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Biomedical subjects

L M Lewis

Publications and source records attributed to L M Lewis.

At least 37 records · Page 2Linked to original sources
PubMed1997

Adolescent girls' perceived prevalence of sexually transmitted diseases and condom use.

Little is known concerning sexually experienced and inexperienced adolescent girls' perceptions of the prevalence of condom use and sexually transmitted diseases (STDs). Girls (n = 174; 41% sexually experienced) rated the prevalence of condom use among friends and STDs among male and female friends and adolescents in general. Girls perceive the prevalence of STDs similarly across both gender and level of familiarity. For the most part, however, the girls perceived the prevalence among boys and girls more similarly than among friends and adolescents in general. No significant differences were found between sexually experienced and inexperienced girls in perceptions of condom use prevalence, but girls with a history of STD perceived condoms as used less frequently. Girls with an STD history perceived STDs as the most prevalent, followed by sexually inexperienced girls and then sexually experienced girls without a history of an STD. After an adolescent girl initiates sexual intercourse, STD experience could be a key variable in affecting her perceptions. Prevention programs can incorporate an understanding of patients' perceptions of condom use and STDs.

Adult↗
PubMed1996

Do estimates of emergency physician workforce underestimate current needs?

STUDY OBJECTIVE: Two widely used formulas for calculating the number of practicing emergency physicians (EPs) are based on the total number of US emergency departments and patient visits. In this study we hypothesized that the number of physicians now working in EDs is significantly greater than the estimates yielded by these formulas. Therefore we attempted to determine the accuracy of these methods for predicting the true number of practicing EPs. We also examined the training, board certification, and distribution of EPs. METHODS: The EDs of all hospitals listed by the Missouri Hospital Association (MHA), excluding children's and psychiatric hospitals, were surveyed over a 9-month period in 1994 with regard to the number and board status of all physicians practicing in their EDs and the numbers of full-time equivalents (FTEs) required for adequate staffing. These numbers were compared with 1994 estimates for Missouri based on two common methods of calculation. RESULTS: Of 134 hospitals with EDs, 118 (88%) completed our survey. These EDs employed 458 full-time EPs and 690 part-time EPs, with 41% and 7% board-certified in emergency medicine, respectively. Board-certified emergency physicians were concentrated in large cities and at university hospitals and were sparsely represented in rural areas. Adequate staffing of these EDs required 677 FTEs, compared with estimates of 358 (formula A) and 555 (formula B). Previously published formulas underestimate the need for EPs in our state by 47% (formula A) or 18% (formula B). CONCLUSION: Current staffing estimates regarding EPs working in Missouri greatly underestimate actual staffing needs. Board-certified EPs are in severe shortage and are unequally distributed in Missouri. Extrapolated nationally, these estimates may negatively affect funding and available residency positions for emergency medicine.

Certification↗
PubMed1996

Emergency medicine credentials in St Louis and Kansas City: does the presence of an emergency medicine residency program have a geographic difference?

STUDY OBJECTIVE: To compare emergency physician (EP) credentialing characteristics in two metropolitan areas of Missouri: Kansas City, which has had an emergency medicine (EM) residency program since 1973, and St Louis, which is without a program approved by the Accreditation Council for Graduate Medical Education. METHODS: A cross-sectional, descriptive survey concerning EP training, certification, and practice characteristics was administered by standardized telephone interviews. Participants were all emergency department directors in Kansas City and St Louis general hospital EDs serving more than 10,000 patients annually. RESULTS: Twenty Kansas City EDs, with an annual census of 20,250 +/- 7,200; and 30 St Louis EDs, with an annual census of 27,100 +/- 13,800, were surveyed. In Kansas City, 68% of practicing EPs were EM trained, versus 10% in St. Louis (P < .0005). The percentage of board-certified EPs was also greater in Kansas City than in St Louis (82% versus 42%, P < .0005). Eighty-six percent of ED directors in St Louis, compared with 30% in Kansas City, reported that they did not attempt to recruit EM-trained staff or that recruitment was difficult (P < .0005). CONCLUSION: The presence of an EM residency training program is associated with favorable EP credentialing characteristics in the Kansas City metropolitan area. This information may prove useful to institutions attempting to establish EM training programs in areas where none currently exist.

Certification↗
PubMed1996

Research directions in emergency medicine.

The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nation's health.

Emergency Medicine↗
PubMed1996

Controlled trial of a geriatric case-finding and liaison service in an emergency department.

OBJECTIVE: To evaluate the effects of a program of case-finding and liaison service for older patients visiting the emergency department. DESIGN: Nonrandomized controlled trial with systematically assembled intervention cohort and matched control group. SETTING: An urban teaching hospital. PARTICIPANTS: There were 385 intervention subjects aged 65 years and older and 385 control subjects matched by day of visit, gender, and age within 5 years. INTERVENTIONS: Geriatric medical, dental and social problems were identified in intervention subjects by a geriatric nurse clinician using well validated assessment instruments during a 30-minute evaluation. Recommendations were made to the patient, family, and attending emergency department physician, and attempts were made to arrange appropriate follow-up services. MEASUREMENTS: Frequency with which geriatric problems were identified in intervention subjects; physician, patient, and family compliance with recommendations; and mortality, institutionalization, health status, use of medical and social services, presence of an advanced directive, and quality of life at 3-month follow-up. RESULTS: Sixty-seven percent of patients were dependent in at least one activity of daily living, 82% had at least one geriatric problem identified, and 77% reported at least one unmet dental or social support need. The cost of identifying geriatric and dental/social issues was $5 and $1, respectively, for each problem. Physicians compiled with 61.6% of suggestions, and patients and families complied with 36.6% of recommendations. Mortality and nursing home residence proportions at 3 months were not significantly different (9.3% vs 9.7% and 5.0% vs 2.5% in intervention and control groups, respectively). Intervention subjects reported more difficulty communicating (21% fair or poor ability vs 13%, P = 0.2) than did control subjects. There were strong trends for fewer subsequent visits to emergency departments (0.26 intervention vs 0.39 control, P = .06) and more advance directives in the intervention group (6.7% intervention vs 2.9% control, P = .07). There was no statistically or clinically significant difference in any other health outcome. The number of new dental or social services initiated per patient over the 3-month follow-up was nearly identical (1.7 in the intervention group vs 1.5 in the control). Results in subjects aged 75 years and older and those discharged home from the emergency department were essentially identical to those in the main group. CONCLUSIONS: Numerous previously unrecognized geriatric medical and social problems can be detected in older persons visiting the emergency department. Despite this, an emergency department-based geriatric assessment and management program failed to produce improved outcomes. This suggests that either disease acuity is an overwhelming factor in subsequent outcome or, alternatively, more control over medical and social service delivery during and after the emergency department visit than was demonstrated in this program will be required before successful outcomes can be assured.

Aged↗
PubMed1996

Impact of point-of-care testing on patients' length of stay in a large emergency department.

We prospectively investigated whether routine use of a point-of-care testing (POCT) device by nonlaboratory operators in the emergency department (ED) for all patients requiring the available tests could shorten patient length of stay (LOS) in the ED. ED patient LOS, defined as the length of time between triage (initial patient interview) and discharge (released to home or admitted to hospital), was examined during a 5-week experimental period in which ED personnel used a hand-held POCT device to perform Na, K, Cl, glucose (Gluc), and blood urea nitrogen (BUN) testing. Preliminary data demonstrated acceptable accuracy of the hand-held device. Patient LOS distribution during the experimental period was compared with the LOS distribution during a 5-week control period before institution of the POCT device and with a 3-week control period after its use. Among nearly 15 000 ED patient visits during the study period, 4985 patients (2067 during the experimental period and 2918 during the two control periods) had at least one Na, K, Cl, BUN, or Gluc test ordered from the ED. However, no decrease in ED LOS was observed in the tested patients during the experimental period. Median LOS during the experimental period was 209 min vs 201 min for the combined control periods. Stratifying patients by presenting condition (chest pain, trauma, etc.), discharge/admit status, or presence/absence of other central laboratory tests did not reveal a decrease in patient LOS for any patient subgroup during the experimental period. From these observations, we consider it unlikely that routine use of a hand-held POCT device in a large ED such as ours is sufficient by itself to impact ED patient LOS.

Blood Chemical Analysis↗
PubMed1996

Issues related to the sexual decision-making of inner-city adolescent girls.

To be effective in reducing the risks of sexual activity in adolescent girls, the context of adolescent sexuality needs to be understood. Two focus groups of high-risk inner-city African-American and Caucasian adolescent girls (15 to 16 years of age) were organized to explore issues related to sexual decision-making. The transcripts of the groups were reviewed for recurrent themes the girls discussed in regard to sexual decision-making, and their views of relationships and images of males. Verbatim examples are presented to exemplify each category. These adolescents experienced multiple pressures to engage in intercourse at young ages, but utilizing the presence of others was described as a helpful means to avoid engaging in sexual activities. The lack of mutual trusting relationships also was an important aspect for the these girls. Interventions which reduce the pressures to engage in sexual behaviours, develop methods for coping with these pressures, and facilitate the ability to establish mutual relationships will aid the healthy psychosexual development of adolescent girls.

Adolescent↗
PubMed1995

Unrecognized delirium in ED geriatric patients.

To determine the sensitivity of an emergency physician's conventional evaluation compared with the validated Confusion Assessment Method (CAM) regarding the recognition of acute confusional states (delirium) in elderly Emergency Department (ED) patients, a cohort of 385 patients presenting to an urban teaching hospital ED was systematically assembled. Patients had to be conscious, able to speak and older than 64 years of age. After the ED physician had examined the patient and test results had been obtained, a series of geriatric assessment results, including one for the likely presence of delirium, was made available to the ED physician; however, no result was specifically highlighted. All patients were assessed by an attending ED physician in the customary fashion. In addition, a study nurse interviewed patients using the CAM and followed patient outcomes for three months. The ED record for all patients with delirium or "probable" delirium, as determined by the CAM, were reviewed for physician diagnosis and disposition to determine how often delirium had been recognized by the emergency physician. Thirty-eight of the 385 patients screened (10%) met criteria for delirium or "probable" delirium; ED charts were complete for 35 of these, which constituted the study sample. The ED diagnosis included delirium or an acceptable synonym in 6 (17%) of these patients. In the 21 patients (62%) admitted to the hospital, the most common ED diagnosis was infection "rule out sepsis" (n = 7). Six of 13 patients discharged (46%) were diagnosed as "status post fall" without evidence of significant injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1995

Failure of a chest pain clinical policy to modify physician evaluation and management.

STUDY OBJECTIVE: To assess the effectiveness of a specific, targeted clinical policy regarding the evaluation of nontraumatic chest pain in the emergency department (ED) to modify physician evaluation and management. DESIGN: Retrospective, blinded chart review. SETTING: Twelve metropolitan EDs. PARTICIPANTS: All males older than 35 years and females older than 45 years who presented with nontraumatic chest pain during one of the two study periods--1 year before (1989) or 1 year after (1991) dissemination of the American College of Emergency Physicians' (ACEP) chest pain clinical policy. MEASUREMENTS: Physician's compliance with various documentation rules regarding history and physical examination were compared between the two periods with chi 2 analysis. Fisher's exact test was used when any one cell value was less than five. The physician's compliance with the rules and guidelines of management (Actions) were compared between the two periods with chi 2 analysis. RESULTS: Rates of compliance for 1989 and 1991 were as follows: history documentation, 368 (82%) vs. 255 (78%) (P = .22); physical examination documentation, 397 (88%) vs. 287 (88%) (P = .94); Action rules, 292 (65%) vs. 208 (64%) (P = .76); and Action guidelines, 247 (55%) vs. 172 (53%) (P = .55). CONCLUSION: We conclude that the dissemination of the ACEP chest pain clinical policy has not significantly modified the behavior of our metropolitan area emergency physicians regarding the evaluation and management of patients who present to the ED with a chief complaint of nontraumatic chest pain.

Adult↗
PubMed1994

A noninvasive method for monitoring cerebral perfusion during cardiopulmonary resuscitation.

PURPOSE: This study evaluates the use of transcranial Doppler (TCD) ultrasound in assessing the changes experienced by the cerebral circulation during cardiopulmonary resuscitation (CPR) and compares it with measurements of internal carotid artery (ICA) flow rates (ultrasonic flow-meter measurements) and cerebral blood flow (CBF) (radioactive-microsphere measurements) in a porcine cardiac arrest model undergoing closed chest CPR. METHODS: Sixteen piglets were anesthetized and subjected to TCD monitoring, ICA flow-rate measurements, and CBF measurements during CPR following induction of ventricular fibrillation. A total of 14 comparisons between TCD and CBF measurements, and 36 comparisons between TCD and ICA flow measurements were performed. Correlations were determined using Pearson's method, and the validity of the correlation was determined using Bonferoni's adjusted probabilities. RESULTS: The correlation between mean cerebral blood flow velocity and mean total ICA flow rate was 0.67 (P < .01). The correlation between peak systolic blood flow velocity and CBF was 0.76 (P = .02). CONCLUSIONS: TCD can provide on-line information about cerebral perfusion during CPR.

Animals↗
PubMed1994

Are emergency physicians too stingy with analgesics?

Several recent reports suggest that emergency physicians do not use adequate analgesia for patients with acutely painful conditions in the emergency department (ED). To quantify the extent of this problem, we retrospectively studied 401 patients who were treated for acute fracture over a 17-day period in eight area-wide emergency departments. Patient age, fracture site, and ED setting (urban or suburban, teaching or nonteaching) were noted. Only 121 patients (30%) received analgesics while in the ED; neither fracture site, ED setting, or patient age significantly altered analgesic dispensing practices. We conclude that inadequate use of analgesics in patients who come to the ED for treatment of acute fractures is widespread and that efforts aimed at improving the appropriate use of analgesics in the ED are warranted.

Acute Disease↗
PubMed1994

Frequency, distribution, and management of injuries due to an ice storm in a large metropolitan area.

Patterns of injuries seen in the emergency department (ED) following an ice storm were evaluated and compared to those seen during a control snow period. We conducted a retrospective chart review for an 11-day ice period and an 11-day control snow period using charts from eight metropolitan area EDs. Charts were reviewed for all patients with complaints of falls, motor vehicle crashes (MVCs), or sledding accidents due to ice or snow conditions. The numbers of injuries resulting from falls, MVCs, and sledding accidents for patients of various ages during each of the two periods were compared by chi-square analysis. Of 1,631 patients seen during the 11-day ice period, 1,181 (72%) had injuries due to falls, 192 (12%) were injured in MVCs, and 232 (14%) suffered sledding injuries. Falls on ice resulted in a fracture 39% of the time, whereas MVCs resulted in fracture 14% of the time. Falls accounted for 90% of the fractures during the ice period versus 76% during the snow period. The risk of sustaining a fracture as a result of a fall was significantly higher in older age groups (relative risk [RR] = 2.1), as was the risk of hospitalization (RR = 2.3). There was a significant increase in the number of falls and sledding accidents during the ice period. Thus, ice coverage resulted in a significant increase in fall-related and sledding-related fractures requiring treatment in the ED.

Accidental Falls↗
PubMed1993

Tissue and organ procurement in the emergency department setting.

A retrospective chart review of all emergency department (ED) deaths in patients younger than 65 years in seven area hospitals was performed for the calendar year of 1990. The number and percentage of families approached and consenting to tissue donation among the various EDs was compared and reasons for not approaching families were evaluated for their validity. Procurement rates between the years 1990 and 1991 were compared for two area hospitals, which made a specified (nonmedical) service responsible for tissue requests in 1991. There were 368 deaths, 255 of which were potential donors by acceptable criteria. Only 109 (43%) families were approached regarding tissue donation. The overall procurement rate was 12%. Suburban EDs had a higher approach and procurement rate than did urban EDs (49% vs 36%; P < .05 and 19% vs 5%; P < .01, respectively). Procurement rates for two hospitals that designated a specific procurement service in 1991 more than doubled (5% vs 11%; P = NS). Tissue procurement rates in EDs with procurement systems in place are low despite consent rates of those approached of 36%. The major contributing factor is the failure to request tissue from the families of eligible candidates even when there are no exclusion criteria met. Suburban EDs had a higher success rate than urban EDs.

Data Collection↗
PubMed1993

Quantitation of impact attenuation of different playground surfaces under various environmental conditions using a tri-axial accelerometer.

OBJECTIVE: To rank playground surfaces with respect to impact attenuation under various simulated environmental conditions. DESIGN: An accelerometer was dropped from a height of 60 inches onto five different playground surfaces (wood chips, sand, gravel, grass, and commercial rubber mats). Impact attenuation was measured (in G forces) with the above surfaces dry, wet, and frozen. INTERVENTIONS: The accelerometer was dropped ten times onto each surface. All surfaces were tested in the wet, dry, and frozen states (saturated with water, then placed at -10 degrees C for 12 hours). RESULTS: Analysis of variance revealed that wood chips significantly lowered impact forces compared with sand in the wet or dry condition and to grass or synthetic mats in the dry or frozen condition (p < 0.05). Wood chips absorbed the shock of impact significantly more than did gravel in the dry, frozen state. CONCLUSION: Wood chips appear to be the single best playground surface under a variety of environmental conditions when assessed by impact attenuation studies.

Acceleration↗
PubMed1992

Correlation of end-tidal CO2 to cerebral perfusion during CPR.

STUDY OBJECTIVE: A number of studies have demonstrated a correlation between end-tidal carbon dioxide (ETCO2), cardiac output, and return of spontaneous circulation in experimental animals and in patients undergoing closed-chest CPR. Our study attempted to correlate ETCO2 to cerebral blood flow during cardiac arrest. DESIGN: Sixteen piglets were anesthetized, intubated, and instrumented for cerebral blood flow studies. An ultrasonic flow probe was placed on both internal carotid arteries for continuous flow measurements. The animal was fibrillated, and closed-chest CPR was begun. Continuous ETCO2 measurements were obtained and compared with simultaneous internal carotid, cardiac output, and cerebral blood flow measurements. MEASUREMENTS AND MAIN RESULTS: Correlations between ETCO2 and carotid and cerebral blood flow were determined using Pearson's method. The correlation between ETCO2 and total internal carotid flow was .58 (P = .01, Bonferroni's adjusted P = .30). Correlation between ETCO2 and cerebral blood flow was .64 (P = .01, Bonferroni's adjusted P = .09). A partial correlation coefficient for ETCO2 versus cardiac output was .70, whereas it was only .30 for ETCO2 versus cerebral blood flow. CONCLUSION: Partial correlation coefficients suggest that ETCO2 correlates with cerebral blood flow when changes in cerebral blood flow parallel changes in cardiac output.

Animals↗
PubMed1992

Acute myocardial infarction in chest pain patients with nondiagnostic ECGs: serial CK-MB sampling in the emergency department. The Emergency Medicine Cardiac Research Group.

STUDY OBJECTIVES: This study tested the hypothesis that serial creatine phosphokinase (CK)-MB sampling in the emergency department can identify acute myocardial infarction (AMI) in patients presenting to the ED with chest pain and nondiagnostic ECGs. DESIGN: Patients more than 30 years old who were evaluated initially in the ED and hospitalized for chest pain were studied. Serial CK-MB levels were analyzed prospectively using a rapid serum immunochemical assay for identification of AMI patients in the ED. Presenting ECGs showing new, greater than 1-mm ST elevation in two or more contiguous leads were considered diagnostic for AMI. All other ECGs were considered nondiagnostic ECGs. CK-MB levels were determined at ED presentation and hourly for three hours (total of four levels). Patients with at least one level of more than 7 ng/mL were considered to have a positive enzyme study. The in-hospital diagnosis of AMI was determined by the development of typical serial ECG changes or separate standard cardiac enzyme changes after admission. SETTING: Eight tertiary-care medical center hospitals. METHODS AND MAIN RESULTS: Of the 616 study patients, 108 (17.5%) were diagnosed in the hospital as AMI; 69 of these AMI patients (63.9%) had nondiagnostic ECGs in the ED. Of the patients with nondiagnostic ECGs, 55 (sensitivity, 79.7%) had a positive ED serial CK-MB enzyme study within three hours after presentation. Combining serial ED CK-MB assay results with diagnostic ECGs yielded an 88.4% sensitivity for AMI detection within three hours of ED presentation. The predictive value of a negative serial ED enzyme study for no AMI was 96.2% (specificity, 93.7%). CONCLUSION: Serial CK-MB determination in the ED can help identify AMI patients with initial nondiagnostic ECGs. Use of serial CK-MB analysis may facilitate optimal in-hospital disposition and help guide therapeutic interventions in patients with suspected AMI despite a nondiagnostic ECG.

Adult↗
PubMed1992

Intracranial abnormalities requiring emergency treatment: identification by a single midline tomographic slice versus complete CT of the head.

We retrospectively reviewed 89 noncontrast computerized tomographic scans of the head in trauma patients to determine whether a single midline image could reliably identify intracranial lesions significant enough to warrant emergency surgery. We found that a midline cut was able to detect 92% of all lesions for which emergency neurosurgical evacuation was considered necessary, though it detected only 71% of the more subtle abnormalities.

Brain↗