Reliability and validity of diagnostic tests.
Explore the source record for details and available documents.
Biomarkers↗
Biomedical subjects
D N Kyriacou
Publications and source records attributed to D N Kyriacou.
Errors in emergency medicine: research strategies.
Medical errors in emergency departments (EDs) may be an important "public health risk." Therefore, scientific public health approaches should be used to 1) assess the magnitude of emergency medical errors with surveillance methods, 2) identify causal factors of these medical errors with clinical epidemiologic methods, and 3) evaluate the effectiveness of interventions aimed at reducing or eliminating emergency medicine errors with health service research techniques. Since errors result from complex human-system interaction, research efforts should focus on actions taken by the patient, factors concerning the ED environment, and actions taken by health care workers. Other medical and nonmedical fields have already made great advancements in studying and reducing human error. Many of these advancements could readily be adapted to study emergency medical errors.
Emergency Medicine↗
Risk factors for injury to women from domestic violence.
BACKGROUND: Domestic violence is the most common cause of nonfatal injury to women in the United States. To identify risk factors for such injuries, we examined the socioeconomic and behavioral characteristics of women who were victims of domestic violence and the men who injured them. METHODS: We conducted a case-control study at eight large, university-affiliated emergency departments. The 256 intentionally injured women had acute injuries resulting from a physical assault by a male partner. The 659 controls were women treated for other conditions in the emergency department. Information was collected with a standardized questionnaire; no information was obtained directly from the male partners. RESULTS: The 256 intentionally injured women had a total of 434 contusions and abrasions, 89 lacerations, and 41 fractures and dislocations. In a multivariate analysis, the characteristics of the partners that were most closely associated with an increased risk of inflicting injury as a result of domestic violence were alcohol abuse (adjusted relative risk, 3.6; 95 percent confidence interval, 2.2 to 5.9); drug use (adjusted relative risk, 3.5; 95 percent confidence interval, 2.0 to 6.4); intermittent employment (adjusted relative risk, 3.1; 95 percent confidence interval, 1.1 to 8.8); recent unemployment (adjusted relative risk, 2.7; 95 percent confidence interval, 1.2 to 6.5); having less than a high-school-graduate's education (adjusted relative risk, 2.5; 95 percent confidence interval, 1.4 to 4.4); and being a former husband, estranged husband, or former boyfriend (adjusted relative risk, 3.5; 95 percent confidence interval, 1.5 to 8.3). CONCLUSIONS: Women at greatest risk for injury from domestic violence include those with male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school-graduate's education, and are former husbands, estranged husbands, or former boyfriends of the women.
Acute Disease↗
A 5-year time study analysis of emergency department patient care efficiency.
STUDY OBJECTIVES: We conducted a 5-year time study analysis of emergency department patient care efficiency. Our specific aims were (1) to calculate the main ED patient care time intervals to identify areas of inefficiency, (2) to measure the effect of ED and inpatient bed availability on patient flow, (3) to quantitatively assess the effects of administrative interventions aimed at improving efficiency, and (4) to evaluate the relationship between waiting times to see a physician and the number of patients who leave without being seen (LWBS) by a physician. METHODS: Seven 1-week ED patient flow time studies were conducted from September 1993 to July 1998 using identical study design and methodology. Patients presenting with complaints of chest pain, abdominal pain, vaginal bleeding, and extremity injury were included to represent the level of severity of patient conditions seen in our Los Angeles County hospital ED. The calculated time intervals representing the main phases of evaluation and treatment were (1) triage presentation to completion of registration, (2) completion of registration to ED treatment area entry, (3) ED treatment area entry to initial medical assessment, (4) triage presentation to initial medical assessment, (5) initial medical assessment to disposition order, and (6) disposition order to patient discharge from the ED. Total ED lengths of stay (LOS) were also calculated as overall measures of efficiency. Time intervals were compared depending on the availability of ED and hospital inpatient beds. The effects of administrative interventions on the specific time intervals were assessed. The relationship between the median waiting time to see a physician and the number of LWBS patients was evaluated. Administrative interventions were implemented by a special interdepartmental continuous quality improvement committee. Interventions were aimed at specific sources of delay and inefficiency identified by the time studies. RESULTS: Eight hundred twenty-six patients were included in the 7 time studies. The unavailability of ED and inpatient beds was associated with significant delays. There was a significant reduction of the median total ED LOS from 6.8 hours to 4.6 hours over the first 5 periods, presumably resulting from the administrative interventions. Median total ED LOS, however, increased from 4.6 hours to 6.0 hours during the last 2 periods, possibly as a result of an increase in our ED patient census and reductions in both nursing and physician staffing imposed by the recent Los Angeles County fiscal crisis. The number of LWBS patients was closely correlated to waiting time to see a physician ( r =0.79, beta=5.20, P =.033). CONCLUSION: Time studies are an effective method of identifying areas of patient care delay. In our ED, targeted administrative interventions apparently reduced the total ED LOS and improved overall efficiency. Despite initial decreases in ED LOS, efficiency appeared to be adversely affected by reductions in nursing and physician staffing and increases in our patient census. The strength of the relationship between waiting times to see a physician and the number of LWBS patients suggests that decreasing waiting times may reduce the number of LWBS patients.
Adult↗
The relationship between socioeconomic factors and gang violence in the City of Los Angeles.
OBJECTIVE: To investigate the relationship between community-level socioeconomic factors and the incidence of gang-related homicide in the city of Los Angeles. METHODS: An ecological group-level analysis was conducted to correlate the 5-year incidence rates (from 1988 through 1992) of gang-related homicide with community-level socioeconomic statistics for the 18 geographically distinct Los Angeles Police Department divisions. Eight socioeconomic factors were examined: (1) log mean per capita income, (2) proportion employed, (3) proportion high school graduates, (4) proportion single-parent families, (5) proportion male, (6) proportion younger than 20 years of age, (7) proportion African American, and (8) proportion Hispanic. Pearson correlation coefficients were calculated for the interrelationships among the study variables and gang-related homicide. Adjusted regression estimates were calculated from a multiple linear regression model. RESULTS: The overall 5-year gang-related homicide rate for the city was 48.8 per 100,000, with a range of 5.2 to 173.5 per 100,000 among the different Los Angeles Police Department divisions. Pearson correlation coefficients revealed that the strongest negative correlations with gang-related homicide were log mean per capita income and proportion employed, and the strongest positive correlations were proportion single-parent families and proportion younger than 20 years of age. With mutual adjustment of all variables, only log mean per capita income and proportion employed were significantly associated with gang-related homicide. CONCLUSION: At the community level, gang-related homicide in Los Angeles is most closely associated with lower income and unemployment. These relationships may provide important insights into the causes of gang formation and gang violence.
Adolescent↗
Emergency department-based study of risk factors for acute injury from domestic violence against women.
STUDY OBJECTIVES: To evaluate the associations between selected socioeconomic risk factors and acute injury from domestic violence against women. METHODS: We conducted a preliminary matched case-control study to measure the association of selected predictor variables with acute injury from domestic, violence against women. Patients identified as cases were Hispanic or white female emergency department patients, 16 to 65 years of age, with acute injury sustained from physical assault by an intimate male partner. Cases were selected for inclusion in the study if they reported or admitted acute physical assault by their male partners. Controls were selected from non-case female ED patients so as to represent the base population of the cases and enhance comparability. Two controls were matched to each case. The socioeconomic predictor variables examined were the education level, employment status, history of alcohol abuse, and history of drug abuse of the male partner and the education level and cohabitation status of the female partner. RESULTS: Forty-six cases were identified and included in the study. The age range was 16 to 51 years (mean, 33 years). There were 26 (57%) Hispanic and 20 (43%) white cases. The strongest predictor for acute injury from domestic violence in these patients was a history of alcohol abuse by the male partner, as reported by the female partner (odds ratio, 12.9). The remaining predictor variables were weakly associated or not associated with domestic violence. One half of the cases stated that their male partners were intoxicated with alcohol at the time of assault. CONCLUSION: Of the socioeconomic variables examined in this preliminary study, a history of alcohol abuse by the male partner, as reported by the female partner, was the strongest predictor for acute injury from domestic violence. A large-scale, multicenter, ED-based study is needed to clarify the relation between alcohol abuse, other socioeconomic factors, and acute physical assaults against women by their intimate male partners.
Academic Medical Centers↗
Emergency medicine residents' perspectives on injury prevention.
STUDY OBJECTIVE: To determine emergency medicine residents' perspectives and opinions concerning the relevance of injury prevention to emergency medicine and their exposure to formal instruction and readings in this subspecialty area. METHODS: A survey was mailed between November 1992 and February 1993 to all 461 residents and 1992 graduates of the 13 emergency medicine residency programs in California. RESULTS: Three hundred ninety questionnaires (85%) were returned. Ninety-seven percent of respondents said they believed injury prevention is pertinent to emergency medicine. Sixty-two percent said they believed inadequate time in residency is devoted to this subject, and 70% said there should be a greater focus on injury prevention in their training. Only 44% of the respondents said they had received lectures and 28% of the respondents said they consistently read journal articles on injury prevention. There were no statistically significant differences between the level of the respondents' training and their answers to the questions. CONCLUSION: Although most emergency medicine residents consider injury prevention pertinent to emergency medicine and important to their training, most perceived a lack of formal instruction on injury prevention during their training and did not consistently read articles on this subspecialty area.
Attitude of Health Personnel↗
Emergency department presentation and misdiagnosis of imported falciparum malaria.
STUDY OBJECTIVE: To review the travel history, clinical presentation, laboratory findings, diagnostic accuracy, management, and outcome of the largest reported series of emergency department patients with imported falciparum malaria in the United States. METHODS: This is a retrospective case series at large, inner-city medical center in Los Angeles. Twenty cases of falciparum malaria with initial medical evaluation in the ED were identified from the period 1979 through 1993. RESULTS: Fifteen male and 5 female patients were identified, with an age range of 5 to 55 years. All had a recent history (within 2 months) of international travel in regions endemic for malaria. Most (85%) were recent immigrants or expatriates returning from a recent visit to their native country. The most common documented symptoms were fever (100%), chills (65%), vomiting (60%), anorexia (45%), and headache (45%). Tachycardia (85%) and hyperpyrexia (> 39 degrees C) (65%) were the most common presenting signs. Malaria was considered in the ED diagnoses in only 12 cases (60%). The specification of falciparum (malignant) malaria was established in only 2 cases (10%). Hepatitis and gastroenteritis were the most common misdiagnoses. Only four patients received antimalarial medication in the ED. There were no deaths, and complications were limited to thrombocytopenia and anemia. Two patients required transfusion. CONCLUSION: Imported falciparum malaria presenting to EDs in the United States is frequently misdiagnosed. Emergency physicians improve their ability to diagnose falciparum malaria by obtaining a thorough travel history on all patients with clinical features suggesting an infectious origin and considering this diagnosis in any patient with a history of travel to or migration from malaria-endemic areas.
Adolescent↗
The epidemic of gang-related homicides in Los Angeles County from 1979 through 1994.
OBJECTIVE: To determine trends in gang homicides and the population at greatest risk for homicide by reviewing all gang-related homicides in Los Angeles County, California, from January 1979 to December 1994. DESIGN: Homicide files of the Los Angeles Police Department and the Los Angeles County Sheriff's Department from 1979 to 1994 involving violent street gang activity were reviewed. Gang files were reviewed for demographic data, weapons used, homicides by drive-by shootings, and times and geographic areas of occurrence. SETTING: Los Angeles County from January 1, 1979, to December 31, 1994. MAIN OUTCOME MEASURES: Age, race, and sex of gang-related homicide victims; frequency of weapon use; and the change in gang-related homicide rates during the study period. RESULTS: A total of 7288 gang-related homicides occurred in Los Angeles County from 1979 through 1994; 5541 of these homicides occurred in Los Angeles Police Department and Los Angeles County Sheriff's Department jurisdictions. During the study period, the proportion of all homicides that were gang related increased from 18.1% to 43.0% (P < .001). Of the 5541 gang-related homicide victims, 4580 (85.6%) were aged 15 to 34 years, 93.3% were African American or Hispanic, 5157 (93.2%) were male, 3559 (64.2%) were gang members, and 1408 (25.4%) occurred during drive-by shootings. Firearms were used in an increasing proportion of homicides, from 71.4% in 1979 to 94.5% in 1994. Homicides by semiautomatic handguns dramatically increased during the study period. Gang-related homicide rates for African-American males aged 15 to 19 years increased from 60.50 per 100,000 population per year in 1979 to 1981 to 192.41 per 100,000 population per year in 1989 to 1991. CONCLUSIONS: Gang-related homicides in Los Angeles County have reached epidemic proportions and are a major public health problem. To prevent gang violence, the root causes of violent street gang formation must be alleviated, the cycle of violent street gang involvement must be broken, and access to firearms must be limited.
Adolescent↗
Emergency department sentinel surveillance for emerging infectious diseases.
Explore the source record for details and available documents.
Centers for Disease Control and Prevention, U.S.↗
I was never afraid.
Explore the source record for details and available documents.
Emergency Service, Hospital↗
Residents' perspectives on violence and personal safety in the emergency department.
STUDY OBJECTIVE: To assess emergency medicine residents' perspectives on violence and personal safety in the emergency department. DESIGN AND PARTICIPANTS: Survey of all 461 current emergency medicine residents and 1992 graduates in the 13 emergency medicine residency programs in California. RESULTS: Eighty-five percent of residents responded to the survey questionnaire. Sixty-two percent of respondents worry about their own safety while working in the ED. The majority of these respondents (72%), however, most fear a needlestick injury from an HIV-positive patient. Fifty percent of the respondents believe that their hospital/residency programs do not provide adequate security in the ED. Respondents overwhelmingly favor some form of gun control legislation. CONCLUSION: Violence and personal safety in the ED are major concerns of emergency medicine residents.
Attitude of Health Personnel↗
Effect of immediate resuscitation on children with submersion injury.
STUDY OBJECTIVE: To determine the effect of immediate resuscitative efforts on the neurological outcome of children with submersion injury. DESIGN: A case-control study was designed to determine if immediate resuscitation by rescuers or bystanders reduces the frequency of severe neurological damage or death in children with a documented submersion event. Logistic regression was used calculate an adjusted odds ratio. PARTICIPANTS: The study group consisted of 166 children, aged zero to 14 years, having a submersion event during May 1984 through August 1992, and admitted through various emergency departments to Huntington Memorial Hospital in Pasadena, California. MEASUREMENTS AND MAIN RESULTS: All study subjects had an observed and documented episode of apnea at the time of submersion. Outcomes were evaluated on the basis of neurological impairment or death. Exposure was verified from historical accounts of postsubmersion events provided by family, friends, and/or paramedical personnel. The study factors included age and gender, duration of submersion, hypothermia, presence of apnea, resuscitative efforts, and clinical outcome. Children with a good outcome were 4.75 (adjusted odds ratio (OR)) times more likely to have a history of immediate resuscitation than children with poor outcome (95% confidence interval: 3.44 < OR < 6.06, P = .0001). Various types of resuscitative efforts and potential confounding factors were also evaluated. CPR and mouth-to-mouth resuscitation were the most effective types for the prevention of death or severe anoxic encephalopathy. CONCLUSION: Immediate resuscitation before the arrival of paramedical personnel is associated with a significantly better neurological outcome in children with submersion injury.
Adolescent↗
A case of Boerhaave's syndrome presenting as diffuse left pulmonary infiltrate.
A case of spontaneous esophageal rupture (Boerhaave's syndrome) is presented. The patient was referred from an outside hospital emergency department to Los Angeles County/University of Southern California Medical Center with a history of acute left-sided chest pain immediately after an episode of forceful vomiting. An upright chest radiograph revealed a left hydropneumothorax. The diagnosis of Boerhaave's syndrome was confirmed with the placement of a chest tube and extraction of serosanguinous fluid and partially digested food particles from the left hemithorax. The patient underwent surgical repair and was discharged from the hospital in good condition. Boerhaave's syndrome is extremely rare. The predominant symptoms of chest pain and dyspnea also are found in many common disease entities, making early diagnosis difficult. Delay in diagnosis and treatment results in substantial morbidity and mortality. This case exemplifies the importance of obtaining an upright chest radiograph to make a prompt diagnosis.
Adult↗
Imported cholera in a 31-year-old Peruvian female.
We present the case of a 31-year-old Peruvian female with severe dehydration due to diarrhea and vomiting. The patient was one of a number of travelers arriving in Los Angeles on an international flight from Argentina and Peru. Because of the travel history and clinical presentation, cholera was suspected and ultimately confirmed by stool culture. The patient's clinical course is outlined, and discussion of the relevant epidemiology and clinical management of cholera is provided. Physicians should suspect cholera when treating patients with severe gastroenteritis. The short incubation period, rapid onset of dehydration and shock, and high case fatality rate of untreated cholera require a consideration of cholera in patients with diarrhea and recent travel to areas where cholera is prevalent.
Adult↗
Eleven-year-old male with high-voltage electrical injury and premature ventricular contractions.
We present a case of a boy with potential high-voltage electrical injury. The patient sustained electrical injuries after his kite became entangled in a high-power electrical line. He presented to the emergency department with minor external electrical burns and frequent premature ventricular contractions (PVCs). The patient's clinical course is outlined. A discussion of the epidemiology of high-voltage electrical injury in children and the clinical management of electrical-injury-induced cardiac complications is provided. Although cardiac abnormalities are found in a significant proportion of high-voltage electrical injuries, the vast majority are evident within 12 h, resolve spontaneously within a few days, and cause little or no long-term sequelae. A small proportion of normal children have clinically benign PVCs.
Child↗