Biomedical subjects
Publications and source records attributed to C M Fernandes.
A pilot study with piracetam (Nootropil; UCB) was performed in 5 selected dizzy patients who had a diagnosis of presbyvertigo or vertebrobasilar insufficiency. The study was monitored by assessing the effect of piracetam on the pursuit-tracking system. All patients showed a remarkable improvement in their pursuit tracking, in addition to marked subjective improvement in their vertigo.
A transnasal approach was employed in 28 neonates (26 blacks and 2 whites) with bilateral choanal atresia. In each patient the atresia was perforated microsurgically with the drill, followed by insertion of a Portex endotracheal tube for a period of three months. By this method a satisfactory nasal respiration was established immediately. Removal of the posterior part of the vomer is crucial to the successful result. During the follow-up, one death was recorded in a microcephalic neonate, unrelated to the operation and another four patients required repositioning of the tube under general anesthesia. We feel that the above technique is simple and definitive with negligible complications.
A review of 21 cases of complications of acute otitis media with a hyperemic, dull, bulging but intact tympanic membrane is presented. All cases had a retroauricular swelling. In 10 cases, a subperiosteal abscess was found, 1 of them complicated with a posterior fossa abscess, 2 had meningitis, 3 had Bezhold's abscess, 2 had thrombosis of the lateral sinus, 1 had a cerebellar abscess, 1 had cerebellitis, and 2 presented with facial nerve palsy. Ninety percent of the patients were below the age of 13. An incomplete course of antibiotic treatment was found to have been given in seven cases (30%) prior to admission. Surgical therapy consisted of a cortical mastoidectomy and a wide myringotomy. Ventilating tubes were inserted in three patients. The mastoid radiography demonstrated cloudiness, and CT scan was performed in six patients with suspected intracranial complications. The present study stresses that an intact tympanic membrane with minimal changes may be regarded by the medical profession with a low index of suspicion and can lead to severe otogenic complications. The disease can be masked by an improper antibiotic therapy.
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The transpalatal trans-sphenoidal approach to the pituitary gland is described and a series of 10 cases is presented. The advantages of this approach - ease of access, low morbidity and good cosmesis - are discussed.
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A case of pseudo-aneurysm of the internal carotid artery with arterio-venous fistula formation, involvement of the vagus and sympathetic nerves and proptosis is described. The diagnostic features are stressed, namely: recurrent minor haemorrhages from the nose and throat, a Horner's Syndrome, a swelling resembling a quinsy and involvement of the last four cranial nerves. Early diagnosis and immediate ligation are essential in these cases.
Seven patients with pyriform fossa carcinoma who presented at Baragwanath Hospital during the period 1973-1976 are discussed. The value of positive contrast studies with special reference to laryngography is emphasized and the results are reviewed.
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Application of Continuous Quality Improvement techniques can identify (a) major causes of delay in evaluation and treatment of ambulatory patients in an Emergency Department (ED) and (b) rational solutions to reduce those delays. To confirm this hypothesis, a prospective interventional study was conducted at a tertiary care teaching hospital with 50,000 emergency visits per year. Participants included all patients discharged from the ED in three separate time periods. A formal continuous quality improvement process was used to document the current process of ambulatory care patient flow and prioritize the causes of delay. Solutions were defined and presented to the hospital administration. Two solutions were implemented immediately. The effect of these changes was assessed by comparing the time interval from presentation to discharge from the ED (length of stay) and the time interval from presentation to generation of a chart (chart generation). These differences were compared by analysis of variance on consecutive patients seen in a 48-hour control period and two postintervention 48-hour periods. The interventions that were identified and immediately implemented were the addition of an admission clerk and the reduction of the Fast-Track nurse function to include only patient placement and vital signs. The length of stay for all patients was significantly reduced from a mean of 163 +/- 170 min to 115 +/- 86 and 122 +/- 105 min in two separate postintervention 48-hour samples. The mean length of stay for Fast-Track patients not requiring X-ray, electrocardiogram, or blood tests was 92 +/- 46 min. After the intervention, this was reduced to 73 +/- 46 and 67 +/- 31 min in the same two 48-hour samples. Chart generation times were significantly reduced from a mean of 21 +/- 18 min to 8 +/- 6 min. We conclude that the formal application of Continuous Quality Improvement techniques in the Emergency Department can result in appropriate changes in the process of patient flow, leading to measurable and significant reductions in length of stay for Fast-Track patients.
Patients with urinary retention frequently present to the emergency department (ED) for evaluation and treatment. Urinary retention is seen most often in males secondary to mechanical causes. However, other etiologies must be considered. We present an unusual case of a 35-year-old male who developed postcoital urinary retention secondary to urogenital diaphragm spasm.
Parenteral chlorpromazine is a frequently used agent in the acute management of tension and vascular headaches. However, headaches caused by other more serious diseases may also respond to this drug. This case report describes a patient with aseptic meningitis who experienced complete but temporary relief of her headache with parenteral chlorpromazine, prior to the eventual diagnosis.
Previous studies have suggested that most emergency department (ED) patients who leave without being seen by a physician (LWBS) are nonurgent. Our institution developed a fast-track process to reduce length of stay (LOS) for these patients. The present study was conducted to determine the effect of reducing LOS on the number of ED patients who leave without seeing a physician and the acuity of this subset of ED patients. We retrospectively audited, at a tertiary care teaching hospital, the number of LWBS patients and their triage status over two 1-mo periods. These sampling periods corresponded to immediately before and after implementation of five solutions developed by a continuous quality improvement (CQI) process to facilitate patient flow through the triage and fast-track areas of our ED. Before the CQI process was begun, 2.4% of patients (110/4553) left without being seen in a 1-mo study period. Of these, 82 were nonurgent and 28 were urgent. After implementation of the CQI process, 1.1% of patients (51/4514) left without being seen. Of these, 35 were nonurgent and 16 were urgent. There was a significant decrease in the LWBS proportion after the CQI process was implemented. We conclude that (1) reducing LOS is associated with a decrease in the number of ED patients who leave without seeing a physician and (2) many patients who leave without being seen are classified as urgent at presentation.
The Q-Probes study has identified benchmark interinstitutional laboratory median turnaround times (TAT) of 25 min for hemoglobin and 36 min for potassium. Our objectives were to measure the emergency department (ED)/laboratory TAT and other relevant laboratory processing and reporting times, and to identify root causes of laboratory delay. A flow chart was developed for the ordering, collecting, analyzing, and reporting of laboratory results. Time intervals were prospectively recorded for complete blood count (CBC) and K+ in a cross-sectional study, using the flow chart, and defined as follows: TAT was the interval from blood draw (BD) to ED report; BD time was the interval from order processing to BD; and order processing time was the interval from physician ordering to the unit coordinator processing the orders. Median times with interquartile ranges are reported. CBC TAT was 38 min (29-51.5), and K+ TAT 58 min (45-76.5). Order processing time was 7 min (4-15). The laboratory assistant BD time was 17 min (8-30) for CBC and 15 min (7.75-32.25) for K+ as compared to 0 min for a nurse, yet the venipuncture method (laboratory assistant technique) had a recollection rate of 1% (1/93) due to hemolysis vs. 20% (19/95) via the i.v. catheter (nurse technique). Of stat ED blood work, 24% was for admitted patients held in the ED. Laboratory reporting times are delayed with these root causes: laboratory assistant availability; recollection rate; volume of tests for ED admitted patients; and order processing time.
Twenty-three cases of tuberculous mastoiditis are presented, nine of which were complicated by facial palsy. Six presented with acute mastoiditis, and two had meningitis. Surgery was required in 16 patients; in four cases the diagnosis was made by culture and in another four by biopsy of the granulations or polyp of the external canal. The response to antituberculous treatment was satisfactory in 22 cases. One patient, whose case was complicated by meningitis, died.