Biomedical subjects
K H Todd
Publications and source records attributed to K H Todd.
Pain assessment and ethnicity.
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Clinical versus statistical significance in the assessment of pain relief.
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Clinical significance of reported changes in pain severity.
STUDY OBJECTIVE: To determine the amount of change in pain severity, as measured by a visual analog scale, that constitutes a minimum clinically significant difference. METHODS: Patients 18 years of age or older who presented with acute pain resulting from trauma were enrolled in this prospective, descriptive study. The setting was an urban county hospital emergency department with a Level 1 trauma center. In the course of a brief interview, patients were asked to indicate their current pain severity with a single mark through a standard 100-mm visual analog scale. At intervals of 20 minutes for the next 2 hours, patients were asked to repeat this measurement and, in addition, to contrast their present pain severity with that at the time of the previous measurement. They were to indicate whether they had "much less," "a little less," "about the same," "a little more," or "much more" pain. All contrasts were made without reference to prior visual analog scale measurements. A maximum of six measurements of pain change were recorded per patient. Measurements ended when the patient left the ED or when the patient reported a pain score of zero. The minimum clinically significant change in visual analog scale pain score was defined as the mean difference between current and preceding visual analog scale scores when the subject noted a little less or a little more pain. RESULTS: Forty-eight subjects were enrolled, and 248 pain contrasts were recorded. Of these contrasts, 41 were rated as a little less and 39 as a little more pain. The mean difference between current and preceding visual analog scale scores in these 80 contrasts was 13 mm (95% confidence interval, 10 to 17 mm). CONCLUSION: The minimum clinically significant change in patient pain severity measured with a 100-mm visual analog scale was 13 mm. Studies of pain experience that report less than a 13-mm change in pain severity, although statistically significant, may have no clinical importance.
Ultrasonography for the initial evaluation of blunt abdominal trauma: A review of prospective trials.
Many trauma centers are considering the addition of diagnostic ultrasonography to their trauma protocols. However, a diagnostic imaging application should not be used in general clinical practice until its efficacy has been demonstrated. A literature search was conducted for prospective trials on the use of ultrasound in evaluation of blunt abdominal trauma. Each study was evaluated with the use of an efficacy assessment model. Within this framework, clinical outcomes were classified according to the following efficacy assessment parameters: technical capacity, diagnostic accuracy, diagnostic effect, therapeutic effect, and patient outcome. This model also provided a systematic process for grading the quality of research methods used to obtain each outcome. Eleven trials were found that fulfilled the study criteria, and all of them concluded that ultrasound was valuable for assessment of blunt intraperitoneal trauma. Frequent methodologic flaws were detected in these studies. None of these trials determined therapeutic effect or patient outcome. The criteria for clinical efficacy were not fulfilled. Additional trials should be conducted before ultrasound is accepted as a standard diagnostic test for the evaluation of blunt abdominal trauma.
Effect of cardiologist ECG review on emergency department practice.
STUDY OBJECTIVE: To determine the effect of cardiology review of ECGs on emergency department practice. METHODS: We carried out a prospective cohort study at an urban teaching ED. Our subjects were adult patients undergoing electrocardiography. We prospectively collected 1,000 consecutive ECGs and classified them by severity according to the following system: class 1, normal or minor abnormalities only; class 2, abnormalities with potential to alter case management; and class 3, potentially life-threatening abnormalities. Actual ECG readings by ED physicians (who had access to computerized interpretations at the time of treatment) were compared with those of staff cardiology quality-assurance reviewers; if they were not in agreement, an expert cardiology panel blindly chose the superior interpretation. Subsequently, an expert emergency physician panel reviewed discordant readings for discharged patients to determine the need for further action. RESULTS: Of 1,000 ECGs, the readings for 190 (19%) were significantly discordant. The expert cardiology panel preferred the ED reading in 72 cases (38%) and the staff cardiology reading in 118 (62%). In 30 other cases no ED reading was recorded in the medical record. Of the 148 cases in which the expert cardiology panel agreed with the cardiology reading or there was no ED reading, 102 patients were admitted and 46 discharged. Of the 46 discharges, 8 cardiology readings were categorized as class 1, leaving only 38 cases in which the staff cardiology reading might have affected the ED decision to discharge a patient. All of these readings were in class 2, with the exception of one unclassifiable diagnosis. There were no class 3 readings. On expert emergency physician panel review of these 38 ECGs and interpretations, only 8 (.8%, 95% confidence interval, .3% to 1.6%) were considered sufficiently important to warrant chart review. In actual practice, none of these cases was affected by the ECG quality-assurance (QA) process. Two of these patients died during our 1-year follow-up. In one of these cases, the ECG QA process could have altered the patient's outcome. CONCLUSION: The existing ECG review process as mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will likely have minimal influence on patient outcomes at our institution. We should establish the effectiveness of this mandated QA process before committing scarce resources to its performance.
The minimum clinically important difference in physician-assigned visual analog pain scores.
OBJECTIVE: To determine the minimum clinically important difference in physician-assigned visual analog scale (VAS) pain scores. METHODS: Physicians attending emergency medicine didactic conferences were enrolled in this descriptive study. The subjects sequentially reviewed 11 written scenarios describing patients in moderate to severe pain. The subjects rated their perceptions of each patient's pain on a 100-mm VAS, then contrasted this pain with that of the previous patient scenario. For these contrasts, the subjects chose one of five responses: "much less," "a little less," "about the same," "a little more," or "much more" pain. The minimum clinically important difference was defined as the difference between scores for scenario pairs in which one patient's pain was rated "a little less" or "a little more" severe. RESULTS: There were 230 comparisons by 23 health professionals. Of these, 64 were judged "a little less," and 56 "a little more," painful. These 120 comparisons, with their pain score differences, were used to determine the minimum clinically important difference. Pain judged to be "a little less" or "a little more" severe was associated with a mean difference in VAS scores of 18 mm (95% CI 16-20 mm), corresponding to a decrement of 23% (95% CI 20-26%) from the more painful scenario. CONCLUSIONS: Pain research outcomes involving a < 18-mm difference, or a 23% decrement in physician-assigned VAS pain scores, although statistically significant, may have little clinical importance.
Air bags and the teachable moment.
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Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments.
STUDY OBJECTIVE: Chest pain and myocardial infarction following the use of cocaine have been well documented. We assessed the prevalence of cocaine use in patients who presented to the emergency department with chest pain of possibly ischemic origin. DESIGN: During times of research assistant availability, consecutive adults with the chief complaint of chest pain unexplained by trauma or radiographic abnormality were questioned about cocaine use in the preceding week. Urine was tested for the presence of cocaine or cocaine metabolites with a highly accurate bedside urine test kit (specificity, 100%; sensitivity 98%). Anonymous unlinked data-collection methods were used. Therefore we could not determine whether the patients who used cocaine had sustained myocardial infarctions. SETTING: One suburban and three urban EDs. RESULTS: We enrolled 359 patients with a mean age of 51 years, 8% of whom sustained myocardial infarctions. Sixty patients (17%) had cocaine or cocaine metabolites in urine. The likelihood of testing positive for cocaine varied by age group: 18 to 30 years, 29%; 31 to 40 years, 48%; 41 to 50 years, 18%; 51 to 60 years, 3%; 61 years or older, 0% (P < .0001). Of the 60 patients who tested positive for cocaine, only 43 (72%) admitted recent use. CONCLUSION: Many ED patients with chest pain have recently used cocaine. Because the recent use of cocaine is not uncommon in patients with chest pain up to 60 years old, such patients should be questioned about cocaine use. When treatment or disposition may be altered, consideration should be given to objective assessment of cocaine use because patient self-report does not appear reliable.
Clinical and sociocultural determinants of gallstone treatment.
Cholecystectomy remains the principal treatment for gallstones. Many gallstone patients do not undergo surgery within 6 months of diagnosis. To determine factors associated with cholecystectomy, treated and untreated patients were compared with respect to clinical and sociodemographic factors. The study population was comprised of outpatients of a public system evaluated in an emergency room or at a community health center. All were interviewed in English or Spanish before completing imaging studies. Of 121 found to have gallstones, 75 underwent early cholecystectomy. Patients reporting episodes of prolonged abdominal pain more often had surgery (p < 0.003). Patients evaluated in the emergency room underwent surgery more often than those from the community health center (p < 0.04). Patient ethnicity was unrelated to treatment, but Mexican Americans who requested interviews in Spanish were less likely to undergo cholecystectomy (p < 0.05). After logistic regression, prolonged abdominal pain was the only significant predictor of surgical management, although relationships with language use and site of diagnosis persisted. It was concluded that clinical presentation largely determines surgical treatment for gallstones but site of diagnosis is also a factor. Patients with poor English language skills undergo cholecystectomy less often. This may be due to poor doctor-patient communication, or it may be a reflection of cultural factors linked to language use.
Clinical evaluation for gallstone disease: usefulness of symptoms and signs in diagnosis.
PURPOSE: Patients with gallstones who have recently experienced biliary tract pain are likely to develop recurrent symptoms in the near future. As a consequence, most symptomatic patients are offered specific treatment. However, disagreement persists regarding which symptoms and signs truly represent symptomatic cholelithiasis. We re-examined the relation of gastrointestinal complaints and physical findings to the presence of gallstones in a clinical population. PATIENTS AND METHODS: Over a 2-year period, we identified outpatients of a public teaching hospital for whom diagnostic studies of the gallbladder had been ordered. Patients were interviewed and examined by research personnel prior to completion of the studies. Gastrointestinal symptoms and physical examination findings in 122 patients found to have gallstones were contrasted with those of 178 gallstone-free patients. RESULTS: In comparison to control subjects, patients with gallstones more often reported epigastric pain lasting at least 30 minutes (64.2% versus 45.1%, p less than 0.004). The latter patients infrequently complained of lower abdominal pain (12.3% versus 29.9%, p less than 0.002), but more often described pain radiating to the upper back. Gallstone-associated pain usually occurred more than 1 hour after meals, persisted from 1 to 24 hours, and was steady in quality. Although these differences were statistically significant, likelihood ratio analysis indicated that clinical symptoms and signs were relatively weak discriminators of gallbladder disease. CONCLUSIONS: Upper abdominal pain is the symptom most closely associated with gallstone disease. Radiation to the upper back, a steady quality, duration between 1 and 24 hours, and onset more than an hour after meals support the diagnosis. Nevertheless, gallstone-associated symptoms are non-specific, and accurate diagnosis cannot rely on the clinical assessment alone. Careful clinical evaluation can guide patient selection for diagnostic imaging and the appropriate management of those found to harbor stones.
Brucellosis and thrombocytopenic purpura: case report and review.
A 21-year-old butcher presented with fever and severe thrombocytopenic purpura, and was found to have acute brucellosis. After treatment with tetracycline, gentamicin, and prednisone, the thrombocytopenia resolved over 14 days. A brief review of thrombocytopenic purpura associated with brucellosis is presented.
Job stressors and job satisfaction in a major metropolitan public EMS service.
INTRODUCTION: Behavioral and social science research suggests that job satisfaction and job performance are positively correlated. It is important that EMS managers identify predictors of job satisfaction in order to maximize job performance among prehospital personnel. PURPOSE: Identify job stressors that predict the level of job satisfaction among prehospital personnel. METHODS: The study was conducted within a large, urban Emergency Medical Services (EMS) service performing approximately 60,000 Advanced Life Support (ALS) responses annually. Using focus groups and informal interviews, potential predictors of global job satisfaction were identified. These factors included: interactions with hospital nurses and physicians; on-line communications; dispatching; training provided by the ambulance service; relationship with supervisors and; standing orders as presently employed by the ambulance service. These factors were incorporated into a 21 item questionnaire including one item measuring global job satisfaction, 14 items measuring potential predictors of satisfaction, and seven questions exploring demographic information such as age, gender, race, years of experience, and years with the company. The survey was administered to all paramedics and Emergency Medical Technicians (EMTs) Results of the survey were analyzed using univariate and multivariate techniques to identify predictors of global job satisfaction. RESULTS: Ninety paramedics and EMT participated in the study, a response rate of 57.3%. Job satisfaction was cited as extremely satisfying by 11%, very satisfying by 29%, satisfying by 45%, and not satisfying by 15% of respondents. On univariate analysis, only the quality of training, quality of physician interaction, and career choice were associated with global job satisfaction. On multivariate analysis, only career choice (p = 0.005) and quality of physician interaction (p = 0.05) were predictive of global job satisfaction. CONCLUSIONS: Quality of career choice and interactions with physicians are predictive of global job satisfaction within this urban emergency medical service (EMS). Future studies should examine specific characteristics of the physician-paramedic interface that influence job satisfaction and attempt to generalize these results to other settings.
The effect of ethnicity on physician estimates of pain severity in patients with isolated extremity trauma.
OBJECTIVE: To determine whether physician estimates of pain severity are influenced by patient ethnicity. DESIGN: Prospective cohort study. SETTING: UCLA Emergency Medicine Center, a level I trauma center, Los Angeles, Calif. PARTICIPANTS: Hispanic and non-Hispanic white patients presenting to the emergency department with extremity trauma when research assistants were present. Exclusion criteria were patient refusal, altered mentation, or severe injury interfering with the interview process. MAIN OUTCOME MEASURES: The difference between patient and physician estimates of pain severity as assessed on a visual analog scale for Hispanics and non-Hispanic whites. RESULTS: A total of 138 non-Hispanic white and 69 Hispanic patients participated in the study. The groups differed in language use, insurance status, and proportions suffering occupational injury. There were no differences between non-Hispanic white and Hispanic patients in patient pain assessments (mean, 39.8 mm vs 39.0 mm, respectively; P = .86), physician pain assessments (mean, 33.6 mm vs 29.7 mm; P = .23), or the disparity between patient and physician pain assessments (mean 6.1 mm vs 9.4 mm; P = .38). The degree of disparity between patient and physician pain assessments remained similar for both groups even after controlling for multiple potential confounders. CONCLUSIONS: Physician ability to assess pain severity does not differ for Hispanic and non-Hispanic white patients. Other explanations for a difference in analgesic practice as a function of ethnicity should be explored.
Ethnicity as a risk factor for inadequate emergency department analgesia.
OBJECTIVE: To determine whether Hispanic patients with isolated long-bone fractures are less likely to receive emergency department (ED) analgesics than similar non-Hispanic white patients. DESIGN: Retrospective cohort study. SETTING: The UCLA Emergency Medicine Center, a level I trauma center. PARTICIPANTS: All Hispanic and non-Hispanic white ED patients aged 15 to 55 years, seen between January 1, 1990, and December 31, 1991, with isolated long-bone fractures, identified by ICD-9 codes 812, 813, 821, and 823, were eligible for inclusion. Exclusion criteria included injury more than 6 hours prior to presentation, "possible" or chip fractures only, altered mentation, or ethanol intoxication. MAIN OUTCOME MEASURES: Emergency department administration of analgesic or no analgesic. RESULTS: The study group consisted of 139 patients meeting inclusion criteria, of whom 31 were Hispanic and 108 non-Hispanic white. Non-Hispanic whites were significantly more likely to speak English, be insured, and suffer nonoccupational injuries. Hispanics were twice as likely as non-Hispanic whites to receive no ED pain medication (crude relative risk [RR], 2.12; 95% confidence interval [CI], 1.35 to 3.32; P = .003). The RR for ethnicity was similar and significant (P < .05) after controlling by stratification for covariates related to patient, injury, or physician characteristics. After controlling for several covariates simultaneously through multiple logistic regression, ethnicity remained the strongest predictor of ED analgesic administration (odds ratio [OR], 7.46; 95% CI, 2.22 to 25.04; P < .01). CONCLUSIONS: Hispanics with isolated long-bone fractures are twice as likely as non-Hispanic whites to receive no pain medication in the UCLA Emergency Medicine Center. No covariate measured in this study could account for this effect. An ethnic basis for variability in analgesic practice needs to be further characterized.