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Biomedical subjects

A M Kelly

Publications and source records attributed to A M Kelly.

At least 55 records · Page 3Linked to original sources
PubMed2000

A problem-based learning resource in emergency medicine for medical students.

Emergency medicine is a relatively new specialty area within medicine, however medical schools, students and standard setting bodies have recognised that learning emergency medicine is integral to the training of medical students. There are, however, significant problems with the delivery of emergency medicine teaching including low teacher numbers, severely limited teaching time and lack of suitable learning resources. This paper describes the process of development of a learning resource, its format and content and summarises student feedback.

Curriculum↗
PubMed2000

Migraine: pharmacotherapy in the emergency department.

Migraine can be a disabling condition for the sufferer. For the small number of patients for whom home therapy fails and who seek treatment in an emergency department, several therapeutic options are available. I review the evidence regarding the effectiveness and safety of the following therapies: the phenothiazines, lignocaine (lidocaine), ketorolac, the ergot alkaloids, metoclopramide hydrochloride, the "triptans," haloperidol, pethidine (meperidine hydrochloride), and magnesium sulfate. Based on available evidence, the most effective agents seem to be prochlorperazine, chlorpromazine and sumatriptan, each of which has achieved greater than 70% efficacy in several studies.

Emergency Service, Hospital↗
PubMed2000

Natural treatment of perennial allergic rhinitis.

Perennial allergic rhinitis is an IgE-mediated inflammatory disorder of the nasal mucosa characterized by paroxysms of sneezing, nasal congestion, pruritus, and rhinorrhea. The condition may be caused by certain environmental agents, food sensitivities, structural abnormalities, metabolic conditions, or synthetic drugs. Recent health impairment outcome studies on allergic rhinitis sufferers reveal a measurable decline in physical and mental health status and the inability to perform daily activities. Antihistamines, decongestants, anticholinergic agents, and corticosteroid drug therapy, alone or in combination, are typically used in the treatment of allergic rhinitis. Reported adverse side effects include sedation, impaired learning/memory, and cardiac arrhythmias. Therapeutic strategies should seek to decrease the morbidity already associated with this condition. Urtica dioica, bromelain, quercetin, N-acetylcysteine, and vitamin C are safe, natural therapies that may be used as primary therapy or in conjunction with conventional methods.

Acetylcysteine↗
PubMed1999

Managing unstable angina and coronary care beds effectively.

This article is an evaluation of a new chest pain admission policy at Western Hospital. Our aim was to determine the clinical outcomes of patients with unstable angina treated according to this new policy. It involved attempting to identify a group at low risk of serious complications and to manage them in a general ward area without cardiac monitoring, to reduce the pressure on coronary care unit beds. We conducted a retrospective case note review and concluded that that selected patients with an admission diagnosis of unstable angina can be safely managed in unmonitored medical beds provided mechanisms are in place for their transfer to the coronary care unit if recurrent pain or a complication occurs.

Angina, Unstable↗
PubMed1998

Rationalising the ordering of blood cultures.

In 1996 a project was undertaken to determine the clinical impact of blood cultures taken in the emergency department. It found that 1.6% of all blood cultures taken resulted in changes in patient management. In response to these findings, guidelines were developed for more appropriate utilisation of blood cultures. It was predicted that the guidelines would result in a reduction in test ordering of approximately 40% and an annual saving of approximately $18,000. The guidelines were implemented in mid-1997. An audit of test ordering for the months of January to August 1998 shows a 53% reduction in the ordering of blood cultures.

Cost Savings↗
PubMed1998

Does the clinically significant difference in visual analog scale pain scores vary with gender, age, or cause of pain?

OBJECTIVES: To determine the minimum clinically significant difference in visual analog scale (VAS) pain scores for acute pain in the ED setting and to determine whether this difference varies with gender, age, or cause of pain. METHODS: A prospective, descriptive study of 152 adult patients presenting to the ED with acute pain. At presentation and at 20-minute intervals to a maximum of three measurements, patients marked the level of their pain on a 100-mm, nonhatched VAS. At each follow-up they also gave a verbal rating of their pain as "a lot better," "much the same," "a little worse," or "much worse." The minimum clinically significant difference in VAS pain scores was defined as the mean difference between current and preceding scores when pain was reported as a little worse or a little better. Data were compared based on gender, age more than or less than 50 years, and traumatic vs nontraumatic causes of pain. RESULTS: The minimum clinically significant difference in VAS pain scores is 9 mm (95% CI, 6 to 13 mm). There is no statistically significant difference between the minimum clinically significant differences in VAS pain scores based on gender (p=0.172), age (p=0.782), or cause of pain (p=0.84). CONCLUSIONS: The minimum clinically significant difference in VAS pain scores was found to be 9 mm. Differences of less than this amount, even if statistically significant, are unlikely to be of clinical significance. No significant difference in minimum significant VAS scores was found between gender, age, and cause-of-pain groups.

Acute Disease↗
PubMed1998

Clinical impact of blood cultures taken in the emergency department.

OBJECTIVES: (1) To establish the proportion of blood cultures that yield a positive microbiological culture. (2) To determine what proportion of blood cultures taken in the emergency department impact on patient management. (3) To develop guidelines for the appropriate ordering of blood cultures from patients in the emergency department (ED). METHODS: Retrospective review of all blood cultures taken in the ED of a metropolitan teaching hospital between 26 September 1995 and 30 June 1996. RESULTS: One thousand and sixty two blood cultures were taken from patients in the ED during the study period. Ninety two (9%) returned a positive microbiological culture. Of these, 52 (5%) were "true" positives and 18 (1.6%) resulted in changes in management. CONCLUSIONS: Blood cultures taken in the ED rarely yield positive cultures. Only 1.6% of blood cultures taken in the ED impact on management of patients. Simple strategies could reduce the number of blood cultures ordered with little prospect of patient compromise.

Blood Specimen Collection↗
PubMed1998

Use of heparin in the treatment of protein-losing enteropathy after fontan operation for complex congenital heart disease.

Protein-losing enteropathy (PLE) is a serious complication of the Fontan operation and is associated with pronounced mortality. Medical management of PLE has been only partially successful. A recent report noted dramatic improvement in patients with PLE within 3 weeks of subcutaneous administration of heparin. We report a case of reversal of PLE with resolution of clinical symptoms and normalization of serum albumin, total protein, and fecal alpha1-antitrypsin values after several months of heparin treatment. Our findings substantiate those recently reported but suggest that reversal of PLE may necessitate more than a few weeks of heparin therapy.

Administration, Cutaneous↗
PubMed1998

Shoulder and elbow injuries and painful syndromes.

Childhood participation in organized sports has led to increased incidence of orthopedic complaints in the pediatric and adolescent populations, and year-round participation in a single sport allows no rest period from muscle use, bone development, and maturation. What effect do these factors have on the musculoskeletal system of the young athlete? They may lead to injuries such as dislocations, fractures, and problems of bone growth. This comprehensive review of shoulder and elbow anatomy and mechanisms of injury includes specific recommendations for rehabilitation.

Adolescent↗
PubMed1997

Nebulized salbutamol with and without ipratropium bromide in the treatment of acute asthma.

BACKGROUND: Routine addition of ipratropium bromide to beta-agonist therapy in acute asthma is of uncertain benefit. OBJECTIVE: This study was carried out to evaluate: (1) whether nebulized ipratropium (0.5 mg) plus salbutamol (2.5 mg) (Combivent) confers additional bronchodilation over nebulized salbutamol (2.5 mg) alone in patients with acute asthma and (2) whether adjustment for prognostic indicators of outcome influences any benefit seen with ipratropium. METHODS: A double-blind, two-center, randomized, single-dose study was performed in 338 patients with asthma, aged 18 to 55 years, who attended the emergency department for treatment of acute asthma. The primary end point was FEV1 at 90 minutes. RESULTS: The mean absolute difference in FEV1 at 90 minutes for Combivent compared with salbutamol was 113 ml (SEM +/- 48 ml, p < 0.05). Independent of the study drug received, a poor response to treatment was predicted by frequent use of inhaled beta-agonist before presentation (p < 0.0001), severity of the attack (p < 0.05), and longer duration of attack (p < 0.05). Subjects who had taken more than 10 puffs of inhaled beta-agonist through a metered-dose inhaler or who had serum salbutamol levels of greater than 2 mmol/L on presentation demonstrated no benefit from the addition of ipratropium. Patients with an FEV1 less than 1 L on presentation also responded less well to Combivent, which was explained by the association between severity of attack and greater use of inhaled beta-agonist therapy. CONCLUSION: A single dose of nebulized Combivent confers additional bronchodilation over salbutamol alone (p < 0.05) in acute asthma. Patients who exhibited most benefit from the addition of ipratropium were those who had consumed the least inhaled beta-agonist before presentation, not those with the most severe asthma.

Acute Disease↗
PubMed1997

Do triage nurse-initiated X-rays for limb injuries reduce patient transit time?

Patients with isolated limb injuries are often required to wait a long time for treatment and investigation in emergency departments. It was hypothesized that allowing triage nurses to initiate X-rays would reduce transit times for these patients. A prospective, randomized comparison trial of 175 patients was conducted, comparing transit times between a group of patients who had X-rays initiated at triage and a group which did not. No statistically significant reduction in transit time was demonstrated by this change in practice, either for a group who had sustained fractures or for one which had not. Despite this finding, staff and patient satisfaction with this change in procedure was high. This justifies continuation of the practice and further research.

Adolescent↗
PubMed1997

Beyond child development centres: care coordination for children with disabilities.

A specific model of care coordination for children with disabilities is described, comprising parental empowerment, a defined client population, individual tailoring of service based on assessment of need, inter-agency collaboration beyond existing team boundaries, continuity of named professional contact across transitions important to families, and a named care coordinator. The first stages of local implementation of the model are described for children with a disability making the transition into nursery school provision. Qualitative findings from interviews with families and care coordinators are presented, and the possibility of care coordinators providing a Named Person function is examined.

Case Management↗
PubMed1997

Managing potentially ischaemic chest pain and coronary care beds effectively.

One of the most common reasons why patients attend emergency departments in Australia is chest pain that is potentially due to coronary artery disease (myocardial infarction, unstable or stable angina pectoris). A number of models for the investigation and treatment of these patients have been employed over the last five to ten years. This paper describes the evolution of a model for managing ischaemic chest pain that aims to avoid potentially preventable deaths from undiagnosed myocardial infarction, to admit to hospital patients who could benefit from inpatient treatment, to admit to a coronary care unit patients at significant risk of complications, and to avoid inter-hospital transfer of patients. Introduction of the model has led to an increase in the appropriate hospital admission of patients with ischaemic chest pain, a marked reduction in inter-hospital transfers, and better utilisation of coronary care beds. Unmonitored, general ward management of low risk patients with clinical unstable angina has not resulted in compromised outcomes.

Angina Pectoris↗
PubMed1997

Is a standard regime for anticoagulation with heparin in unstable angina adequate?

AIM: To establish the proportion of patients with unstable angina in whom adequate anticoagulation is achieved using a standard regime of intravenous heparin. METHOD: A prospective series of 108 Emergency Department attendees over a six-month period with a clinical diagnosis of unstable angina for whom anticoagulation with heparin was prescribed were included in the study. The standard regime was a 5000 unit bolus followed by an intravenous infusion of 1000 units per hour (1200 units if the patient's weight was greater than 80 kg), with subsequent adjustments being made by reference to a nomogram. The activated partial thromboplastin time (APTT) was measured at six and 12 hours after treatment began. Two commonly used criteria for adequate heparinisation were compared: 1. APTT greater than 1.5 times control and 2. APTT in the range of 60-85 seconds. RESULTS: There were valid data for 90 patients at six hours and 79 at 12 hours. Compared to the criterion for adequate anticoagulation of APTT greater than 1.5 times the control, 25% of patients were subtherapeutic at six hours and 12% at 12 hours. Compared to the criterion APTT greater than 60 seconds, 53% of patients were subtherapeutic at 6 hours and 47% at 12 hours. At 6 hours, 26% of patients were over-anticoagulated as defined as APTT greater than 85 seconds. This had reduced to 13% by 12 hours. CONCLUSIONS: In the context of recent research suggesting that an APTT of greater than 1.5 times the control is sufficient to reduce complications in unstable angina, our results demonstrate that a standard regime of heparinisation will achieve this goal in the majority of patients within 6 hours of starting heparin therapy. However, if an APTT of 60-85 seconds is the goal, this standard regime is inadequate.

Adult↗
PubMed1997

Experience with the use of continuous positive airway pressure (CPAP) therapy in the emergency management of acute severe cardiogenic pulmonary oedema.

BACKGROUND: Acute pulmonary oedema (APO) is a frequent cause of respiratory failure and a common reason for presentation to emergency departments (EDs). To date, no paper has been published on the application of continuous positive airway pressure (CPAP) therapy for a large broad-based patient group. AIM: To report our experience with the use of CPAP in severe APO oedema, with particular reference to safety, intubation rates and impact on EDs' resources. METHOD: A retrospective chart review was undertaken of 75 patients with acute severe pulmonary oedema who were treated with adjuvant CPAP in an urban teaching hospital ED. RESULTS: Three patients (4%) required subsequent endotracheal intubation and mechanical ventilation. The average duration of CPAP was 1.9 hours. Eighty nine per cent of patients experienced no adverse events while being treated with GPAP. Five patients failed to tolerate the tight fitting mask necessitating removal of CPAP, three patients experienced arrhythmias related to underlying cardiac disease and two patients experienced mild transient hypotension. Seventy one per cent of patients were discharged from the ED to general medical wards. The in-hospital mortality for patients treated with CPAP was 15%. CONCLUSION: This series has demonstrated that CPAP therapy delivered via a face mask for the treatment of acute severe APO is safe and effective when applied to a broad range of patients. We recommend the use of CPAP therapy for all suitable patients presenting in severe APO irrespective of age or underlying pulmonary disease.

Acute Disease↗
PubMed1997

Growth of Pakistani children in relation to the 1990 growth standards.

This study was designed to compare the growth of Pakistani schoolchildren in the UK with the 1990 UK growth standards. Measurements of height, weight, and sitting height were performed on 785 Pakistani schoolchildren aged 5-14 years with the mean values for each age and sex being plotted on the UK growth standards. The results were expressed as SD scores relative to the 1990 reference data. The mean height for the boys was only 0.2 SD scores below the mean for the new growth standards with the mean height for the girls being 0.4 SD scores below the mean. The mean values for weight and body mass index were 0.3 and 0.5 SD scores less than the mean for boys and girls respectively. This study demonstrates that the growth of Pakistani schoolchildren in the UK is comparable to the 1990 UK growth standards with only minor differences. It is not safe to assume that short stature or low body weight in a Pakistani child is due to his or her ethnic background.

Adolescent↗
PubMed1997

Titrated intravenous opioids from the same syringe: an infection risk?

OBJECTIVE: (1) To compare the rate of contamination of syringes prepared under laminar flow conditions in pharmacy with those prepared by nurses in the emergency department; (2) to determine whether the time elapsed since preparation or number of doses given affected the contamination rate; (3) to determine whether any adverse effects resulted from bacterially contaminated drugs. METHODS: Prospective, blinded trial exploring the effect of method of preparation, time since preparation, and number of doses given on contamination rates and infective adverse events associated with bacterially contaminated specimens. RESULTS: The rate of bacterial contamination was 12% (95% confidence interval 6% to 18%). There was no difference in contamination rate in respect of method of preparation, number of doses given, or time since preparation. No infective complications were identified. CONCLUSIONS: Abandonment of titrated intravenous opioids is not justified by the results. However, there is concern about the use of this technique of pain control for immunocompromised patients and those with prosthetic heart valves.

Analgesia↗