bluuebunny/crossref_metadata_2025 huggingface dataset:
EFFECT OF STREPTOZOTOCIN‐INDUCED DIABETES ON NGF, P75(NTR) AND TRKA CONTENT OF PREVERTEBRAL AND PARAVERTEBRAL RAT SYMPATHETIC GANGLIA
Authors: Schmidt Re , Dorsey Da , Roth Ka , Parvin Ca , Hounsom L , Tomlinson Dr
Published: August 2010

Diabetic autonomic neuropathy results in significant morbidity and mortality. Both diabetic humans and experimental animals show neuroaxonal dystrophy of autonomic nerve terminals, particularly in the prevertebral superior mesenteric ganglia (SMG) and celiac ganglia (CG) which innervate the hyperplastic/hypertrophic diabetic small intestine. Previously, investigators suggested that disturbances in ganglionic nerve growth factor (NGF) content or transport might play a pathogenetic role in diabetic autonomic pathology. To test this hypothesis, we measured NGF content and NGF receptor expression, p75(NTR) (low affinity neurotrophin receptor) and trkA (high affinity NGF receptor), in control and diabetic rat SMG, CG and superior cervical ganglia (SCG). Surprisingly, rather than a decrease, we observed an approximate doubling of NGF content in the diabetic SMG and CG, a result which reflects increased NGF content in the hyperplastic diabetic alimentary tract. No change in NGF content was detected in the diabetic SCG which is relatively spared in experimental diabetic autonomic neuropathy. NGF receptor expression was not consistently altered in any of the autonomic ganglia. These observations suggest that increased NGF content in sympathetic ganglia innervating the diabetic alimentary tract coupled with intact receptor expression may produce aberrant axonal sprouting and neuroaxonal dystrophy.
Etanercept reduces hyperalgesia in experimental painful neuropathy
Authors: Sommer Claudia , Schäfers Maria , Marziniak Martin , Toyka Klaus V.
Published: August 2010

Abstract  Etanercept, a recombinant tumor necrosis factor receptor (p75)‐Fc fusion protein competitively inhibits tumor necrosis factor‐alpha (TNF). Etanercept has been successfully used in patients with rheumatoid arthritis, where it reduces pain and inflammation. Because locally produced proinflammatory cytokines play a role in pain after nerve injury, we investigated whether etanercept can reduce pain and hyperalgesia in an animal model of painful neuropathy, the chronic constriction injury of the sciatic nerve. C57BL/6 mice received etanercept or sham treatment by local near‐nerve injection to the injured nerve or by systemic application. Treatment with etanercept reduced thermal hyperalgesia and mechanical allodynia significantly in both modes of application. The effect of etanercept was present in animals that were treated from the time of surgery and in those that were treated from day 6, when hyperalgesia was already present. These results suggest the potential of etanercept as a treatment option for patients with neuropathic pain.
Histopathological features of X‐linked Charcot‐Marie‐Tooth disease in 8 patients from 6 families with different connexin32 mutations
Authors: Vital Anne , Ferrer Xavier , Lagueny Alain , Vandenberghe Antoon , Latour Philippe , Goizet Cyril , Canron Marie‐Hélène , Louiset Pierre , Petry Klaus G. , Vital Claude
Published: August 2010

Abstract  There is still confusion as to whether X‐linked Charcot‐Marie‐Tooth disease (CMTX) is primarily an axonal disorder or is primarily demyelinating. Eight symptomatic patients, 7 males and 1 female, from 6 families with identified connexin32 mutations underwent a superficial peroneal nerve biopsy. Quantitative and ultrastructural studies were performed, and histopathological lesions in these 8 patients proved to be quite homogeneous. The myelinated fiber count was within normal values or only moderately decreased. In 7 cases, the distribution of myelinated fibers was unimodal due to a loss of large fibers, coexisting with numerous clusters of small regenerating fibers. At ultrastructural level, these clusters were often surrounded by flattened Schwann cell processes giving an aspect of “pseudo‐onion bulb” formation. There was no “naked axon” (ie, demyelinated axon), and real “onion bulb” formations composed of flattened Schwann cell processes surrounding an isolated myelinated fiber were discrete and not numerous. Macrophages laden with myelin debris were scarce or absent in the endoneurium. Several fibers appeared discretely hypomyelinated and the calculated g‐ratio was scarcely higher than the mean control value. Lesions of unmyelinated fibers were absent in 7 cases and mild in one. Given that the primary defect concerns connexin32, we think that the histopathological features observed in our patients correspond to primary hypomyelination rather than to ongoing demyelination. The associated axonal degeneration might be secondary to defective axon‐Schwann cell interactions.
A new Ser472Asn (Cab2a+) polymorphism localized within the αIIb “thigh” domain is involved in neonatal thrombocytopenia
Authors: Jallu Vincent , Dusseaux Mathilde , Kaplan Cecile
Published: August 2010

BACKGROUND: A new platelet antigen, Cab2a+, was identified in a case of severe neonatal alloimmune thrombocytopenia (<8 × 109/L) in twins.

STUDY DESIGN AND METHODS: Coding sequences of αIIb and β3 genes from parents were amplified and sequenced. CHO cell lines expressing wild‐type or mutated forms of the complex were established to study the role of the mutation in alloimmunization and in αIIbβ3 functions.

RESULTS: The father and twins were heterozygous for a single αIIb c.1508G>A mutation leading to a Ser472Asn substitution. Immunologic assays with transfected CHO cells revealed the Asn472 form of αIIbβ3 responsible for the Cab2a+ epitope but not an Ala472 form. Using these cells lines we demonstrated that both Ser472Asn and Ser472Ala substitutions produced limited structural alteration as revealed by the reactivity of a panel of anti‐αIIbβ3 monoclonal antibodies (MoAbs). Activated Asn472 and Ala472 forms of αIIbβ3 supported 1) binding of soluble fibrinogen and of the ligand mimetic MoAb PAC‐1, 2) ligand‐induced binding site epitopes exposure (MoAbs AP‐5 and D3GP3), and 3) cell aggregation. Adhesion onto adsorbed fibrinogen was conserved and was specifically inhibited by MoAb AP‐2 or peptide RGDS. Finally outside‐in signaling was not affected.

CONCLUSION: We have characterized a new low‐frequency alloantigen (<1%) resulting from the Ser472Asn substitution in αIIb and shown this polymorphism to have a limited effect, if any, on the αIIbβ3 complex functions.
Dose‐Response Model of Coxiella burnetii (Q Fever)
Authors: Tamrakar Sushil B. , Haluska Anne , Haas Charles N. , Bartrand Timothy A.
Published: August 2010

Q fever is a zoonotic disease caused by the intracellular gram‐negative bacterium Coxiella burnetii (C. burnetii), which only multiplies within the phagolysosomal vacuoles. Q fever may manifest as acute or chronic disease. The acute form is generally not fatal and manifestes as self‐controlled febrile illness. Chronic Q fever is usually characterized by endocarditis. Many animal models, including humans, have been studied for Q fever infection through various exposure routes. The studies considered different endpoints including death for animal models and clinical signs for human infection. In this article, animal experimental data available in the open literature were fit to suitable dose‐response models using maximum likelihood estimation. Research results for tests of severe combined immunodeficient mice inoculated intraperitoneally (i.p.) with C. burnetii were best estimated with the Beta‐Poisson dose‐response model. Similar inoculation (i.p.) trial outcomes conducted on C57BL/6J mice were best fit by an exponential model, whereas those tests run on C57BL/10ScN mice were optimally represented by a Beta‐Poisson dose‐response model.
Behavioral Channels in the Cross‐Market Diffusion of Major Terrorism Shocks
Authors: Drakos Konstantinos
Published: August 2010

The diffusion mechanism of terrorist shocks to third countries’ stock market responses is explored by employing a Heckit model. Stock market response is broken down to (i) the direction of reaction and (ii) conditional on negative reaction, its magnitude. The analysis puts forward two behavioral factors (memory‐based utility/availability heuristic, social amplification of risk), proxied by past terrorism record and terrorism risk concern as the shocks’ diffusion channels. The findings are that the likelihood and the size of negative stock market reaction increase with terrorism record and risk concern. Additionally, weak evidence is uncovered for a mitigation of risk concern's impact by favorable macroeconomic stance. Furthermore, the impact of behavioral factors, especially over the magnitude of reaction, is robust when controlling for economic linkages. The latter are also significant predictors of the direction of stock market reaction, but not of its magnitude.
Recurrence of RVOT PVCs with a Marked Shift of Its Exit Point. Gradual Elimination of Arrhythmogenic Focus by Multisite Approach
Authors: DEREJKO PAWEŁ , ORCZYKOWSKI MICHAŁ , SZUMOWSKI ŁUKASZ J. , WALCZAK FRANCISZEK
Published: August 2010

We present a case of recurrent outflow tract arrhythmia despite repeated ablations. Premature ventricular contractions (PVCs) morphology suggested a right‐sided focus. However, electrograms preceding PVCs were recorded from the right and left outflow tracts, distal coronary sinus, and right sinus of Valsalva. Arrhythmia was eliminated after radiofrequency (RF) applications delivered from different sites. We conclude that, in patients with recurrent outflow tract PVCs, mapping all the sites mentioned above may be necessary to find the earliest activation site and carry out successful ablation. In some patients, RF applications from multiple sites may be necessary to completely eliminate arrhythmia. (PACE 2012; 35:e6–e9)
Hemiazygous Coil Placement for High‐Defibrillation Thresholds in a Patient with a Right‐Sided Implantable Cardioverter Defibrillator
Authors: NILSSON KENT R. , JACKSON KEVIN P.
Published: August 2010

A 41‐year‐old man underwent implantation of a right‐sided implantable cardioverter defibrillator after removal of an infected left‐sided system. Defibrillation threshold (DFT) testing on the right‐sided system failed to convert ventricular fibrillation at maximum device output (35 J) compared with a DFT of less than 15 J on the previous left‐sided system. A single‐coil lead was selectively placed into the hemiazygous vein, which courses leftward of the spine in a posterior‐anterior projection, resulting in an improved shocking vector and reduction in DFTs to less than 25 J. (PACE 2012; 35:e10–e12)
Epicardial Macroreentrant Ventricular Tachycardia Associated with a Left Ventricular Aneurysm
Authors: YAMADA TAKUMI , DOPPALAPUDI HARISH , McELDERRY H. THOMAS , KAY G. NEAL
Published: August 2010

A 62‐year‐old man with severe coronary artery disease and a left ventricular aneurysm underwent catheter ablation of ventricular tachycardia (VT) with right bundle branch block QRS morphology. Endocardial bipolar voltage mapping with standard threshold settings demonstrated no low‐voltage areas within the aneurysm. Catheter ablation of the epicardial surface of the aneurysm eliminated the VT. Endocardial bipolar voltage mapping with any other settings could not predict the site of the epicardial arrhythmogenic substrate whereas endocardial unipolar voltage mapping could. Endocardial unipolar voltage mapping may be helpful for predicting epicardial arrhythmogenic substrates. (PACE 2012; 35:e13–e16)
Comparison of Sinus X‐rays with Computed Tomography Scans in Acute Sinusitis
Authors: Burke Thomas F. , Guertler Andrew T. , Timmons James H.
Published: August 2010

Objective:To determine the sensitivity and specificity of sinus x‐rays of patients clinically diagnosed as having acute sinusitis.

Methods:Thirty consecutive adult, nonpregnant emergency department (ED) patients clinically diagnosed as having acute sinusitis and meeting study criteria were entered into the study. Sinus x‐rays were obtained immediately after study entry and sinus computed tomography (CT) scans were done within 72 hours. Radiologic criteria for sinusitis were defined as more than 3 mm of mucoperiosteal thickening (MPT), an air/fluid (A/F) level, or opacification. All films were read in a blinded fashion [CT scans by two radiologists and plain films by two emergency medicine (EM) staff members and the same radiologists]. A third radiologist interpreted CT scans when the initial radiologists disagreed.

Results:Sinus CT scans were obtained for 29 of 30 patients. Radiologists interpreted 28 of 29 CT scans identically, with 21 being positive for sinusitis. Sensitivity and specificity of x‐rays were 57% and 88%, 62% and 88%, 67% and 75%, and 48% and 100% for the two radiologists and the two EM physicians, respectively. Four ethmoid, five frontal, and five sphenoid sinuses were opacified or had A/F levels on CT scan. No ethmoid, frontal, or sphenoid sinus was interpreted as being opacified or having an A/F level on plain film. Sensitivity and specificity of maxillary sinus opacification or A/F level on x‐ray were 70% and 100%, 70% and 100%, 70% and 96%, and 70% and 96% for the two radiologists and the two EM physicians, respectively. Mean concordances (kappa) of x‐ray and CT scan interpretations for the four reviewers were 0.34 (range, 0.30–0.39) for the diagnosis of sinusitis and 0.77 (range, 0.74–0.79) for maxillary sinus opacification or A/F level.

Conclusion:Sinus x‐rays are less sensitive than sinus CT scans for demonstration of radiographic changes consistent with acute sinusitis. Sinus plain films may not be reliable enough to assist with clinical decision making. If severity of patient illness requires diagnostic certainty, more sensitive imaging studies, such as CT scans of the sinuses, should be considered.
The Effects of Lidocaine Pretreatment on Cocaine Neurotoxicity and Lethality in Mice
Authors: Heit Jeffrey , Hoffman Robert S. , Goldfrank Lewis R.
Published: August 2010

Objective:To evaluate the effects of an antiarrhythmic dose of lidocaine on cocaine‐induced ataxia, seizures, and death in mice.

Methods:A randomized, controlled, blinded investigation was conducted using 220 female Swiss albino mice. Groups of 20 animals received intraperitoneal (IP) administration of either 31.6 mg/kg of lidocaine hydrochloride in 0.9% NaCl (ten animals) or an equal volume of 0.9% NaCl solution (ten animals). After 5 minutes, all the animals received IP cocaine in incremental doses ranging from 40 to 110 mg/kg. The animals were observed for ataxia, seizures, and death. The animals pretreated with lidocaine were compared with the control animals for the number of adverse effects from cocaine at each dose tested.

Results:Lidocaine significantly increased the overall incidences of cocaine‐induced ataxia (p = 0.02) and seizures (p < 0.001). However, pretreatment with lidocaine offered protection against cocaine lethality (p < 0.0001).

Conclusion:In this preexposure model, lidocaine protects mice against cocaine‐induced lethality. These effects seem to be independent of convulsive activity. Further study is required to determine the safety and efficacy of lidocaine for the management of cocaine‐induced arrhythmias.
The Evolution of Abdominal Compression in Cardiopulmonary Resuscitation
Authors: Babbs Charles F.
Published: August 2010

Objective: To review the history of external abdominal compression as an adjunct to cardiopulmonary resuscitation (CPR), tracking the development of five major themes over the course of the 20th century: 1) augmentation of peripheral resistance by physical means, 2) risk of hepatic injury with abdominal compression, 3) counterpulsation vs sustained compression, 4) the abdominal pump mechanism, and 5) contact compression techniques.

Methods: Literature retrieved from successive MEDLINE English‐language searches was reviewed with a special emphasis on work and concepts highlighted by participants at the First Purdue Conference on Interposed Abdominal Compression‐CPR, September 1992.

Results: External abdominal compression of one form or another has been studied as a means of resuscitation by many investigators throughout the 20th century. Experimental and clinical studies have shown generally consistent evidence of hemodynamic augmentation by abdominal compression during various forms of CPR. Recent advances include a modified theoretical understanding of hemodynamic mechanisms and demonstration of clinical potential in humans. Inconsistencies in published results may be due to differences in mechanical techniques of abdominal compression. Based on these studies, a modified manual technique for “contact compression” of the abdominal aorta is recommended.

Conclusions: A technique for left‐of‐center, angled compression of the abdominal aorta against the crest of the spine is recommended. Further well‐supervised and controlled clinical trials using this standardized technique are warranted as a prelude to more widespread clinical application of abdominal compression in CPR.
Possible Reasons for the Variability of Human Responses to IAC‐CPR
Authors: Ward Kevin R.
Published: August 2010

Objective: To propose reasons for the variability of the hemodynamic responses and survival data observed when interposed abdominal compression cardiopulmonary resuscitation (IAC‐CPR) is performed on humans in cardiac arrest.

Methods: Critical content review of all studies performed in the United States examining IAC‐CPR in humans and of selected animal studies addressing hemodynamic mechanisms of CPR. Articles in the English language dealing with human IAC‐CPR studies from 1970–1993 were retrieved using the MEDLINE database of the National Library of Medicine.

Results: IAC‐CPR does not consistently improve coronary perfusion pressure (CPP) over standard CPR in humans and is capable of decreasing as well as increasing CPP. This variability does not seem dependent on the manner in which abdominal compressions are performed. Because of the limited response to standard CPR, significant increases in return of spontaneous circulation would be expected with IAC‐CPR if a large percentage of patients were to have favorable increases in CPP. However, other patients may be adversely affected by decreases in CPP during IAC‐CPR, with unsuccessful resuscitation of those individuals. Return of spontaneous circulation also may be enhanced using IAC‐CPR due to other factors reflected in the initial arrest rhythm and in arrest‐population demographics.

Conclusion: IAC‐CPR should not be recommended for routine use until the mechanism of its beneficial effects is known and until those patients who are likely to benefit from the technique can be better identified.
Hemodynamics of Interposed Abdominal Compression during Human Cardiopulmonary Resuscitation
Authors: Adams Craig P. , Martin Gerard B. , Rivers Emanuel P. , Ward Kevin R. , Smithline Howard A. , Rady Mohamed Y.
Published: August 2010

Objective: Clinical studies of interposed abdominal compression CPR (IAC‐CPR) have had diverse outcomes. This study compared the hemodynamics of standard CPR and IAC‐CPR in humans.

Methods: A 24‐month prospective nonrandomized analysis of hemo‐dynamic parameters was performed in a convenience cohort of 20 adults who had had out‐of‐hospital, nontraumatic, normothermic cardiac arrests. The study took place in the resuscitation unit of a large urban hospital. Thoracic aortic and right atrial catheters were inserted and pressures were recorded during standard CPR and IAC‐CPR. Coronary perfusion pressures (CPPs) were determined during standard CPR and IAC‐CPR. The patients were separated into two groups based upon their responses to IAC‐CPR. Responders had increases in CPP during IAC‐CPR; nonresponders had decreases or no change in CPP during IAC‐CPR. Aortic relaxation, right atrial relaxation, aortic compression, and right atrial compression phase pressures were compared between the two groups.

Results: CPPs increased in 13 patients and decreased in seven patients. The mean change in CPP with IAC‐CPR was an increase of 5.8 ± 15.1 torr. An elevated right atrial compression phase pressure (RaComp) during standard CPR was predictive of an increase in CPP during IAC‐CPR (p = 0.047). In those patients who showed improvements in CPP during IAC‐CPR, mean aortic relaxation phase pressures (AoRelax) increased by 9.5 ± 14.2 torr (p = 0.026) and mean right atrial relaxation phase pressures (RaRelax) decreased by 2.6 ± 6.2 torr (p = 0.099) during IAC‐CPR.

Conclusions: The variable effects of IAC‐CPR on CPP appear to be multifactorial. The improvement in CPP that occurred in responders to IAC‐CPR was secondary to an increase in AoRelax as well as a decrease in RaRelax.
A Comparative Study of the Percutaneous versus Intraoral Technique for Mental Nerve Block
Authors: Syverud Scott A. , Jenkins J. Matthew , Schwab Robert A. , Lynch Michael T. , Knoop Kevin , Trott Alexander
Published: August 2010

Objective: Mental nerve block is frequently used to aid repair of facial lacerations; both percutaneous and intraoral approaches to blocking this nerve are used, but have never been compared. The authors compared the two techniques for pain of administration and effectiveness of anesthesia.

Methods: A prospective, randomized, single‐blind, crossover study was conducted using ten healthy volunteers aged 22 to 33 years. Patients having prior experience with mental nerve blocks, lidocaine allergy, active oral/facial infection, or previous facial fractures were excluded. Bilateral mental nerve blocks were done using intraoral technique on one side and percutaneous technique on the other. Both techniques were used by the same investigator and were carried out with 27‐gauge needles and 2.5 mL of 2% buffered lidocaine at room temperature injected over 20 seconds. The oral mucosa was topically anesthetized with viscous lidocaine for 1 minute prior to intraoral injection. The orders of the blocks and sides of the face anesthetized were randomized. Subjective and objective pain (visual‐analog scale), efficacy (anesthesia of lower lip), time to onset, and duration of anesthesia were evaluated.

Results: The intraoral technique was subjectively less painful than the percutaneous approach in nine of ten subjects (p = 0.02). Scores on the visual‐analog pain scale were significantly lower for the intraoral technique (p = 0.03). Intraoral injection produced lower‐lip anesthesia in 10/10 subjects versus 7/10 for percutaneous (p = 0.25). Times to onset (approximately 1–2 minutes) and durations of anesthesia (approximately one hour) were similar for the two techniques.

Conclusion: The intraoral approach to the mental nerve block with adjunctive topical anesthesia was subjectively and objectively less painful than the percutaneous approach without adjunctive anesthesia. While the intraoral approach had a greater efficacy of lower‐lip anesthesia and a longer duration of action, these differences were not statistically significant.
Percutaneous Central Venous Access for Resuscitation in Trauma
Authors: Scalea Thomas M. , Sinert Richard , Duncan Albert O. , Rice Phillip , Austin Reinaldo , Kohl Lewis , Trooskin Stanley Z. , Talbert Susan
Published: August 2010

Objective: To determine the safety of percutaneous central venous access when used for trauma resuscitation and whether the initial hemodynamic status of the patient or the site of placement affects the ease or success of line placement.

Methods: Consecutive major‐trauma patients were managed using a resuscitation protocol guiding intravenous line use. Percutaneous peripheral venous access was initially attempted in all patients. If this approach was unsuccessful or proved to be inadequate for volume resuscitation, venous access was attempted using central venous catheter‐introducer sets. The site of the central venous access was determined by protocol. For thoracic injury, access was via the ipsilateral subclavian vein (SCV), the ipsilateral internal jugular vein (IJV), or the femoral vein. For suspected mediastinal injury, access was via the contralateral SCV or IJV, or the femoral vein. For abdominal or flank injury, access was via the SCV or IJV only. Multiple central venous access sites were used at the discretion of the trauma team.

Results: Central venous access was successful at 144 of 147 sites (99%) used in 122 patients during the study period. There was only one major complication (rate = 0.7%; 95% CI 0.0–3.8%). Mean catheter placement time was 1.9 minutes, and cannulation occurred with a mean of 1.8 needle passes. Most patients (81/122) were hypotensive (blood pressure ≤90 torr) at the time of line placement, including 44 who were in cardiac arrest and four awake patients who had no obtainable blood pressure. Neither the access site nor the presence of hypotension was associated with the mean time to obtain central venous access, the mean number of attempts, or the complication rate.

Conclusion: Percutaneous central venous access is relatively safe and reliable for gaining intravenous access when resuscitating trauma patients, when used in a center where physicians are experienced in the technique. Consideration should be given to expanding the use of central venous access in trauma resuscitation.
Ketorolac TVomethamine Use in a University‐based Emergency Department
Authors: Bartfield Joel M. , Kern Audrey M. , Raccio‐Robak Nancy , Snyder Howard S. , Baevsky Robert H.
Published: August 2010

Objective: To assess the use of parenteral ketorolac tromethamine (KT) in the emergency department (ED).

Methods: During a six‐month period, KT was administered in an uncontrolled, nonblinded fashion to a series of ED patients experiencing acute pain. The patients rated pain on a previously validated visual analog pain scale before receiving KT. They repeated this procedure one hour after KT administration, prior to additional analgesia, or preceding release, whichever came first. Analgesic response was assessed by comparing pretreatment and posttreatment pain scores for the entire study population by the Wilcoxon rank sum test. Possible effects of specific variables (patient age, gender, race, indication for KT, route, dose, previous use of NSAIDs, and concurrent administration of muscle relax‐ants) were assessed using the Kruskal‐Wallis test.

Results: Of the 445 patients enrolled, 375 (84%) reported pain relief with KT, only seven (2%) worsened, and the remainder (14%) reported no change. Overall pain reduction was 37.6 ± 27.2 (SD) mm (100‐mm scale) for the entire study population. The pain scores obtained after KT administration were significantly lower than those obtained prior to KT administration (p < 0.001). The only variable that significantly influenced pain score reduction was indication for KT (p = 0.0001). Nephro‐lithiasis and toothache patients had the largest mean reductions in pain. No significant side effect was reported.

Conclusion: Parenteral KT is a useful and safe analgesic for ED patients. The agent generally provides analgesia and is particularly promising for patients with nephrolithiasis or toothache.
Ketorolac vs Meperidine for the Management of Pain in the Emergency Department
Authors: Koenig Kristi L. , Hodgson Laurel , Kozak Richard , Jordan Kathy , Sexton Thomas R. , Leiken Alan M.
Published: August 2010

Objective: To compare the pain relief, sedation, and common side effect profiles of ketorolac tromethamine and meperidine for the management of acute pain in the emergency department (ED).

Methods: A prospective, double‐blind, randomized clinical trial was conducted over a 12‐month period using consecutive adult patients presenting to a university teaching hospital ED (annual census: 32,000), who required IM analgesia for acute pain. Adult patients with acute pain of various etiologies were randomly assigned to receive a single fixed IM dose of ketorolac (60 mg) or meperidine (100 mg).

Results: Ninety‐three patients were enrolled in the study; 46 were randomized to meperidine and 47 to ketorolac. Using a visual analog scale, there was no difference in pain relief between the ketorolac and meperidine groups even after adjusting for baseline pain level. Ketorolac caused significantly (p < 0.005) less sedation than did meperidine at one hour. Rescue analgesia was required for seven of the 46 (15.2%) patients receiving meperidine and five of the 47 (10.6%) patients receiving ketorolac (p = NS). Seventeen of 45 (38%) patients receiving meperidine experienced side effects compared with eight of the 47 (17%) patients receiving ketorolac (p = 0.0452).

Conclusions: When used to treat patients who had acute pain states, 60 mg of IM ketorolac produced analgesia similar to that produced by 100 mg of IM meperidine; however, the ketorolac produced fewer subjective side effects and less sedation than did the meperidine.
Air Embolism Death of a Pregnant Woman Secondary to Orogenital Sex
Authors: Kaiser Rachel T.
Published: August 2010

Air embolism produced by vaginal insufflation is an unusual but potentially lethal consequence of sexual activity, especially in the pregnant patient. Reported here is the case of a young pregnant woman who presented to the ED in full cardiac arrest, with little history to explain her condition. Despite aggressive resuscitative measures, the patient died, but her infant son was delivered via perimortem cesarean section and survived. A high level of suspicion for air embolism should be maintained for young women who unexpectedly develop cardiac arrest, particularly during sexual activity. Air embolism patients may require vigorous medical resuscitation, hyperbaric oxygen therapy, or surgical intervention to survive. The emergency physician should be familiar with the indications for perimortem cesarean delivery in the third‐trimester patient presenting to the ED with cardiac arrest.
Gynecologic Disorders in the Older Patient
Authors: Jones Jeffrey S. , Montgomery Matthew
Published: August 2010

This review addresses the presentation and management of gynecologic disorders in older women. While these conditions are often managed by a primary caregiver, many women may present to the ED because they lack a primary gynecologic caregiver, their established gynecologic caregiver is not available, they are embarrassed to discuss their symptoms with an established caregiver, or they seek immediate relief of symptoms and reassurance. The emergency physician (EP) must be aware of the normal physiologic changes that occur with aging and how these changes may produce symptoms in older women. This review addresses physiologic changes and pathophysiologic conditions. Knowledge of these conditions and their management will facilitate reassurance of the patient, expedite appropriate initial therapy, and enable the EP to efficiently refer patients requiring further gynecologic assessment.
Outcome of Acute Otitis Media with Abnormal Tympanometric Patterns in Children
Authors: Green Steven M. , Rothrock Steven G. , Nesper Timothy P. , Hummel Christopher B.
Published: August 2010

Objective: To assess the ability of ED tympanometry to identify those children with acute otitis media who are at greater risk for treatment failure, recurrent infection, or persistent middle ear effusion.

Methods: A prospective observational study was performed in the EDs of a county hospital and a university medical center. One hundred seventeen children, aged 5 months to 5 years, with acute otitis media and abnormal tympanometric patterns were categorized into three groups —low compliance, high pressure, and low pressure—based on the initial patterns. All the children received oral amoxicillin for ten days. They had repeat tympanometry and otoscopy at 14‐ and 60‐day follow‐up visits, and were followed to determine clinical outcomes.

Results: Initial treatment success was equivalent for all groups: low compliance 93% (95% confidence interval 81%‐97%), high pressure 91% (95% CI 71%‐98%), and low pressure 89% (95% CI 59–99%). Rates of relapse, reinfection, 90‐day non‐recurrence, and persistent otoscopic and tympanometric middle ear effusion did not differ significantly between groups.

Conclusion: ED tympanometry of children with acute otitis media is unable to provide prognostic information regarding treatment failure, recurrent infection, or persistent middle ear effusion.
A Comparison of Proparacaine and Tetracaine Eye Anesthetics
Authors: Bartfield Joel M. , Holmes Thomas J. , Raccio‐Robak Nancy
Published: August 2010

Objective: To compare two topical eye anesthetics, proparacaine and tetracaine, for pain of instillation and duration of activity.

Methods: Volunteers received both anesthetics in a prospective, randomized, double‐masked protocol. The subjects were given one drop of a study solution in the lower lid fornix of the left eye. Immediately after receiving the medication, they rated the pain of instillation on a previously validated visual‐analog pain scale. This procedure was then repeated in the right eye with the other study solution. Pain scales were quantified by making measurements to the nearest millimeter from the point of scale origin to the point marked by the patient. The time interval until return of the corneal blink reflex was determined using a cotton wisp. Pain scores and the time to return of corneal reflex were analyzed by the Sign test and Wilcoxon rank‐sum test, respectively, with significance defined as p < 0.05.

Results: Twenty‐three subjects were available for analysis. Twenty subjects reported proparacaine hurt less than tetracaine, two felt the pain was the same for the two agents, and only one reported that proparacaine was more painful. The mean pain score for tetracaine was 24 mm (100 mm maximum) higher than that for proparacaine (p < 0.0002). Proparacaine lasted 1.3 minutes longer than tetracaine, 10.7 minutes versus 9.4 minutes (p = 0.0001).

Conclusion: Proparacaine eye drops cause less pain than tetracaine eye drops upon instillation. Anesthesia from proparacaine lasts slightly longer. These properties make proparacaine preferable to tetracaine.
Emergency Thoracotomy: Comparison of Medical Student, Resident, and Faculty Performances on Written, Computer, and Animal‐model Assessments
Authors: Chapman Dane M. , Marx John A. , Honigman Ben , Rosen Peter , Cavanaugh Sally H.
Published: August 2010

Objective: In clinical practice, thoracotomy and other critical emergency procedures are rarely required. Consequently, medical students and residents have difficulty acquiring procedural competency in these critical procedures. The authors developed objective written, computer, and animal‐model assessments of thoracotomy procedural competency to permit comparison of the reliability and validity of these three procedural assessment modalities.

Methods: Thoracotomy procedural competency was evaluated for 18 persons at three levels of training (medical student, resident, faculty), using written, computer, and animal‐model assessments. A prospective, sequential assessment design was used, with the examinees serving as their own controls. Procedural competency was defined in terms of performance time (animal time scale) and performance accuracy (written accuracy, computer accuracy, and animal accuracy scales) for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross‐clamping). Level of training was the independent variable, and procedural competency scores were the outcome measures. Confounding variables included previous thoracotomy and computer experience.

Results: Computer and animal‐model assessments produced reliable results (Chronbach's alpha > 0.50). The animal time scale and computer accuracy scale best reflected the expected skill differences among levels of physician training, providing support for construct validity. In contrast, written and animal accuracy scale scores did not significantly differ by level of physician training. Moreover, previous thoracotomy experience (i.e., number of procedures previously performed) was not a significant predictor of procedural competency.

Conclusions: This study demonstrates that critical emergency medicine procedures can be evaluated reliably and validly using computer simulation and animal‐model assessments. Neither previous thoracotomy experience nor knowledge of procedure content adequately predicts thoracotomy competency.
Variations in the Electrocardiograms of Young Adults: Are Revised Criteria for Thrombolysis Needed?
Authors: Hollander Judd E. , Lozano Michael , Goldstein Evan , Gennis Paul , Slater William , Fairweather Philip , Thode Henry C. , Gallagher E. John
Published: August 2010

Objective:The evaluation of chest pain in young adults has changed with the recognition of cocaine‐induced myocardial ischemia. The high frequency of abnormal electrocardiograms (56–84%) in the cocaine‐user population is largely due to “normal” electrocardiographic variants (early repolarization). The authors sought to determine the frequency of these “normal” variants in a young population, and whether these findings can be confused with acute ischemia.

Methods:A prospective convenience sample of subjects aged 18 to 35 without known heart disease was interviewed and had 12‐lead electrocardiographic tracings performed. An emergency physician (physician 1) and a cardiologist (physician 2) read the tracings while blinded to patient history, age, and race. When the physicians disagreed, another physician adjudicated the diagnosis.

Results:Four hundred fourteen subjects (127 black, 175 Hispanic, and 112 Caucasian) were enrolled. Overall, 154 tracings (37%) were normal, 245 (59%) were abnormal but nondiagnostic for ischemia, and 15 (4%) were consistent with ischemia. Frequencies of repolarization “abnormalities” as determined by physicians 1 and 2, respectively, were: blacks, 32%, 51%; Hispanics, 26%, 35%; Caucasians, 17%, 27%; chi‐squared, p = 0.02 and 0.0004. Patients with ischemic electrocardiograms according to physician 1 had a high frequency of repolarization “abnormalities” according to physician 2, and vice versa (100%, 61%). Electrocardiographic criteria for thrombolytic use per physician 2 were present in 31 patients (7%): blacks, 9%; Hispanics, 10%; and Caucasians, 2%; chi‐squared, p = 0.03.

Conclusions:Repolarization “abnormalities” in young patients are common. These “normal” electrocardiographic variants can be confused with ischemia. Based on the degree of ST‐segment elevation, these variants commonly meet current criteria for thrombolytic therapy.
Recovery from Severe Cyclic Antidepressant Overdose with Hypertonic Saline/Dextran in a Swine Model
Authors: McCabe James L. , Menegazzi James J. , Cobaugh Daniel J. , Auble Thomas E.
Published: August 2010

Objective:To determine the effect of a hypertonic saline and dextran (HSD) solution on blood pressure and QRS duration during severe cyclic antidepressant (CA) toxicity in swine.

Methods:Ten domestic swine weighing 20–24 kg were anesthetized and placed on mechanical ventilation. Nortriptyline solution was infused intravenously to achieve hypotension (systolic blood pressure equal to 50% of baseline) and a QRS duration of 120 msec. After reaching toxicity, the animals received in a randomized fashion either 10 mL/kg of a 7.5% saline/6% dextran solution or an equal volume of 0.9% saline as a rapid intravenous bolus. The animals were observed for one hour or until they died. Blood pressure and ECG were recorded continuously. Arterial pH was maintained in the physiologic range by controlled ventilation.

Results:Mean systolic blood pressure 10 minutes after treatment was 45 ± 8 torr in the normal‐saline group compared with 115 ± 12 torr in the HSD group (p < 0.05). Mean QRS duration 10 minutes after treatment was 180 ± 8 msec in the normal‐saline group; it was 88 ± 13 msec in the HSD group (p < 0.05). All normal‐saline‐group animals died within 20 minutes, and four of the five animals in the HSD group survived to 60 minutes (p < 0.05). The mean peak sodium concentration was 157 mmol/dL (mEq/dL) in the HSD group, and this was transient.

Conclusions:In this swine model of severe CA toxicity, a solution of 7.5% saline/6% dextran significantly reversed hypotension and QRS prolongation. HSD also improved survival to 60 minutes.
Survey of Follow‐up Systems in Emergency Medicine Residencies: Analysis and Proposal
Authors: Bentley Burton , DeBehnke Daniel , Ma O. John
Published: August 2010

Objective:For educational purposes, the Residency Review Committee for Emergency Medicine requires that emergency medicine residencies “provide a mechanism for each resident to obtain information on outcomes of patients the resident has evaluated in the emergency department.” The authors analyzed the current patient follow‐up systems of emergency medicine residencies and, based upon survey results, propose a comprehensive organized system of follow‐up.

Methods:The 84 emergency medicine residency directors listed in the 1991 Society for Academic Emergency Medicine Handbook were polled regarding the current follow‐up systems at all hospitals affiliated with their residencies. The survey contained 11 items, including two five‐point Likert scales for rating system effectiveness and satisfaction. A description of each hospital's follow‐up system was requested, and other comments were reviewed.

Results:The 72 (86%) respondents represented residencies with a total of 138 affiliated hospitals, of which 89 (64.5%) had formal follow‐up systems. Of those 89 hospitals, 39% (n= 80) residency directors reported that fewer than half of their residents used the systems, 63% (n= 87) had mandatory compliance policies; 53% had the capability for residents to obtain discharge summaries on admitted patients; and 66% (n= 83) had mechanisms for follow‐up of patients released from the emergency department. Twenty‐three percent of the systems were considered effective, with ratings of 4 or higher, and only 31% received satisfaction ratings of 4 or more.

Conclusion:Most emergency medicine residency‐affiliated hospitals in our survey had follow‐up systems in place. Of existing systems, only a minority were rated by residency directors as effective or satisfactory. A model for a comprehensive system of patient follow‐up is proposed.
Assessment of the “Scholarly Project” Requirement for Emergency Medicine Residents: Report of the SAEM Research Directors Workshop
Authors: Summers Richard L. , Fish Sue , Blanda Michelle , Terndrup Thomas ,   SAEM RESEARCH DIRECTORS' INTEREST GROUP
Published: August 2010

Objectives: Differences in interpretation of the residency review committee (RRC) directive concerning resident scholarly activity have resulted in inconsistencies in the practical fulfillment of this responsibility among the various training programs in emergency medicine. During a workshop organized by the SAEM Research Directors Interest Group (RDIG), a consensus statement was developed regarding the scope, definition, and purpose of the scholarly project requirement. Methods: During the workshop, the NIH model of consensus building was used to develop statements pertaining to specific questions of the goals, definition, and endpoints of the scholarly project. The program consisted of an overview of the history and issues related to the scholarly project and presentations of varying viewpoints from interested parties. A final consensus of answers to the defined questions was then developed by the workshop participants during roundtable discussions and further refined through interactive debate using the RDIG e‐mail list server. Results: By consensus it was agreed that the primary role of the scholarly project is to instruct residents in the process of scientific inquiry, to teach problem‐solving skills, and to expose the resident to the mechanics of research. To realize these goals, the project should include the general elements of hypothesis formulation, data collection, analytic thinking, and interpretation of results. It was also thought that these elements should be documented in some written form with a literature review. Conclusions: While each residency program must implement the RRC residency requirements in a manner that best suits the needs and culture of its individual environment, a concurrence of definition and approach to satisfying the scholarly project requirement would provide better consistency in resident training. Guidelines developed by consensus during the SAEM RDIG workshop may serve as a general recipe that can be used to fulfill the goals of the scholarly project and the spirit of the RRC directive.
The Informed Consent Process and the Use of the Exception to Informed Consent in the Clinical Trial of Diaspirin
Authors: Sloan Edward P. , Koenigsberg Max , Houghton Jaime , Gens David , Cipolle Mark , Runge Jeffrey , Mallory Mary Nan , Rodman George ,   For the DCLHb Traumatic Hemorrhagic Shock Study Group
Published: August 2010

In the clinical trial of diaspirin crosslinked hemoglobin (DCLHb), optimal therapy required the immediate enrollment of patients with severe, uncompensated, traumatic hemorrhagic shock. When it was not feasible to obtain prospective consent, an exception to informed consent was used according to FDA regulation 21 CFR 50.24. Objectives: To examine the informed consent process and the use of the consent exception and consent to continue (CTC), and to describe the patients for whom this process was used. Methods: This was a multicenter, randomized, controlled, single‐blinded efficacy trial of DCLHb as an adjunct to standard therapy in the treatment of severe, traumatic hemorrhagic shock. Patients with unstable vital signs or a critical base deficit were treated, with a primary study endpoint of 28‐day mortality. Results: During the 11‐month study period, 112 patients were randomized in 18 U.S. trauma centers, and data from 98 of the infused patients were analyzed. Prospective consent was obtained from two patients, three family members, and one legally authorized representative (LAR) (6%). Consent to continue was requested for 89 patients (89%), and full participation was granted for 87 of these patients (98%). Consent to continue was provided by 54 (98%) of the 55 patients approached. The mean number of days for family/LAR CTC was 1.1 ± 3.8 days, and 50% of the time it was obtained on the day of study enrollment. Patient CTC was obtained in an average of 13 ± 23 days, with a median of four days. Patients treated in this protocol were more likely to have sustained penetrating trauma than the overall trauma patient population treated in these trauma centers (44% vs 21%, p = 0.002). Conclusions: Informed consent in this study of an emergent therapy most often involved the use of the consent exception and consent to continue, the latter of which occurred in a timely manner. Nearly all of those who were approached for CTC approved full participation in the study, suggesting acceptance of the process outlined in the new regulations. Patients treated in a hemorrhagic shock clinical trial may differ from the general trauma patient population.