PubMed Health⌕ Search

Biomedical subjects

F L Zwemer

Publications and source records attributed to F L Zwemer.

12 recordsLinked to original sources
PubMed2001

Recently discharged inpatients as a source of emergency department overcrowding.

OBJECTIVE: To assess the impact on the emergency department (ED) of recently discharged inpatients and how they contribute to and worsen the current situation of ED overcrowding. METHODS: Retrospective, observational study of medical records and billing data of all patients presenting to the ED within seven days of inpatient discharge from the hospital ("returns") in September 2000. The data were collected from electronic logs. Billing charges were used to estimate ED resources. Medical records were reviewed to classify visits: 1) new problem, 2) related problem, likely preventable, 3) related problem, not likely preventable, 4) unable to classify, or 5) incomplete chart. RESULTS: One-hundred seventy-four returns occurred among 6,290 total ED visits (3%). Significant differences between returns and total ED patients were noted for length of stay (LOS) (6.58 vs 5.22 hours, p = 0.000), percent admitted (47% vs 19%, p = 0.000), and ED billing (1,415.67 dollars vs 391.00 dollars, p = 0.000). The highest rate of admission was for patients presenting 48-72 hours after inpatient discharge (65.4%). Admission rate was higher for patients presenting >48 hours than <48 hours (54% vs 33%, p = 0.01). A review of the medical records (117/174) revealed: 15 new problems (13%); 16 related, likely preventable (14%); 72 related, not likely preventable (62%); 4 unable to assess (2%); and 10 incomplete charts (9%). CONCLUSIONS: The ED is appropriately utilized as a safety net for discharged inpatients. Though "returns" are a small percentage of ED patients, they have longer LOSs, have higher ED charges, and are more frequently admitted. Returns increase the strain on an already overcrowded ED.

Crowding↗
PubMed1998

Use of lumbosacral spine radiographs in a level II emergency department.

OBJECTIVE: We studied indications for lumbosacral spine radiographs in an emergency department setting. SUBJECTS AND METHODS: Clinicians completed a lumbosacral spine request form before obtaining lumbosacral radiographs on 482 patients who were examined in a level II emergency department. The clinicians detailed the indications for the examination, their suspected clinical diagnoses, and the expected effect of the lumbosacral spine study on management. In addition, the duration of the patients' symptoms was recorded as well as their age and sex. These data were compared with the actual radiographic findings as interpreted by board-certified musculoskeletal radiologists. RESULTS: Major indications for lumbosacral radiographs were lower back pain (92%) and trauma (36%). Patient expectation and medicolegal concerns, related either to insurance documentation or to physician litigation, were cited in 42% of cases. A neurologic deficit was present in 88% of patients, and a history of neoplasm was elicited in 4%. Strain (56%) and fracture (20%) were the most commonly suspected clinical diagnoses. Radiographs showed either normal findings or spondylosis in 86% of cases. Fractures, of which 10 were definitely acute, were identified in 55 patients. No fracture required decompression. Neoplastic involvement was found in seven patients, all of whom had histories of osseous metastases. Neurologic deficit, present in 37 patients, did not correlate with abnormalities seen on lumbosacral radiographs. CONCLUSION: As with studies of lumbosacral spine radiographs obtained in outpatient settings, our data from a level II emergency department support the use of lumbosacral spine radiographs for patients with a history of trauma, even if relatively minor, in elderly patients and in patients with lower back pain who have a history of neoplasm. Lumbosacral radiographs obtained for an isolated complaint of lower back pain generally provide no clinically useful information. Similarly, lumbosacral radiographs obtained for patients with isolated neurologic abnormalities are unrevealing. Such patients are better examined (although not necessarily at the time of emergency department evaluation) with techniques such as MR imaging that show soft-tissue lesions.

Aged↗
PubMed1997

Descending necrotizing mediastinitis: complication of a simple dental infection.

Descending necrotizing mediastinitis (DNM) is a rare complication of periodontic infection. The delay in diagnosis of DNM is believed to contribute to its high mortality rate. We report the case of a healthy 23-year-old man who was seen in the urgent care center, given the diagnosis of dental infection, prescribed penicillin, and sent home. He returned 48 hours later complaining of myalgias, purulent drainage from around his teeth, chest pain, and dyspnea. DNM was diagnosed, and aggressive treatment comprising thoracotomy, cervical incision and drainage, and antibiotics was begun. The patient responded well to treatment and was discharged from the hospital on postoperative day 20. Prompt diagnosis and immediate therapy are imperative for this rare condition.

Adult↗
PubMed1996

Prospective optimization of patient selection for emergency cranial computed tomography: univariate and multivariate analyses.

RATIONALE AND OBJECTIVES: To determine if the clinical variables that are important for selecting patients for emergency cranial computed tomography (CT) are population dependent. METHODS: Prior to obtaining scans, physicians working in an emergency department in a level II trauma center completed a form describing the indication for the CT examination. These data were matched to the CT scan results and analyzed statistically using univariate and multivariate methods. These results were compared with a prior study at a level I trauma center. RESULTS: Of 551 patients having cranial CT, neurologic examination was positive in 340 and CT scan was positive in 122. The neurologic examination correlated strongly with the results of the CT scan (P < 0.00001). In this patient population, the most important clinical predictors of 17 abnormal CT scans from the 211 patients without positive neurologic examinations were seizure and a history of neoplasm. These high-yield variables differ from our prior retrospective study in which intoxication and amnesia were the important predictors in patients with negative examinations. The difference in predictors between the populations most likely results from different prevalences of trauma and ischemic disease. CONCLUSIONS: Abnormal neurologic examination is the most important criterion available to select patients for emergency cranial CT. Other variables (eg, seizure, amnesia, intoxication, and history of neoplasm) that help select patients without neurologic findings appear to be population dependent.

Brain↗
PubMed1994

Clinical prediction of emergency cranial computed tomography results.

STUDY PURPOSE: To determine the ability of clinicians to predict the results of emergency head computed tomography (CT) scans. METHODS: Clinicians requesting cranial CT scans from the emergency department prospectively filled out a form detailing their patients' complaints, possible diagnoses, and the likelihood of finding those diagnoses on CT. The results of the scans were catalogued according to diagnosis and classified as acutely abnormal, chronically abnormal, or normal. RESULTS: Analysis of 536 consecutive patients showed a significant direct correlation between clinical prediction of CT abnormality and scan results. No definite differences in the ability to predict scan results were observed among different physician training levels. Thirty-six patients had acute abnormalities on CT despite a clinical prediction of remote or low likelihood. CONCLUSION: Although clinical predictions of CT abnormality correlate with actual CT results, the correlation is not adequately refined to rely on for selection of patients for emergency cranial CT scans.

Acute Disease↗
PubMed1994

Emergency imaging of patients with resolved neurologic deficits: value of immediate cranial CT.

OBJECTIVE: The purpose of this study was to evaluate the utility of cranial CT performed emergently in patients with neurologic deficits of acute onset that had resolved by the time of presentation to an emergency department. MATERIALS AND METHODS: Data were evaluated from 1518 patients presenting to level I (967 patients) and level II (551 patients) emergency departments. All patients underwent cranial CT during their visit to the emergency department to exclude potential intracranial hemorrhage or life-threatening mass effect from other causes. Of the 1518 patients who had CT done in one of these two departments and were entered into this study, 71 had histories compatible with resolved neurologic deficits, including 62 with apparent cerebrovascular disease, six with trauma, and three with seizure. The data collected included demographic information, medical history, physical and neurologic examinations, relevant laboratory data, results of CT, and information regarding patients' disposition from the emergency department. RESULTS: All CT scans in patients with resolved deficits were normal except for one in a patient who had had trauma. The scan of this patient showed a left frontal bone fracture and a subtle underlying subdural hematoma. These required no therapy. The rate of abnormal findings on CT scans was significantly lower in the 71 patients in whom acute neurologic deficits had resolved than in the other 1447 patients who underwent CT for other reasons (chi 2: p < .001). CONCLUSION: Immediate cranial CT is not indicated in the evaluation of patients with resolved neurologic deficits, except possibly when the patient has a history of trauma.

Brain↗
PubMed1992

Silo filler's disease in New York State.

Twenty new cases of Silo filler's disease (SFD) have been collected, documenting the incidence and clinical features of exposure to nitrogen oxides present in freshly filled silos. Cases of SFD were identified using a statewide computerized discharge diagnosis system. Fifteen of these were identified in the index period, allowing us to calculate an approximate annual incidence of 5.0 cases/100,000 silo-associated farm workers/yr in New York State. All cases occurred during harvest periods, with 80% in September and October. Corn silage was the gas source in 18 (90%). All cases involved young white men (mean age, 31.5 yr). The most common presenting feature was dyspnea. All victims entered a silo during the peak danger period, and only one used recommended ventilation techniques. Four cases ended in death (20% mortality). Silo filler's disease, although rare, is a potentially devastating disease involving otherwise young, healthy farm workers. It is readily prevented.

Adult↗
PubMed1988

Tracheoesophageal fistula secondary to muriatic acid ingestion.

Acid ingestion may result in a variety of early and late complications. A patient is presented with severe sequelae from muriatic acid ingestion, including a tracheoesophageal fistula which is a previously unreported complication of acid ingestion injury. Recommendations are made for diagnosis and prevention of this potentially lethal complication.

Burns, Chemical↗
PubMed1988

Lower-extremity amputations in NIDDM. 12-yr follow-up study in Pima Indians.

The incidence of lower-extremity amputations was estimated in the Pima Indians of the Gila River Indian Community in Arizona, a population with a high prevalence of non-insulin-dependent diabetes mellitus (NIDDM). Between 1972 and 1984, from a study population of 4399 subjects, lower-extremity amputations were performed on 84 patients, 80 (95%) of whom had NIDDM. Among diabetic subjects, the incidence rate of first lower-extremity amputations was higher in men than in women. Rates increased significantly with increasing duration of diabetes. Presence of medial arterial calcification, retinopathy, or nephropathy; absence of patellar tendon reflexes; impaired great toe vibration-perception threshold; and degree of fasting and 2-h postload hyperglycemia were significant risk factors for amputations. Serum cholesterol concentration, blood pressure, age, and absence of Achilles tendon reflexes were not predictive of amputations. The death rate was greater in diabetic amputees than in diabetic nonamputees of similar age, sex, and duration of diabetes, and a significant increase in cardiovascular deaths was observed in diabetic subjects with amputations. The incidence rate of lower-extremity amputations in diabetic Pima Indians is higher than that reported in other diabetic populations. This may reflect differences in risk or a more complete case ascertainment than was possible in previous studies. If the latter is true, the rate of amputations in diabetic individuals may be higher than has been previously appreciated.

Adolescent↗
PubMed1987

Pancreatitis in a native American Indian population.

We have studied pancreatitis in a population of Southwestern American Indians where gallstones are frequent, alcohol consumption is presumably high, but where smoking is an uncommon habit. Over a 5-year period, 131 cases of pancreatitis (65 males, 66 females) were observed: 66 (50%) were thought to be biliary pancreatitis, 54 cases (41%) alcoholic pancreatitis, and 5 cases (4%) were caused by injuries. In 6 cases (5%) no definite cause was found. Smoking appeared to be increased in male subjects with alcoholic pancreatitis when compared to subjects with alcoholic liver cirrhosis--a group with similar drinking habits. (Adjusted odds ratio = 12.5, p = 0.008). No such relationship was observed for females. Our findings suggest that in this population smoking may be an additional important risk factor for male subjects with alcoholic pancreatitis.

Alcohol Drinking↗
PubMed1979

Biliary enteric fistulas. Management of 47 cases in native Americans.

The management of 47 patients with spontaneous biliary fistulas is reported. Thirteen did not have surgery, and another 8, although operated on, did not have the fistulas closed. In none of these patients have recurrent biliary symptoms developed. The 26 patients who did have surgical closure of the fistula were operated on, in nearly every instance, for symptoms of residual cholelithiasis or choledocholithiasis, and in only 4 of these patients was the fistula known to exist preoperatively.

Adolescent↗