A prospective study of the accuracy of interpretation of radiographs by casualty officers and radiologists is presented. The casualty officers readings were correct in 83% of cases, and the radiologists' in 95%. There was agreement of interpretation in 83% of the examinations. This study indicates that there are clinical and economic benefits when the radiologist's report is available before the patient leaves the hospital. Delayed reporting of films is considered to be less satisfactory but is still of value as it increases the detection of clinically significant abnormalities and also clarifies most of the 10% of studies about which the casualty officer is uncertain. Where a delayed reporting system is practised, a25% reduction in radiologist's workload would be achieved by reporting only those films considered by the casualty officer to be "normal" or "uncertain". Attempts to reduce workload still further by not reporting any films will increase the number of patients poorly managed in casualty.
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OBJECTIVE:We examined the impact of an aspart insulin protocol for treatment of hyperglycemia in the emergency department (ED) coupled with rapid initiation of a detemir-aspart insulin protocol for patients admitted to the hospital.RESEARCH DESIGN AND METHODS: ED patients with type 2 diabetes mellitus and a blood glucose (BG) 200 mg/dL were randomized to intervention (INT) or usual care (UC). INT patients (n ¼ 87) received aspart every 2 hours when BG > 200 mg/dL, and if admitted, began daily detemir in the ED. UC patients (n ¼ 89) were treated per hospital physicians.
RESULTS:The initial ED BG was 304 6 76 mg/dL. The final ED BG differed: 217 6 71 mg/dL for INT patients versus 257 6 89 mg/dL for UC patients (P < .01). No INT patients and 3 UC patients had a BG < 50 mg/dL (P ¼ .5). ED length of stay (LOS) was similar: 5.4 6 1.8 hours for INT patients versus 4.9 6 1.9 hours for UC patients (P ¼ .06). Sixty-nine percent from each group were admitted. Admission BG was 184 6 74 mg/dL for INT patients versus 224 6 93 mg/dL for UC patients (P < .01). Patient-day weighted mean glucose was 163 6 39 mg/dL for INT patients versus 202 6 39 mg/dL for UC patients (P < .01). One INT patient and 6 UC patients had a BG < 50 mg/dL (P ¼ .11). Hospital LOS was similar: 2.7 6 2.0 versus 3.1 6 1.9 days, respectively (P ¼ .58).CONCLUSIONS: An aspart insulin protocol safely lowers BG levels in the ED without prolonging LOS. During hospitalization, a detemir-aspart protocol achieves significantly better glycemic control compared with guideline-driven use of NPH-aspart or glargine/detemir-aspart (usual care) without increasing hypoglycemia. Standardization of insulin protocols in the ED and hospital settings leads to improvement in overall glycemic control with greater safety and efficacy than usual care. 1 For non-critically ill patients, it is recommended to target a fasting blood glucose (BG) < 140 mg/dL and a random BG < 180-200 mg/dL, without excess hypoglycemia. Prior studies recommended using a basal-bolus insulin protocol that specifies starting doses and parameters for dose adjustment, applied by well-educated teams of physicians and nurses. [2][3][4][5][6][7] We have shown that insulin detemir given as a once-daily basal injection coupled with rapid-acting insulin aspart with meals is an effective regimen for managing hyperglycemia in hospitalized patients with type 2 diabetes.
7We and others have shown that once-daily basal insulin 6 mealtime rapid-acting insulin is significantly more effective than sliding-scale regular insulin in the hospital setting.
6,8The majority of patients admitted to general medical units are first evaluated in the emergency department (ED), and significant hyperglycemia is not uncommon in ED patients. However, protocols for the treatment of hyperglycemia in the ED have not been widely implemented. Ginde et al studied 160 ED patients with a history of diabetes and BG > 200 mg/dL and found that although 73% were admitted to the hospital, only 31% were treated with insuli...
Twenty-three cases of congenital malignant melanoma have previously been reported. Here the authors report the first case of a congenital malignant melanoma arising in the eye. A newborn girl had a large pigmented ocular tumor, hepatomegaly, and multiple pigmented skin and choroidal lesions. The histopathologic diagnosis was of a malignant melanoma with hepatic metastases. The skin and choroidal lesions were considered to be congenital melanocytic nevi. The most plausible pathogenetic link between these two conditions was that the malignancy had arisen as a second-hit mutation within a choroidal congenital melanocytic nevus. Despite widespread metastases the baby, treated by surgery and chemotherapy, survives in good health, aged 2 years, 10 months.
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