Objective To evaluate immersive virtual reality’s (IVR) effectiveness as a distraction in reducing perceived pain and anxiety among adults undergoing intravenous (IV) blood draw. Methods In this randomized controlled trial, we recruited adult patients 18-50 years of age scheduled for routine blood draws at the phlebotomy lab and randomized them into experimental and control groups. The experimental group underwent IV blood draw with IVR, and the control group underwent IV blood draw with standard practice. Before the procedure, subjects rated their anxiety level and the pain they “expected” to experience during blood draw. Immediately afterward, the subjects rated their actual “perceived” pain level. We measured the “expected” and the “perceived” pain and anxiety scores using a 100 mm visual analog scale. The primary outcome was the difference in “perceived” pain scores (0-100) between the two cohorts. Secondary outcomes were differences between the anxiety scores and the “expected” and “perceived” pain between the two cohorts, as well as degree of satisfaction with IVR during the blood draw and willingness to use IVR in future procedures. Results Fifty-nine subjects completed the study, 31 in the experimental group and 28 in the control group. For the primary outcome, the control group reported a perceived median pain score of 6.5 vs. the experimental group of 5; P = .55. For the secondary outcomes, the median anxiety scores were 22 (6.25-45.75) and 24 (2.00-35.00) for the control and the experimental groups, respectively, P = .44. The control group reported an expected median pain score of 20 vs. a perceived score of 6.5; P = .25, and the experimental group reported an expected median pain score of 22 vs. a perceived score of 5; P < .01. Median Likert scores were 5 (1-5) for satisfaction and preference for future use during painful procedures. Conclusions The results of our study demonstrated that there was no significantly lower perceived pain or anxiety when using IVR compared to standard practice in adults undergoing IV blood draw.
Introduction Pulmonary embolism (PE) can be difficult to rule out without computed tomography pulmonary angiograms (CTPAs), as presentations vary. Multiple clinical decision rules (CDRs) exist to risk-stratify patients to avoid unnecessary CTPAs. However, the currently used CDRs are complex, and research has shown low compliance with their usage. The YEARS algorithm is less complex and excludes patients from CTPA if PE is not the most likely diagnosis, they do not have a history of hemoptysis, and no clinical signs of deep vein thrombosis, is less complex. However, no studies have evaluated YEARS in the U.S. Military health care beneficiary population. Therefore, this study sought to determine if implementing the YEARS algorithm could decrease the number of CTPAs ordered to rule out PE in low-risk patients. Methods This retrospective, single-center cohort study applied the YEARS algorithm to low-risk military beneficiaries presenting to the emergency department in the calendar year 2020 at a single U.S. Army MTF. The primary outcome was the number of CTPAs indicated by the YEARS algorithm versus the number ordered via standard practice. We used chi-square testing to compare the number of subjects in whom YEARS indicated CTPA (meets criteria/does not meet criteria) versus the actual number of subjects who underwent CTPA (meets criteria/does not meet criteria). The secondary outcomes included applying YEARS similarly to the number of subjects >50 years of age (as opposed to age-adjusted d-dimer), determining the number of pregnant patients who could have avoided CTPA via application of YEARS, and assessing possible cost savings via reduction of CTPA. Results We included 353 subjects during the study period, 271 of whom underwent CTPA. YEARS would have only indicated 25 of them, P = .018. In patients >50 years of age, 164 underwent CTPA versus nine who met YEARS criteria, P = .014. Among pregnant patients, six underwent CTPA versus one who YEARS would have indicated, P = .130. Application of the YEARS algorithm would have led to a 90.8% reduction in CTPAs ordered with an overall known missed PE rate of 1.1%. Applying the YEARS algorithm in 2020 could have led to 246 fewer CTPAs at a minimum cost savings of $38,762.22 for the MTF based on the coded billing cost of $157.57 per CTPA when local staff radiologists performed image interpretation. This estimate does not consider the additional undisclosed cost of contracted radiologists interpreting after regular duty hours. Conclusions For our military beneficiaries, our study indicates that the YEARS algorithm would have reduced CTPA utilization in all age ranges and potentially among pregnant patients with a known missed PE rate of 1.1%.
Background: In the absence of fragility fractures, the diagnosis of osteoporosis is established by bone densitometry: a T-score of -2.5 or lower in the femoral neck, total hip or lumbar vertebrae. One hip and the lumbar vertebrae are routinely scanned, and there is no consensus which hip should be used. The purpose of this retrospective study is to determine whether, in a male population, scanning both hips and the lumbar vertebrae identifies more patients with osteoporosis than scanning only one hip and the lumbar vertebrae. Methods:We retrieved data from 1,048 male Caucasian patients referred to our Center who were not on treatment for osteoporosis, had no documented bone pathology and had interpretable scans of both hips and the lumbar vertebrae.Results: More men aged 80 years and older were diagnosed with osteoporosis when scans of both hips and the lumbar vertebrae were considered, compared to the left hip and lumbar vertebrae (7%) or right hip and lumbar vertebrae (6%). The differences in diagnostic categories were less pronounced in younger subjects: only 2% more men younger than 60 years were diagnosed with osteoporosis when both hips and the lumbar vertebrae were scanned compared to just one hip and the lumbar vertebrae. Conclusions:We recommend that in Caucasian men, especially those aged 80 years and older, both hips be scanned in addition to the lumbar vertebrae.
We report the case of a 37-year-old man presenting with pain out of proportion to the exam with hydrofluoric acid burns to his upper extremities after he spilled a wheel-stripping compound on his forearms while working at his powder coating business. His burns initially appeared mild and superficial, but over the course of several days, these evolved from simple erythema to significant partial thickness tissue destruction and ulceration. He required substantial topical, intradermal, and intravenous therapies to control the unseen burning process during his index visit to the emergency department. We transferred the patient to a burn center given the location of his burns and the causative agent. The burn center clinicians observed him over the course of two nights and then discharged him with instructions to come for multiple follow-up visits during the subsequent month. Following nonoperative management, he had an uneventful recovery with full function retained in the affected extremities. Hydrofluoric acid burns require prompt treatment with calcium to neutralize the burning process, despite a potentially benign initial appearance. The emergency clinician should use an aggressive diagnostic and therapeutic approach to patients presenting with pain out of proportion to their exam, as this finding is associated with various serious underlying pathology.
Diarrhea is a common condition seen among soldiers in both garrison and deployed environments. Although the vast majority of soldiers with diarrhea will recover uneventfully with supportive care, clinicians should also maintain suspicion for less common causes and perform a thorough physical exam. We report the case of a young, healthy soldier with chronic diarrhea and progressively worsening abdominal distention that began during his deployment to Honduras who was subsequently found to have a large intra-abdominal desmoid tumor. Desmoid tumor is a rare and benign neoplasm that typically appears on the extremity, abdominal wall, intra-abdominal space, and occasionally in the chest wall. This tumor may be associated with abdominal distension and gastrointestinal complaints. A large tumor can compress organs, causing local tissue damage and, in rare cases, death.
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