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Biomedical subjects

S R Lowenstein

Publications and source records attributed to S R Lowenstein.

At least 37 records · Page 2Linked to original sources
PubMed1995

Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.

OBJECTIVES: To determine: 1) the extent of emergency physicians' (EPs') training in smoking cessation counseling; 2) their understanding of counseling and pharmacologic treatment techniques; 3) their current practices in screening, counseling, and referring patients who smoke; and 4) perceived barriers to routine smoking cessation counseling in emergency medical practice. METHODS: A 26-item questionnaire addressing the above issues was mailed to all 256 members of the Colorado Chapter of the American College of Emergency Physicians. RESULTS: Completed questionnaires were returned by 196 physicians (77% response rate). The majority of respondents were men (80%), practiced in urban settings (87%), and were board-certified in emergency medicine (82%). Most EPs lacked formal smoking cessation training (55%) and felt poorly prepared to counsel patients about smoking cessation (65%). A minority (27%) of the physicians reported routinely asking patients to quit smoking. The physicians with formal smoking cessation training were more likely to counsel and refer patients routinely (34% vs 20%, p = 0.03). The physicians cited the following barriers to routine smoking cessation counseling: a lack of time; a perception that patients are not interested; a belief that the ED setting is inappropriate for counseling; and a sense that counseling is ineffective. Lack of reimbursement was cited by only 13% of the respondents. The physicians who had formal smoking cessation training perceived fewer barriers to ED-based counseling. CONCLUSIONS: Emergency physicians have received little training in smoking cessation and perceive many barriers to ED-based smoking cessation interventions. Not surprisingly, they infrequently take action to encourage or assist their patients to quit smoking.

Adult↗
PubMed1994

Quality of life following spinal cord injury: knowledge and attitudes of emergency care providers.

STUDY OBJECTIVES: To measure emergency care providers' attitudes toward quality of life after spinal cord injury (SCI) and to determine if their perceptions influence the care they provide. DESIGN: A closed-ended questionnaire. SETTING AND PARTICIPANTS: Two hundred thirty-three emergency nurses, emergency medicine technicians, emergency medicine residents, and attending physicians at three level I trauma centers were surveyed. Their responses were compared with previously reported quality-of-life ratings of a group of 128 high-level SCI survivors. MEASUREMENTS AND RESULTS: One hundred fifty-three emergency care providers completed the survey (response rate, 63%). Forty-one percent believed that resuscitation efforts after severe SCI are too aggressive, and 28% believed that future quality of life should be a factor in determining the interventions that should be provided. If they sustained severe SCIs themselves, 22% of providers would want nothing done to ensure their survival, and 23% would want pain relief only. Only 18% imagined they would be glad to be alive with a severe SCI, compared with 92% of a true SCI comparison group. Seventeen percent of providers anticipated an average or better quality of life compared with 86% of the actual SCI comparison group. CONCLUSION: The quality of life, self-esteem, and outcomes that emergency health care providers imaging after SCI are considerably more negative than those reported by SCI survivors. Because providers' knowledge and attitudes may affect the care they provide and may influence patients and families struggling with critical treatment decisions, emergency care providers must be aware of outcomes, well-being, and life satisfaction following severe SCI.

Activities of Daily Living↗
PubMed1993

Do-not-resuscitate order. What happens after hospital discharge?

We observed 55 inpatients with "do-not-resuscitate" (DNR) orders to determine what happened to their DNR status after hospital discharge. All were admitted to the medical service of a Department of Veterans Affairs hospital. Of the 55 patients, 16 died in the hospital, 10 were discharged to inpatient hospice units, and 1 was transferred to an acute care hospital. An additional 19 patients were discharged to nursing homes. The other 9 patients (16% of the total) survived their hospital stays; 6 successful contacts were made with patients' spouses. In 1 case the spouse thought a DNR order was no longer desirable. In the other 5 cases the spouse said the DNR status was "probably" or "definitely" still warranted, but only 1 spouse had a written DNR order at home. We contacted 9 of the 14 house officers who had cared for the patients in hospital. Only 2 had ever written a DNR order after hospital discharge. Two house officers said they routinely discussed with family members a patient's expected dying process at home. Unwanted resuscitation is as undesirable at home as in the hospital. Physicians should discuss future resuscitation procedures with patients who have DNR orders at the time of hospital discharge. Physicians, paramedic service directors, and policymakers also should develop protocols and standardized home DNR orders so that paramedics can honor the wishes of patients in the prehospital setting.

Adult↗
PubMed1993

Facts versus values: why legislators vote against injury control laws.

BACKGROUND: Control of motor vehicle-related injuries depends upon passage of mandatory safety belt and other injury control laws. Unfortunately, state legislators often oppose these laws. METHODS: In 1988, a 62-item questionnaire was mailed to the 97 Colorado legislators who voted on a 1987 safety belt law to identify factors (knowledge, experiences, attitudes, and beliefs) associated with "yes" and "no" votes. To test for associations between these attributes and the legislators' recorded votes, odds ratios (OR) and 95% confidence intervals (CIs) were calculated. A stepwise logistic regression identified independent predictors of "vote." RESULTS: Fifty-three (55%) of the legislators responded. Responders and nonresponders were demographically similar. "Vote" was not associated with age; sex; having young children in the family; perceived injury risk; recent traffic tickets; family or personal crash experience; or knowledge of the fatality risk reductions attributable to wearing safety belts. Ninety-six percent of the legislators knew that safety belts reduce the risk of death and 87% believed a safety belt law would save lives. The strongest predictors of a "yes" vote were impression that constituents favored the law (OR = 31, CI 95 = 3.5, 270); belief that a mandatory safety belt law will save lives (OR = 20, CI 95 = 2.1, 203); and "extreme" importance paid in the voting decision to effectiveness of the law in reducing deaths (OR = 19, CI 95 = 3.5, 107). Legislators who considered restrictions on individual freedoms an "extremely" important decision criterion were 43 times (CI 95 = 7, 267) more likely to vote "no." In the logistic model only extreme importance assigned to individual freedoms (beta = 3.7; OR = .025; p = 0.002) and policy effectiveness (beta = +3.1; OR = 22; p = 0.01) predicted "vote." The logistic model correctly predicted 90% of legislators' votes. CONCLUSIONS: In this study the strongest predictors of voting behavior were concern for individual freedoms, perceived constituents' support and attention paid to policy effectiveness. Those seeking to persuade legislators to vote for mandatory safety belt laws must pay attention to attitudes and values in addition to scientific facts.

Accidents, Traffic↗
PubMed1993

The forgotten vital sign: temperature patterns and associations in 642 trauma patients at an urban level I trauma center.

OBJECTIVES: (1) Identify compliance with the standard of practice that trauma patients have body temperature measurement recorded. (2) Describe the range of temperatures in a sample of trauma patients. (3) Identify associations between temperature and other clinical and trauma variables. DESIGN: Descriptive analysis of a cohort of trauma victims. METHODS: We identified patients with traumatic injuries during a 14-month period with a computer-based trauma registry. Patient charts were reviewed for demographic information, injury data, assessment data, and outcomes. The ED chart, nursing notes, and trauma flow sheets were reviewed in search of a documented temperature assessment. RESULTS: A cohort of 642 trauma patients was identified during the study period. Thirty-two percent were admitted to an ICU; 17% went directly to surgery. The mortality rate was 3.4% (n = 22). Most patients were male (65%), young (mean age, 34 +/- 18 years), and victims of blunt trauma (93%). Seventy-seven percent of patients had a temperature measurement recorded in the emergency department. Patients with minor injuries were more likely to have had their temperature measured (79%) than those with moderate (64%) or severe (64%) injuries (p = 0.0009). Among the 495 patients with recorded temperatures, temperatures ranged from 26.5 degrees to 39 degrees C, with a mean of 36.7 degrees +/- 1.1 degrees C. Ten percent of the patients had temperatures less than 36 degrees C. Temperature correlated negatively with ISS (r = -0.20; p = 0.0001) and positively with RTS (r = 0.37; p < 0.0001). CONCLUSIONS: We conclude that a significant proportion of trauma patients brought to a level I trauma center are hypothermic, with temperatures lower in patients more severely injured and in patients who die. Yet temperature measurement, a simple and standard nursing procedure, is often ignored in trauma resuscitation.

Adolescent↗
PubMed1992

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.

BACKGROUND: Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. METHODS: In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. RESULTS: Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. CONCLUSIONS: Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.

Esophageal and Gastric Varices↗
PubMed1992

Frequently nebulized beta-agonists for asthma: effects on serum electrolytes.

STUDY OBJECTIVE: To determine the magnitude of the changes in serum potassium, magnesium, and phosphate during the treatment of acute bronchospasm with repeated doses of beta-adrenergic agonists. DESIGN: Prospective study of a convenience sample of asthmatic patients. SETTING: University teaching hospital emergency department. TYPE OF PARTICIPANTS: Twenty-three patients met the inclusion criteria of age of more than 16 years; a history of asthma or chronic obstructive pulmonary disease; and an acute exacerbation. INTERVENTIONS: Baseline peak expiratory flow rate and serum potassium, magnesium, and phosphate levels were measured. Nebulized albuterol (2.5 mg) was administered every 30 minutes until the patient was discharged from the ED. Before each albuterol treatment, repeat serum levels of potassium, magnesium, and phosphate were determined. MEASUREMENTS AND MAIN RESULTS: Baseline peak expiratory flow rate averaged 188 +/- 119 L/min. Serum potassium levels decreased significantly (P = .0001 by repeated-measures analysis of variance) from 4.10 +/- 0.468 (baseline) to 3.55 +/- 0.580 mmol/L (90 minutes) and 3.45 +/- 0.683 mmol/L (180 minutes). Potassium decreased to less than 3.0 mmol/L in 22% of patients at some point during the study. Magnesium decreased from 1.64 +/- 0.133 mmol/L (baseline) to 1.48 +/- 0.184 mmol/L (90 minutes) and 1.40 +/- 0.219 mmol/L (180 minutes) (P = .0001). Phosphate levels also decreased, from 3.74 +/- 1.029 (baseline) to 2.84 +/- 0.957 mmol/L (90 minutes) and 2.55 +/- 0.715 mmol/L (180 minutes) (P = .0001). CONCLUSION: Aggressive administration of nebulized albuterol during the emergency treatment of acute bronchospasm is associated with statistically significant decreases in serum potassium, magnesium, and phosphate. The mechanism and clinical significance of these findings are unknown and warrant further study.

Adolescent↗
PubMed1991

The role of the pneumatic antishock garment in penetrating cardiac wounds.

UNLABELLED: OBJECTIVE--To determine the impact of the pneumatic antishock garment on survival in patients with cardiac wounds. DESIGN--A retrospective review of a 6.5-year experience in a population of patients with gunshot or stab wounds to the heart (N = 70). SETTING--The city and county of Denver, Colo, where all patients were transported by paramedic ambulances to Denver General Hospital, an urban, level 1 trauma center. PATIENTS--All patients were analyzed, including those transported to the emergency department with no vital signs at the trauma scene. Only patients with definite penetrating cardiac injuries were included. METHODS--Paramedic trip sheets and emergency department, operating room, in-hospital, and autopsy records were reviewed. Demographic, clinical outcome, and treatment data were collected. A multiple logistic regression model was developed to determine which characteristics and treatment variables were independently predictive of patient outcome. The ability of each independent variable to predict outcome was determined by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS--Seventy patients (31 gunshot and 39 stab wounds) had a revised trauma score of 2.8 +/- 4.0 (mean +/- SD; range, 0-12; median, 0). Thirty-two (46%) had cardiac tamponade. Overall, 21 (30%) of the patients survived. In the logistic model, the presence of cardiac tamponade (OR, 9.1; 95% CI, 1.5 to 56.1) and a higher revised trauma score were associated with higher survival. Inflation of the pneumatic antishock garment was associated with sevenfold lower survival (adjusted OR, 0.14; 95% CI, 0.02 to 0.86); the effect was negative across all trauma score groups. CONCLUSION: --Survival in patients with penetrating cardiac wounds is highly associated with anatomic and physiologic factors, while application of the pneumatic antishock garment appears to be detrimental.

Adolescent↗
PubMed1991

Management of acute pyelonephritis in an emergency department observation unit.

STUDY OBJECTIVES: To determine whether moderately to severely ill patients with acute pyelonephritis can be treated successfully on an outpatient basis, and whether any aspect of history, physical examination, or initial laboratory data predicts failure of outpatient therapy and the need for hospitalization. DESIGN: Retrospective chart review of all patients with a diagnosis of acute pyelonephritis seen during a three-year period. SETTING: Emergency department observation unit of an urban teaching hospital serving residents of the city and county of Denver. TYPE OF PARTICIPANTS: Women between the ages of 15 and 50 with symptoms, physical examination, and initial laboratory data consistent with a diagnosis of pyelonephritis. INTERVENTIONS: Patients received IV antibiotics, rehydration, analgesics, and antiemetics in an observation unit for up to 12 hours, when they were either admitted to the hospital or discharged home on oral antibiotics. MEASUREMENTS AND MAIN RESULTS: Sixty-three of 87 patients (72%) with acute pyelonephritis were managed successfully as outpatients, nine (22%) were hospitalized directly from the observation unit because they were considered to be too ill to go home, and five (6%) returned with persistent symptoms after ED therapy and were hospitalized. No clinical or laboratory variable predicted success or failure of ED observation unit therapy at the time of initial presentation. CONCLUSION: In selected patients, the observation unit may be used to initiate therapy for acute pyelonephritis. Those with an adequate clinical response to initial treatment may be discharged on oral antibiotic therapy with appropriate follow-up.

Adolescent↗
PubMed1991

Orthostatic vital signs in emergency department patients.

STUDY OBJECTIVE: To examine the variability and define the normal ranges of orthostatic vital signs in an emergency department population. DESIGN: Descriptive. TYPE OF PARTICIPANTS: Adult ED patients with no history of recent blood or fluid losses. MEASUREMENTS: Lying and standing heart rate and blood pressure measured by an automated instrument. RESULTS: In 132 presumed euvolemic patients, the statistical normal ranges (mean +/- 2 SD) of orthostatic vital signs were wide: on standing, the heart rate range was from decreases 5.0 to increases 39.4 beats per minute; for systolic blood pressure, the range was decreases 20 to increases 25.7 mm Hg; and for diastolic blood pressure, the range was decreases 6.4 to increases 24.9 mm Hg. In this sample, 43% had "positive" orthostatic vital signs according to currently accepted values. CONCLUSION: The data from this study indicate that there is a wider than expected variation in orthostatic vital signs among presumed euvolemic ED patients.

Adolescent↗
PubMed1990

Ectopic pregnancy: ten common pitfalls in diagnosis.

Ectopic pregnancy (EP) is a common, life-threatening complication of pregnancy. Modern technology (ultrasonography and improved pregnancy tests) should facilitate the diagnosis of EP. However, in a retrospective review of 65 cases of confirmed EP managed over 18 months at an urban teaching hospital, only 37 of 65 patients (57%, Cl95 = 44%, 69%) received prompt diagnosis and treatment; delays occurred in 28 patients (43%). In 10 of the 27 delayed cases, the diagnosis of EP was not even considered at the time of the first visit. In patients with a delayed diagnosis, morbidity (transfusions, cardiovascular instability, progression of illness) did occur. Diagnostic pitfalls that resulted in delayed care were reviewed, delays most commonly occurred in patients with a benign examination or "atypical" pain. Risk factors for EP were missed (7 patients, 25%), subtle clues to blood loss were often ignored (10 patients, 36%), and passage of tissue was thought to exclude EP (2 patients). Ultrasound was only helpful for half of the diagnoses and was misinterpreted in 27%. A dry or serous culdocentesis occurred frequently. In five patients, a falling or low quantitative human chorionic gonadotropin level was believed to indicate a completed abortion. The authors conclude that almost half of EPs are still missed on the first physician visit; errors and pitfalls in diagnosis are still common in the 1980s.

Adolescent↗
PubMed1990

Prehospital advanced trauma life support for penetrating cardiac wounds.

Prehospital advanced trauma life support (ATLS) is controversial because the risks, benefits, and time required to accomplish it remain unknown. We studied 70 consecutive patients with penetrating cardiac injuries to determine the relationships among prehospital procedures, time consumed in the field, and ultimate patient outcome. Thirty-one patients sustained gunshot wounds, and 39 had stab wounds. The mean Revised Trauma Score was 2.8 +/- 0.5. Paramedics spent an average of 10.7 +/- 0.5 minutes at the scene. Seventy-one percent of the patients underwent endotracheal intubation; 93% had at least one IV line inserted; and 57% had two IV lines inserted. Twenty-one (30%) survived. There was no correlation between on-scene time and either the total number of procedures performed (r = .17, P = .17) or IV lines established (r = .06, P = .6). On-scene times did not differ regardless of whether endotracheal intubation or pneumatic antishock garment applications occurred. We conclude that well-trained urban paramedics can perform multiple life-support procedures with very short on-scene times and a high rate of patient survival and that prehospital trauma systems require a minimum obligatory on-scene time to locate patients and prepare them for transport.

Adolescent↗
PubMed1990

Alcohol intoxication, injuries, and dangerous behaviors--and the revolving emergency department door.

Suicides, homicides, motor vehicle crashes, and other violent deaths and injuries are linked inextricably to alcoholism. The association of injury and alcoholism should be particularly obvious to Emergency Department (ED) physicians. We sought to determine the extent to which intoxicated patients in an ED were properly diagnosed, counselled, and referred for substance abuse care. We reviewed the charts of 153 consecutive patients seen in a teaching hospital ED who had blood alcohol levels above 100 mg%. Most were male (70%), white (62%), young (mean age, 34 years) and severely intoxicated (mean BAL, 245; range, 109-558 mg%). Forty-six per cent of visits were for trauma; half of the patients were victims of violent assaults. The intoxicated patients received extensive medical and surgical management: an average of five tests or X-rays were performed per patient; 75% received at least one medication; at discharge 48% were referred for followup to medical or surgical clinics. In contrast, few patients were evaluated for dangerous behaviors or referred for treatment of alcoholism: only 19 patients (12.5%) were asked about depression, suicide, or homicide; 15% were advised to stop drinking; 13% received a referral to a psychiatrist, mental health worker, or alcohol rehabilitation facility. Forty-seven per cent of patients received "stat" intravenous thiamine (although the Wernicke-Korsakoff syndrome is rare). In contrast, only 16% received a stat on-site psychiatric consultation (although dangerous behaviors are common in alcoholics). There was a strong, statistically significant negative association between the occurrence of an injury and the decision to initiate treatment and referrals for alcoholism.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1989

Vertical trauma: injuries to patients who fall and land on their feet.

We reviewed the patterns of injuries sustained by 12 consecutive fallers and jumpers in whom primary impact was onto the feet. The fall heights ranged from 20 to 100 ft. The 12 patients sustained 49 significant injuries. Skeletal injuries were most frequent and included 15 lower extremity fractures, four pelvic fractures, and nine spinal fractures. In two patients, paraplegia resulted. Genitourinary tract injuries included bladder hematoma, renal artery transection, and renal contusion. Thoracic injuries included rib fractures, pneumothorax, and hemothorax. Secondary impact resulted in several craniofacial and upper extremity injuries. Chronic neurologic disability and prolonged morbidity were common. One patient died; the patient who fell 100 ft survived. After initial stabilization, survival is possible after falls or jumps from heights as great as 100 feet It is important to recognize the skeletal and internal organs at risk from high-magnitude vertical forces.

Accidental Falls↗
PubMed1988

Hemodynamic effect of mannitol in a canine model of concomitant increased intracranial pressure and hemorrhagic shock.

The use of mannitol in the management of head injury has been considered a threat to hemodynamic stability in hypotensive multiply injured patients. To evaluate this contention, we compared mannitol with normal saline administration in a canine model combining elevated intracranial pressure (ICP) and hemorrhagic shock. Mongrel dogs were bled to and maintained at a mean arterial pressure (MAP) of 60 mm Hg for 30 minutes. Following this, ICP was elevated to and sustained at 25 mm Hg for 45 minutes by inflating an epidural balloon. The dogs were then randomized to resuscitation with 2 g/kg of mannitol in saline (total volume, 20 mL/kg; n = 5) or 20 mL/kg of normal saline alone (n = 5). All dogs were successfully resuscitated, and MAP returned to baseline levels in both groups. ICP was significantly lower and urine output significantly higher in the mannitol group than in saline controls (P less than .01). Moreover, cerebral perfusion pressure, cardiac index, and left ventricular stroke work index were significantly improved in dogs given mannitol versus controls during the first hour of resuscitation (P less than .05). Mannitol ameliorates increases in ICP without compromising hemodynamic resuscitation in a canine model of concomitant increased ICP and shock.

Animals↗