volatile anesthetics.

Fatal intentional poisoning cases admitted to the University Hospitals of Leuven, Belgium from 1993 to 1996.

Between January 1993 and July 1996, a total of 2827 intentional cases of poisoning were registered in the University Hospitals of Leuven, Belgium. Ten of these cases were fatal. This study was set up to evaluate the substances involved, the circumstances, the features and the characteristics of the patients who died due to intentional poisoning. The male to female ratio of these fatal cases was 9 : 1. The median age was 43 years. Two groups of substances were revealed to be associated with fatal outcome. The first group consisted of chemicals (seven lethal cases): cholinesterase inhibitors (n =3), methanol (n =2) and paraquat (n =2). The second group consisted of benzodiazepines (three lethal cases). In the cases of poisoning with chemicals, death was directly related to product toxicity and the severity of the poisoning, whilst with benzodiazepines, which are considered to be relatively safe drugs even when taken in overdose, there was a clear relationship between a fatal outcome and a delay between ingestion and medical support. Product toxicity, complications and a delay in medical support may be considered as predictors for the effectiveness and efficacy of treatment and may influence which medical treatments need to be administered.

Attenders of a university hospital psychiatric emergency service in Belgium: General characteristics and gender differences

Abstract.Objective:The aim of this study was to provide a clinical and epidemiological profile of patients consulting the psychiatric emergency team (PET) of an emergency service of a Belgian university hospital.Method:Of all PET patients (N = 1,050), demographic characteristics, axis I diagnosis, any axis II diagnosis, presenting problems, psychiatric antecedents, and patterns of referral were assessed.Results:Male patients presented more with hostility or violence towards others (10 %) and substance abuse (23 %); female patients presented more with suicidality (31%) and depressed mood (24 %). Male patients had more psychoactive substance use disorders (21 %); female patients had more mood (21%) and adjustment disorders (19 %). About 50% of the patients were unemployed and had sought psychiatric help in the past. Female patients were more often referred by the emergency physician (35%) and health care professionals (29 %); male patients were more often self-referred (23 %) and referred by the police (9 %).Conclusion:A PET could overcome the discrepancy between the need of treatment and the effective use of mental health services. Male and female PET patients presented different complaints and were given different axis I diagnoses; they also had different pathways to care.

Survival after a lethal dose of arsenic trioxide.

A case of a 27‐year‐old woman who ingested 9000 mg arsenic trioxide (As2O3) is reported. Classical symptoms of an acute arsenicum (As) poisoning such as gastrointestinal cramps, vomiting, diarrhea, ECG changes and disturbed liver function tests were observed. The absorption of the ingested As was minimalized by a continuous gastric irrigation with highly concentrated NaHCO3 andintestinal cleansing with NaHCO3 and polyethyleneglycol was performed. Forced diuresis, BAL (2,3‐dimercaptopropanol) and DMSA (meso‐2,3‐dimercaptosuccinic acid) were started and therapy to enhance the formation of methylated As derivatives, which are potentially less toxic and which can be excreted more easily, was then administered. The patient survived this massive dose of ingested inorganic As with only polyneuropathy one year later.

Screening for risk of unplanned readmission in older patients admitted to hospital: predictive accuracy of three instruments

Background and aims: Hospital readmission after discharge is an important clinical and health policy issue. We compared the predictive accuracy of the Identification of Seniors at Risk (ISAR), the Flemish version of the Triage Risk Screening Tool (TRST) and Variable Indicative of Placement risk (VIP) assessing unplanned readmissions. Methods: We included 213 patients (≥65 years), hospitalized following admission to the emergency department. The ISAR, TRST and VIP were administered at admission. Unplanned readmissions were registered by telephone follow-up 14, 30 and 90 days post-discharge. Results: Unplanned readmission rates were 6.8%, 14.7% and 23.5% after 14, 30, and 90 days, respectively. The ISAR showed low to moderate sensitivity (54%–69%) and a high negative predictive value (≥78%) at all measurement points. Specificity and positive predictive value were low (≤33% and ≤24%, respectively). The TRST had low to moderate sensitivity (42%–67%) and a high negative predictive value (≥82%). Specificity and positive predictive value were low (≤45% and ≤27%, respectively). The VIP had very low sensitivity (≤26%) and high specificity (≥80%). Its negative predictive value was high (≥79%) and its positive predictive value was low (≤22%). Conclusions: Due to their moderate to low sensitivity, and low specificity and positive predictive value, none of the instruments was capable of accurately predicting unplanned readmission in older, hospitalized patients. Overall, reducing or increasing the original cut-off value by one point did not result in improved performance. Our findings suggest that these instruments lack the necessary sophistication to capture the complexity of (unplanned) readmissions.

The effect of helmets on the incidence and severity of head and cervical spine injuries in motorcycle and moped accident victims: a prospective analysis based on emergency department and trauma centre data

The aim of this prospective study was to quantify the anatomic severity of head and cervical spine injuries in hospital admitted victims of motorcycle and moped accidents in relation to helmet use and controlled for non-head injuries (i.e. kinetic impact). Two hundred and twenty-three patients entered the study group, of which 152 were motorcyclists and 71 were moped riders. Our results reveal that helmets do prevent head injury in motorcycle and moped accidents, especially in those crashes involving relatively low kinetic energy transfers. Helmet use does not lead to an increase of the incidence or severity of cervical spine injury. As a result compulsory helmet laws should not be limited to motorcyclists but also focus on all moped riders and probably also bicyclists. This study illustrates that emergency departments can provide important epidemiological information for injury control purposes. However, the epidemiological use of emergency department data and hospital data in general requires cautiousness. Confounding is a common problem which should be dealt with during analysis.

Prehospital stroke scales in a Belgian prehospital setting: A pilot study

Objective To compare the diagnostic value of the Cincinnati Prehospital Stroke Scale, the Face Arm Speech Test, the Los Angeles Prehospital Stroke Screen and the Melbourne Ambulance Stroke Screen for identifying patients with an acute stroke in a prehospital setting in Belgium. Methods A prospective study was performed, using a questionnaire for every primarily transported patient within emergency medial service with relevant neurological complaints. Exclusion criteria were: patients below 18 years, trauma victims, Glasgow Coma Scale of less than 8 or transported to another hospital. The questionnaire is a comprehension of different stroke scales. Results The Face Arm Speech Test and Cincinnati Prehospital Stroke Scale demonstrate a high sensitivity (95%) but a lower specificity (33%). The sensitivity of the Los Angeles Prehospital Stroke Screen and Melbourne Ambulance Stroke Screen was lower (74%), but the specificity increased (83 and 67%). Items investigating unilateral facial paralysis and unilateral loss/absence of motor response in upper extremities seemed to be most discriminating between the stroke group (68–78%) and the nonstroke group (17%), suggesting that items related to clinical assessment are more important in stroke recognition than history items. Combination of all clinical parameters of the different scores resulted in a sensitivity and specificity of 95 and 83%, respectively. Conclusion The results obtained in this study are comparable with earlier investigations. Given the limitations of the study, we could not identify the most adequate stroke scale. History items seem to be less relevant compared with clinical assessment. Further research is needed to determine the most adequate stroke scale.