bluuebunny/crossref_metadata_2025 huggingface dataset:
Underrecognition of Cervical Neisseria gonorrhoeae and Chlamydia trachomatis Infections in the Emergency Department
Authors: Yealy Donald M. , Greene Thomas J. , Hobbs Gregory D.
Published: September 2008

Objectives: 1) To quantify the frequency of underrecognized Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in women tested in the ED, 2) to describe and compare the characteristics of those treated and not treated during the initial visit, and 3) to quantify the delay interval until treatment was provided.

Methods: A 2‐year, retrospective consecutive case series was performed from June 1, 1992, to May 31, 1994. There were 148 women with ≥1 discrete occurrence of culture‐proven cervical N. gonorrhoeae or C. trachomatis infection studied. All the patients were evaluated in a university‐affiliated, tertiary care hospital‐based ED with a large rural referral area. The main outcome measures were the proportions of patients with positive cultures both treated and not treated in the ED, the clinical characteristics of each group, and the proportion remaining untreated or experiencing treatment delays of ≥ 2 weeks after attempted phone, mail, and public health follow‐up.

Results: Of 157 occurrences of positive cultures for N. gonorrhoeae or C. trachomatis, 86 (53%) were treated with a regimen suggested by the CDC prior to ED release. The proportion of women with isolated C. trachomatis infections that were underrecognized and untreated initially was larger than the proportions with isolated N. gonorrhoeae or combined infections (79% vs 27% and 53%, respectively, p < 0.0001). Women with findings suggestive of advanced disease (history of fever or chills, or examination evidence of temperature >38°C, purulent vaginal discharge, or any uterine/salpinx/ovarian tenderness) were more often recognized and treated with appropriate antibiotics initially (p = 0.02 to <0.00001 for all). After phone, mail, and public health follow‐up, treatment could not be documented for 25% of the occurrences, in all cases due to an inability to locate the patient. An additional 20% of the women did not receive treatment for 14–60 days.

Conclusions: In this population, both N. gonorrhoeae and C. trachomatis cervical infections are frequently underrecognized in the ED, with isolated C. trachomatis infections associated with significantly higher proportions of underrecognition. Many affected women remain untreated for extended intervals, creating public and individual health risks. Improved point of contact detection, follow‐up, and treatment policies are needed to limit these risks.
The Development of International Emergency Medicine: A Role for U.S. Emergency Physicians and Organizations
Authors: Kirsch Thomas D. , Holliman C. James , Hirshon Jon Mark , Doezema David
Published: September 2008

ABSTRACT

There is a rapidly growing interest in emergency medicine (EM) and emergency out‐of‐hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly “reinventing the wheel” with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.
Evaluation of a Bedside Whole‐blood Rapid Troponin T Assay in the Emergency Department
Authors:   Rapid Evaluation by Assay of Cardiac Troponin T (REACTT) Investigators Study Group
Published: September 2008

Objective: To evaluate the performance of a new bedside whole‐blood rapid assay for cardiac troponin T (cTnT) in patients presenting to the ED with symptoms consistent with acute coronary ischemia.

Methods: A prospective, observational trial was performed in 8 participating medical centers. Serial blood samples were obtained on presentation to the ED and 3 and 6 hours later. The cTnT whole‐blood rapid assays were performed immediately at the site. Treating physicians and patients were blinded to the results of the rapid assays. Serum samples were analyzed at the core laboratory for serum cTnT, creatine kinase (CK)‐MB, and myoglobin. The sensitivity of the rapid assay for detecting acute myocardial infarction (AMI) was compared with the sensitivities of serum cTnT, CK‐MB, and myoglobin assays.

Results: Of 721 patients, 102 were diagnosed as having AMI. The median elapsed time from symptom onset to ED arrival was 3 hours. The sensitivities of the rapid assay for detecting AMI were 19.6%, 59.0%, and 69.7% at 0, 3, and 6 hours, respectively. The sensitivities of the serum cTnT assay (p‐values for comparison with the rapid assay for cTnT) were 25.0% (p = 0.18), 69.6% (p = 0.04), and 79.8% (p = 0.02) at 0, 3, and 6 hours, respectively. The CK‐MB and myoglobin sensitivities were 21.9%, 64.5%, and 81.0%; and 43.8%, 77.4%, and 71.4%, respectively. There were 7 patients with AMI who had negative rapid assay readings and positive serum cTnT levels; 4 of these patients were enrolled at the same site. Twenty patients not diagnosed as having AMI had at least one positive rapid assay. Fourteen of these 20 patients had a diagnosis of clinically relevant cardiac disease.

Conclusions: The sensitivity of this whole‐blood rapid cTnT assay for detecting AMI is comparable to that of current serum assays and offers the advantage of providing rapid bedside results. Discrepancies between serum and whole‐blood assays for cTnT noted in this study may indicate the need for further education for the test reader prior to patient use.
Detection of Electrolyte Abnormalities in Children Presenting to the Emergency Department: A Multicenter, Prospective Analysis
Authors: Rothrock Steven G. , Green Steven M. , McArthur C. L. , DelDuca Kevin ,   Detection of Electrolyte Abnormalities in Children Observational National Study (DEACONS) Investigators
Published: September 2008

Objective: To prospectively derive high‐yield criteria for the detection of clinically significant electrolyte abnormalities (CSEAs) in children presenting to the ED.

Methods: A prospective, multicenter, observational study was performed at the EDs of 2 urban teaching hospitals, a university medical center, and a children's hospital with a combined census of >275,000 patient visits/year (100,000 visits for children <13 years old). All children <13 years old who had electrolyte panels obtained were eligible for analysis. A data form containing potential predictor variables for a CSEA was completed by the clinician prior to receipt of electrolyte results. A CSEA was any abnormal electrolyte value that 1) stimulated constructive assessment of the patient's condition (monitoring, reevaluation of nonspurious laboratory values, or admission), 2) led to further diagnostic studies, 3) led to a new diagnosis, or 4) affected therapy, χ2 recursive partitioning was used to derive a decision rule for ordering electrolytes.

Results: Of 715 eligible patient visits, 488 (68%) electrolyte panels contained a laboratory abnormality, with 182 (25%) CSEAs. A decision rule requiring 1 of 6 clinical criteria was 100% sensitive (95% CI 98–100%) and 24% specific (95% CI 21–28%) in detecting CSEAs with positive and negative predictive values of 31% (95% CI 28–34%) and 100% (95% CI 97–100%), respectively. If these criteria had been used to screen patients for whom electrolyte panels were ordered, 128 patients (18%) would not have had electrolyte panels obtained and no CSEAs would have been missed.

Conclusion: A set of clinical criteria was derived that may be useful for limiting electrolyte panels ordering in children. This criterion set requires prospective validation in a separate patient population.
Case Management by Physician Assistants and Primary Care Physicians vs Emergency Physicians
Authors: Hirshberg Alan J. , Holliman C. James , Wuerz Richard C. , Chapman Dane M.
Published: September 2008

Objectives: To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs).

Methods: An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed.

Results: The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows:

Conclusion: The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.
Analysis of Alcohol Use Clusters among Subcritically Injured Emergency Department Patients
Authors: Minugh P. Allison , Nirenberg Ted D. , Clifford Patrick R. , Longabaugh Richard , Becker Bruce M. , Woolard Robert
Published: September 2008

Objectives: 1) To cluster patients according to self‐reported drinking patterns using cluster analysis; 2) to externally validate clustered groups on variables related to drinking but not used in the cluster analysis; and 3) to use the clustered patients' responses to alcohol consumption questions to develop a brief screening tool emergency physicians can use to identify patients in need of referral or intervention related to potentially hazardous alcohol consumption.

Methods: A self‐report battery was administered to 95 subcritically injured patients. Patients also were saliva alcohol‐tested upon arrival to the ED. Using the patients' self‐reported quantity, frequency of alcohol consumption, and frequency of having ≥6 drinks on a drinking occasion, patients were categorized into 3 groups using cluster analysis. The 3 clusters were externally validated using injury‐related variables, alcohol‐related consequences, and the patients' reported readiness to change drinking. A screening tool was developed using cutoff values reported by the patients' answers to drinking pattern questions.

Results: Fifty‐nine patients were alcohol‐negative, and 36 tested alcohol‐positive (i.e., >4 mmol/L [>20 mg/ dL]) or had elevated scores on an alcohol problem screening instrument. Three distinct drinking pattern clusters were found. Clusters were validated using discriminant function analysis and multivariate analyses of variance to confirm cluster classifications. Steady and high‐intensity drinkers reported more alcohol‐related negative consequences, and high‐intensity drinkers indicated they would consider changing their drinking. The screening tool correctly classified 97% of the patient sample into their respective clusters.

Conclusions: Using the drinking pattern questions in the clustering procedure was effective for grouping injured patients into clusters that could be differentiated on other drinking‐related variables. The resulting screening tool can be used in the ED setting to screen patients for further assessment and intervention. The readiness‐to‐change results support the assertion that the injury event provides a “teachable moment” for subcritically injured patients whose injury may be related to their alcohol consumption.
Proper Depth of Placement of Nasotracheal Tubes in Adults Prior to Radiographic Confirmation
Authors: Reed David B. , Clinton Joseph E.
Published: September 2008

Objective: To determine the optimal initial depth of tube placement in nasotracheal intubation (NTI) of adult patients, measured at the naris, prior to obtaining a chest radiograph (CXR).

Methods: Part 1: A prospective, observational study was performed to compare the initial depth of NTI, measured at the naris, with the observed height of the endotracheal tube (ETT) tip above the carina on the initial CXR. Optimal depths were predicted by gender. Part 2: Results from Part 1 were prospectively validated by measuring the frequency of adequate placement when ETTs were placed to this depth. ETT placement was considered adequate if the tip was at least 2 cm above the carina and below the larynx on the CXR.

Results: Part 1: The mean depth measured at the naris was 27.5 ± 1.5 cm in women (n = 50) and 27.8 ± 1.0 cm in men (n = 74). The mean distance of the tip of the ETT to the carina was 3.9 ± 2.7 cm in women and 6.4 ± 2.2 cm in men. Initial tube position was adequate in 39 (78%) of the women and 72 (97%) of the men. It was determined that if a depth of 26 cm had been used in the women and 28 cm in the men, 45 (90%) of the women and 70 (95%) of the men would have had adequate tube placement, resulting in statistically significant improvement of placement in the women (p < 0.05; McNemar & chi2)‐ Part 2: These calculated depths (26 and 28 cm) were then prospectively applied in 26 women and 52 men. Twenty‐five (96%) of 26 women and 51 (98%) of 52 men had adequate placement, with a mean height above the carina of 4.5 ±1.4 cm in women and 5.6 ± 1.8 cm in men.

Conclusion: Initial placement of NTI at 26 cm in women and 28 cm in men, measured at the naris, resulted in adequate initial placement for most adult patients.
Comparison of Routes of Flumazenil Administration to Reverse Midazolam‐induced Respiratory Depression in a Canine Model
Authors: Heniff Melanie S. , Moore Gregory P. , Trout Anne , Cordell William H. , Nelson David R.
Published: September 2008

Objective: To determine whether flumazenil, a drug used to reverse benzodiazepine‐induced respiratory depression and approved only for IV use, is effective by alternative routes.

Methods: A randomized, controlled, nonblinded, crossover canine trial was performed to evaluate reversal of midazolam‐induced respiratory depression by flumazenil when administered by alternative routes. Mongrel dogs were sedated with thiopental 19 mg/kg IV, then tracheally intubated. With the dogs spontaneously breathing, tidal volume, end‐tidal CO2, and O2 saturation were observed until a stable baseline was achieved. Incremental doses of midazolam were administered until respiratory depression (30% decline in tidal volume, 10% decrease in O2 saturation, and 15% increase in end‐tidal CO2) occurred. Flumazenil was administered by a randomly selected route [0.2 mg followed 1 minute later by 0.3 mg IV, sublingual (SL) or intramuscular (IM); or 1 mg followed 1 minute later by 1.5 mg per rectum (PR)]. Time to return to baseline respiratory functions was recorded (“time to reversal”). Each of 10 dogs was studied using all 4 routes of flumazenil administration with a washout period of at least 7 days. An additional dog served as a control (no flumazenil).

Results: The control time to reversal was 1,620 seconds. The IV route was significantly faster (mean 120 ± 24.5 sec) than the other 3 routes (p < 0.005). The SL route was the second fastest (mean 262 ± 94.5 sec), the IM route was the third fastest (mean 310 ± 133.7 sec), and the PR route was the slowest (mean 342 ± 84.4 sec). The SL, IM, and PR routes did not differ significantly from one another.

Conclusions: Flumazenil administered by all 4 routes reversed midazolam‐induced respiratory depression in a dog model. For the selected dosages used, the IV route was significantly faster than all 3 other routes, and SL was the second fastest.
Incidence of Deep Venous Thrombosis Associated with Femoral Venous Catheterization
Authors: Mian Nabeela Z. , Bayly Robert , Schreck David M. , Besserman Eva B. , Richmond David
Published: September 2008

Objective: To determine in adult medical patients the incidence of deep venous thrombosis (DVT) resulting from femora] venous catheterization (FVC).

Methods: A prospective, observational study was performed at a 420‐bed community teaching hospital. Hep‐arin‐coated 7‐Fr 20‐cm femoral venous catheters were inserted unilaterally into a femoral vein. Each contra‐lateral leg served as a control site. Age, gender, number of FVC days. DVT risk factors, administration of DVT prophylaxis, and DVT formation and site were tabulated for each patient. Venous duplex sonography was performed bilaterally on each patient within 7 days of femoral venous catheter removal.

Results: Catheters were placed in 29 men and 13 women. Femoral DVT was identified by venous duplex sonography in 11 (26.2%) of the FVC legs and none (0%) in the control legs. Posterior tibial and popliteal DVT was identified in both the FVC and control legs of 1 patient. DVT formation at the site of FVC insertion was highly significant (p = 0.005). There were no statistically significant associations with age (p = 0.42), gender (p = 0.73), number of DVT risk factors (p = 0.17), number of FVC days (p = 0.89), or DVT prophylaxis (p — 099).

Conclusion: Placement of femoral catheters for central venous access is associated with a significant incidence of femoral DVT as detected by venous duplex sonography criteria at the site of femoral venous catheter placement. Physicians must be aware of this risk when choosing this vascular access route for adult medical patients. Further studies to assess the relative risk for DVT and its clinical sequelae when using the femoral vs other central venous catheter routes are indicated.
Medically Unnecessary Pediatric Ambulance Transports: A Medical Taxi Service?
Authors: Camasso‐Richardson Karen , Wilde James A. , Petrack Emory M.
Published: September 2008

Objective: To characterize ambulance utilization in a pediatric population and pediatric emergency physicians' judgment of the medical need for ambulance transport.

Methods: A convenience sample of ambulance transports were studied prospectively during a 5‐week period. Exclusion criteria included transfer from another medical facility, study physician not available, need for immediate resuscitation, or trauma team activation. A questionnaire completed by the physician assessed medical need for the ambulance based on chief complaint, general appearance, vital signs, and ambulance run sheet information. A separate questionnaire was administered to the parents regarding reasons for ambulance use and other available means of transportation. Caregivers were contacted by telephone 2–3 days later to determine the mode of transportation home and the clinical outcome.

Results: Of 172 eligible patients, 92 (53%) were enrolled. Most (61%; 56/92) transports were considered medically unnecessary. Interestingly, 40% (37/92) of the subjects had no other means of transportation; 86% (32/37) of ambulance transports for this group were judged medically unnecessary. Overall, 86% (79/92) of families had not called their physician. There was no association between having spoken with the physician and medical need for an ambulance. Many (82%; 46/56) Medicaid transports were judged medically unnecessary. Overall, follow‐up was achieved for 91% (85/92) of the patients. No patient for whom transport was medically unnecessary had a repeat ED visit for the same complaint or required admission. Most patients (74%; 68/92) returned home without any assistance. Among the medically unnecessary transports, 52% (32/ 60) of the caregivers cited no other means of transportation, yet 34% (11/32) of these patients returned home by private car.

Conclusions: Most pediatric ambulance transports in this sample, which excluded patients requiring immediate resuscitation or trauma team care, were judged to be medically unnecessary. Caregivers often use an ambulance as a convenience or as the only means of transportation. An alternate, less resource‐intensive transportation system may be more appropriate for this population.
Alkalinization Is Ineffective for Severe Hyperkalemia in Nonnephrectomized Dogs
Authors: Kaplan Justin L. , Braitman Leonard E. , Dalsey William C. , Montgomery Michael , Mangione Antoinette ,   Hyperkalemia Research Group
Published: September 2008

Objective: To determine whether alkalinization with sodium bicarbonate (NaHCO3) in near‐lethal hyperkalemia either lowers potassium (K) rapidly or shortens duration of cardiac conduction disturbances. Methods: A controlled canine laboratory investigation of 3 treatments for severe hyperkalemia. Conditioned dogs (n = 8; 17–30 kg) received, in random order, 2 mmol/kg of each of 3 treatments (matched in sodium and water) in separate experiments ≥1 week apart: 1.05% NaHCO3 over 60 minutes (infusion therapy); 8.4% NaHCO3 over 5 minutes, then 14 mL/kg sterile water over 55 minutes (bolus therapy); 8.4% NaCl over 5 minutes, then 14 mL/kg sterile water over 55 minutes (saline therapy). Prior to administering one of the above therapies, the animals were anesthetized with 0.5–2.5% isoflurane and ventilated to maintain a normal Pco2. After 30 minutes of equilibration, 2 mmol/kg/hr (loading dose) of a 2‐mmol/mL KCl solution was given until idioventricular or relative junctional bradycardic dysrhythmias were sustained for 15 minutes. Then KCl was decreased to 1 mmol/kg/hr (maintenance dose) for 2 hours and 45 minutes. Treatment was begun after 45 minutes of maintenance KCl infusion.

Results: The pretreatment K level (all studies) was 9.06 ± 0.82 mmol/L (mean ± SD). Although the mean K level decreased more after saline therapy than after bolus therapy at every time, differences were neither statistically significant nor clinically important during the first 30 minutes. The means of the differences in decreases (saline minus bolus) were small, 0.26 (95% CI, ‐0.48 to 1.00) at 15 minutes, 0.16 (95% CI, ‐0.67 to 0.98) at 30 minutes. Dysrhythmia duration was shorter with bolus therapy than for saline therapy in only 1 of 5 dogs (p = 0.38).

Conclusions: Hypertonic saline bolus lowered plasma K as effectively as NaHCO3 bolus in this animal model within the first 30 minutes. Clinically meaningful decreases due to alkalinization alone within 30 minutes are unlikely.
Efficacy of Atropine Sulfate in Combination with Albuterol in the Treatment for Acute Asthma
Authors: Díaz José E. , Dubin Reva , Gaeta Theodore J. , Pelczar Peter , Bradley Keith
Published: September 2008

Objective: To determine the efficacy of combination therapy using atropine sulfate and albuterol in the treatment for an acute exacerbation of asthma.

Methods: A prospective, randomized double‐blind, placebo‐controlled study was performed in the ED of a large, inner‐city, university‐affiliated teaching hospital. Participants were a convenience sample of patients presenting to the ED between September 1993 and March 1994 with acute exacerbations of their asthma. Patients judged to be in extremis were excluded. All patients received 3 nebulized treatments with 2.5 mg of albuterol at 0, 30, and 60 minutes. Patients were randomized into 1 of 3 groups with the following added to their nebulizer solutions: 1) saline placebo during all 3 treatments; 2) 2.0 mg atropine sulfate added to the first nebulizer and saline in the second and third; or 3) 2.0 mg atropine to the first and third treatments (with saline in the second). No other medication was administered during the study period. At 90 minutes, the patients were evaluated for admission or release from the ED according to predetermined criteria, and additional medications were given as necessary. Vital signs, peak expiratory flow rate (PEFR), degree of wheezing, level of distress, and side effects were measured before and after each nebulizer treatment. Results: Of the 153 patients eligible for the study, 126 completed the entire study protocol. There was no significant difference between the 3 groups on any parameter studied, including improvement of PEFR, vital signs, or level of distress. There was no difference in the admission rate between the 3 groups, nor was there a difference in the incidence of side effects among the groups.

Conclusion: In this study population, combination therapy with atropine sulfate and albuterol offered no significant benefit over the use of albuterol alone in the treatment for acute exacerbation of asthma.
Mortality and Morbidity Associated with the Distribution of Monthly Welfare Payments
Authors: Verheul Glenn , Singer Sharon Manson , Christenson James M.
Published: September 2008

Objective: The impact of major social policy decisions on community health is rarely considered or analyzed. This article describes the association of major community and health resource use in relation to the distribution of monthly welfare payments.

Methods: A descriptive, retrospective study was performed using existing accessible databases in the city of Vancouver, British Columbia (BC), and St. Paul's Hospital, a tertiary care, downtown institution. The mean numbers of admissions or responses per week and per day related to the monthly welfare check issue day in 1993 were collected from the following health agencies: the BC Ambulance Service, the Vancouver Fire Department, the BC Coroner's Office, the Vancouver Detox Center, the Vancouver City Police Jail for public drunkenness, and St. Paul's Hospital ED.

Results: Comparison of weekly events for non‐payweeks vs the week starting on welfare payday (mean ± SD) are: St. Paul's ED, 949 ± 51 vs 993 ± 81 (p = 0.10); Detox Center observation admissions, 29 ± 5.6 vs 40 ± 7.3 (p < 0.001); Vancouver Fire Department medical responses, 453 ± 44 vs 527 ± 45 (p < 0.001); BC Ambulance Service responses, 3,338 ± 101 vs 3,634 ± 85 (p < 0.001); and coroner‐reported deaths, 8.8 ± 3.0 vs 13.6 ± 2.6 (p < 0.0001).

Conclusions: As measured in multiple independent databases, there is a significant increase in morbidity and mortality in the week after the distribution of monthly welfare paychecks.
Advantage of High‐surface‐area Charcoal for Gastrointestinal Decontamination in a Human Acetaminophen Ingestion Model
Authors: Roberts James R. , Gracely Ed. J. , Schoffstall John M.
Published: September 2008

Objective: To compare the abilities of low‐surface‐area (LSA) vs 2 types of high‐surface‐area (HSA) activated charcoal given orally to adsorb acetaminophen in the gastrointestinal (GI) tract, as demonstrated by the impact of these agents on the serum levels and area under the curve (AUC) in a simulated human overdose model.

Methods: The main arm of the study was a prospective double‐blind crossover trial in which 6 volunteers, serving as their own controls, ingested acetaminophen (50 mg/kg), followed randomly in 10 minutes by either powdered LSA charcoal (950 m2/g) or powdered HSA charcoal (2,000 m2/g) in a charcoal:drug ratio of 8:1. In a second arm of the study, 3 subjects additionally ingested an equal dose of a granular preparation of the HSA charcoal. Serial serum acetaminophen levels were analyzed at various intervals (30, 60, 90, 120, 180, 240, and 300 minutes postingestion), and a 5‐hour AUC was calculated. The subjects also rated the charcoal preparations for palatability.

Results: Serum acetaminophen levels were lower at all measured times in the groups receiving both forms of the HSA charcoal vs the LSA product. With the powdered HSA charcoal, comparison serum levels were significantly lower at 120 minutes postingestion and all times thereafter (p < 0.05), reaching high significance at 4 and 5 hours (p < 0.001). The subjects receiving the granular HSA charcoal also had consistently lower serum acetaminophen levels than did those receiving the LSA product, and the difference in mean serum levels was significant at the 4‐ and 5‐hour sample (p = 0.012). Compared with the LSA charcoal, at the 4‐hour postingestion sample, serum acetaminophen levels were reduced by 44% to 85% by the powdered HSA charcoal. The total AUC for the 5‐hour study period was also significantly reduced by the powdered HSA product (p = 0.005) and the granular HSA product (p = 0.043). All the subjects rated the powdered HSA charcoal to be more palatable and easier to drink than the powdered LSA charcoal.

Conclusion: The surface area of oral activated charcoal is a major determining factor in its ability to limit acetaminophen absorption and to fulfill its adsorptive role in GI decontamination. In a human acetaminophen overdose model, 2 types of HSA charcoal, when compared with equal doses of LSA charcoal, significantly reduced serum levels and total acetaminophen absorption as measured by the AUC.
Enhancement of Lithium Elimination by Multiple‐dose Sodium Polystyrene Sulfonate
Authors: Linakis James G. , Hull Keith M. , Lacouture Peter G. , Lockhart Gregory R. , Lewander William J. , Maher Timothy J.
Published: September 2008

Objective: To determine whether multiple doses of sodium polystyrene sulfonate (SPS) enhance the elimination of IV‐administered lithium (Li).

Methods: The study was a placebo‐controlled, investigator‐unblinded, murine trial of multiple doses of SPS on serum Li concentrations. Seventy‐five male CD‐1 mice were given IV pretreatment with LiCl (125 mg/ kg) followed by gavage treatments with SPS (5 g/kg/dose) 20, 40, 90, 150, and 210 minutes after LiCl (experimental group) or deionized water at equivalent times (control group). Subgroups of each treatment group were sacrificed at 1, 2, 4, and 6 hours after LiCl administration and blood was collected for Li analysis.

Results: Statistical analyses indicated that the SPS group had lower serum Li concentrations overall than did the control animals. This difference was apparent at the 2‐, 4‐, and 6‐hour time points.

Conclusion: In this murine model, repetitive doses of orogastric SPS enhanced the elimination of parenterally administered Li.
Prevalence of Positive Serology for Acute Chlamydia pneumoniae Infection in Emergency Department Patients with Persistent Cough
Authors: Wright Seth W. , Edwards Kathryn M. , Decker Michael D. , Grayston J. Thomas , Wang Sanpin
Published: September 2008

Objective: To determine the prevalence of acute Chlamydia pneumoniae infection in ED patients presenting with a persistent cough.

Methods: This was a case series consisting of a convenience sample of 65 patients ≥18 years of age who presented with a chief complaint of a cough lasting ≥2 weeks. Patients were treated in the ED of an urban university hospital. Patients with immunosuppression, lung disease, pneumonia, or a cough lasting ≥3 months were excluded. Acute and convalescent sera were assayed for antibody to C. pneumoniae. Subjects with C. pneumoniae antibody titers showing a fourfold rise in either immunoglobin M (IgM) or immunoglobin G (IgG) antibody, an IgM titer of ≥16, or an IgG titer of≥512 were considered to have evidence of acute C. pneumoniae infection.

Results: Thirteen (20%; 95% CI, 11% to 32%) of the 65 subjects had serologic evidence of acute C. pneumoniae infection. Except for an increased rate of fever, clinical signs and symptoms and laboratory studies did not differentiate those who had C. pneumoniae from those who did not have the disease. Patients diagnosed as having Bordetella pertussis or Mycoplasma pneumoniae infection did not have serologic evidence of concurrent C. pneumoniae infection.

Conclusions: C. pneumoniae infection appears to be associated with a persistent cough in ED patients. Clinicians should consider this organism when evaluating these patients. It is unclear whether antibiotic therapy is indicated for these patients. If antibiotics are used, a tetracycline or macrolide antibiotic would be most appropriate.
Prospective Crossover Study of the Effect of Phlebotomy and Intravenous Crystalloid on Hematocrit
Authors: Kass Lawrence E. , Tien Irene Y. , Ushkow Bruce S. , Snyder Howard S.
Published: September 2008

Objective: To compare the changes in hematocrit (Hct) between phlebotomized and nonphlebotomized individuals given IV crystalloid.

Methods: A prospective, crossover volunteer study was performed comparing Hct changes immediately and 30 minutes after IV crystalloid bolus in 20 healthy adults with and without prebolus phlebotomy. In the control portion, volunteers were given a 15‐mL/kg bolus of normal saline over 30 minutes with Hct determination before (H1), immediately after (H2), and 30 minutes after (H3) crystalloid infusion. At least 7 days later, the same subjects were phlebotomized 1 unit of blood and then administered a 15‐mL/kg IV bolus of normal saline 30 minutes later. Hcts were obtained before (H4) and 30 minutes after (H5) phlebotomy (immediately prior to crystalloid infusion). Hcts were also obtained immediately after (H6) and 30 minutes after (H7) crystalloid infusion. A post‐hoc test performance analysis was then performed to determine the Hct drop thresholds that would yield the maximal sensitivity and specificity for 500 mL of blood loss (via phlebotomy) in this population.

Results: The Hct (%) drops in the nonphlebotomized individuals receiving IV fluids averaged 4.5 ±1.3 immediately and 3.2 ± 1.3 30 minutes after infusion. These drops were different (p < 0.05) from the Hct drop in individuals receiving IV fluids after phlebotomy, which averaged 6.6 ± 1.5 and 5.7 ± 1.1, respectively. Post‐hoc analysis revealed that Hct drops of 5.4 immediately, or 4.3 at 30 minutes after infusion, had a sensitivity of >90% and a specificity of 75% for identification of patients in the phlebotomy group.

Conclusions: The practice of measuring serial Hcts may be helpful to identify trauma patients with occult blood loss. A prospective clinical trial is needed to validate these Hct drop thresholds (immediate and 30 minutes postinfusion) in crystalloid‐resuscitated trauma patients.
Using Age‐appropriate Prolactin Levels to Diagnose Children with Seizures in the Emergency Department
Authors: Fein Joel A. , Lavelle Jane M. , Clancy Robert R.
Published: September 2008

Objective: To assess the utility of serum and cerebrospinal fluid (CSF) prolactin levels for identifying children who have experienced seizures.

Methods: A prospective cohort study was performed in a pediatric ED at an urban children's hospital. A convenience sample of children underwent blood and CSF analyses in the ED over a 2‐year period.

Results: Thirty‐five children (aged 3 months‐15 years) with generalized tonic‐clonic seizures and 48 ill control patients were studied. Both groups included febrile and afebrile patients. The patient characteristics in the seizure and control groups were similar with respect to age, fever, current medications, and blood, urine, and CSF cultures. When serum prolactin levels were assigned age‐adjusted dichotomous values of “elevated” or “normal,” the rates of elevation between the seizure and control patients were different (p < 0.001). The positive and negative predictive values of these age‐adjusted levels were 68% (95% CI 47–85%) and 76% (95% CI 61–87%), respectively. The mean CSF prolactin levels of the seizure and control groups were not significantly different. In addition, there was no single threshold CSF prolactin level that could delineate seizure patients from control patients.

Conclusions: Age‐adjusted serum prolactin levels are useful only as an adjunct in the prospective evaluation of the individual pediatric patient for epileptic seizure activity. CSF prolactin levels are not useful in the diagnosis of generalized seizures in children in the acute care setting.
Cranial Computed Tomography in the Emergency Evaluation of Adult Patients without a Recent History of Head Trauma: A Prospective Analysis
Authors: Rothrock Steven G. , Buchanan Carlton , Green Steven M. , Bullard Tim , Falk Jay L. , Langen Michael
Published: September 2008

Objectives: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. Methods: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection, χ2 recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. Results: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age ≥60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94–100%) and 31% specific (95% CI: 28–33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8–13%) and 100% (95% CI: 98–100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed.

Conclusion: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high‐ and low‐risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.
Blood‐Brain Barrier Water Permeability and Brain Osmolyte Content during Edema Development
Authors: Olson James E. , Banks Mark , Dimlich Ruth V. W. , Evers Julie
Published: September 2008

Objective: To determine mechanisms that limit changes in brain water content during acute edema development.

Methods: A controlled, laboratory investigation of the physiologic and biochemical correlates of osmotic edema was performed in rats. Hypoosmotic hyponatremia was induced by intraperitoneal injection of distilled water. Serum osmolality and electrolytes and regional blood‐brain barrier water permeability surface area (P · S) product, osmolyte contents, and capillary size were determined during 120 minutes of hypoosmotic brain edema development. Cerebral water content predicted from these data using a mathematical model of brain water movements was compared with measured changes in brain water content.

Results: Fifteen minutes after distilled water injection, mean ± SEM blood serum osmolality and sodium concentration decreased from 291 ± 3 mOsm and 131 ± 13 mmol/L to 267 ± 3 mOsm and 102 ± 9 mmol/L, respectively. Specific gravity of cerebral gray matter, cerebral white matter, and basal ganglia decreased throughout the hypoosmotic exposure period and, for gray and white matter, correlated with blood serum osmolality and sodium plus potassium content. Glutamate, but not glutamine, glycine, or taurine, decreased 120 minutes after water injection. The regional water P · S product decreased by 40% to 60% within 60 minutes of the water injection, while capillary diameters in gray and white matter were unchanged. Brain water movements calculated from the mathematical model correctly predicted actual brain water content only if the hydraulic conductivity of the blood‐brain barrier was allowed to vary in proportion to the measured P · S product and the measured loss of brain osmolytes was incorporated into the formulation. Conclusions: During the first hours of hypoosmotic hyponatremia, changes in brain volume are limited by increased resistance to osmotic flux of water into the brain and reduction in the brain content of inorganic and, to a smaller degree, organic osmolytes.
Comparative Efficacy of Hemodialysis and Hemoperfusion in Severe Theophylline Intoxication
Authors: Shannon Michael W.
Published: September 2008

Objective: To determine the comparative efficacy of hemoperfusion and hemodialysis for severe theophylline toxicity in concurrent case series.

Methods: A 10‐year, prospective, observational study was performed of consecutive patients referred to a regional poison control center with severe theophylline intoxication in whom either hemodialysis or hemoperfusion was used. The primary outcomes were 1) incidence of major theophylline toxicity (convulsions or life‐threatening cardiac dysrhythmias) during or after each procedure, 2) calculated theophylline clearance, and 3) procedure‐related complications.

Results: Over the study period, 56 patients underwent hemodialysis or hemoperfusion as treatment of severe theophylline intoxication. Overall mean age was 40. 5 ± 22. 9 years. Mean peak serum theophylline concentration was 103. 3 ± 39. 1 μ g/mL (range 36 to 245 μ g/mL). Thirty patients (54%) were victims of acute theophylline intoxication, while 18 (32%) had chronic overmedication and 8 (14%) had acute‐on‐therapeutic intoxication. Thirty‐nine patients (70%) underwent hemodialysis, while 17 (30%) underwent hemoperfusion. There were no significant intergroup differences in age (39. 4 vs 43. 0 yr), peak serum theophylline concentration (99. 5 vs 112. 1 μ g/mL), time to procedure (8. 4 vs 6. 3 hr), or duration of procedure (4. 1 vs 3. 7 hr). Thirty‐three percent of the patients undergoing hemodialysis had major toxicity during or after the procedure, compared with 18% of those who received hemoperfusion (p = NS). Post‐procedure serum theophylline concentrations were 26. 9 vs 30. 4 μ g/mL, corresponding to drug clearance rates of 185. 1 and 294. 8 mL/kg/hr (p = 0. 03). Procedural complications occurred in 3 patients who received hemoperfusion and consisted of bleeding diatheses and hypocalcemia. No complications occurred in patients receiving hemodialysis (p = 0. 007).

Conclusions: These data confirm that hemoperfusion provides a higher theophylline clearance rate than hemodialysis. However, hemodialysis appears to have comparable efficacy in reducing the morbidity of severe theophylline intoxication and is associated with a lower rate of procedural complications.
Pilot Study of Cytokines in Emergency Department Patients with Systemic Inflammatory Response Syndrome
Authors: Terregino Carol A. , Quinn James V. , Slotman Gus J.
Published: September 2008

Objective: To determine the potential utility of cytokine and arachidonic acid metabolite levels in ED patients with systemic inflammatory response syndrome (SIRS) as a predictor of progression to severe sepsis. Methods: A prospective, observational study of test performance was performed using convenience samples of adult control subjects and admitted patients. The latter patients were identified in the ED as having signs of SIRS. Levels of cytokines and arachidonic acid metabolites measured from specimens obtained in the ED were compared between groups and associated with the progression of sepsis within 24 hours in the SIRS patients.

Results: There were 30 control patients and 29 SIRS patients. There were 8 SIRS subjects who progressed to severe sepsis within 24 hours using the following criteria (hypotension, n = 5; hypoperfusion, n = 1; and organ dysfunction, n = 2). Of the 21 SIRS subjects who did not progress to severe sepsis, 11 had resolution of SIRS criteria at 24 hours. There were no significant differences in mean mediator levels between the SIRS patients who progressed to severe sepsis and those who did not. Of the 11 patients with resolution of SIRS criteria at 24 hours, the mean interleukin‐6 (IL‐6) level was significantly lower than that for the patients who did not recover or who progressed at 24 hours (n = 18); 65.4 ± 49.1 vs 230 ±112 pg/mL, p = 0.001). Six of 15 subjects with IL‐6 >150 pg/mL progressed to severe sepsis (p = NS). Using threshold values based on the range of levels for normals, the sensitivity of an abnormal marker for the development of severe sepsis within 24 hours varied from 50% to 87%, while the specificity varied from 11% to 84%. Conclusion: While mean levels were significantly elevated when compared with those of normal control subjects, they had limited ability to predict the subset of patients likely to progress to severe sepsis. However, initial low levels of cytokines may have exclusionary prognostic value. Prospective validation of the latter finding is warranted.
New‐onset Bronchospasm or Recrudescence of Asthma Associated with Cocaine Abuse
Authors: Osborn Harold H. , Tang Mark , Bradley Keith , Duncan Brian R.
Published: September 2008

Objective: To determine whether the occurrence of new‐onset bronchospasm or the recrudescence of asthma is associated with the use of cocaine.

Methods: A consecutive sample of patients presenting to an inner‐city adult ED with new‐onset bronchospasm or recrudescence of bronchospasm after >5 years were prospectively enrolled in a case‐control prevalence study. The bronchospasm patients were queried as to their exposure to illicit drugs, and urine was obtained to screen for cocaine and its metabolite, benzoylecgonine. An age‐ and sex‐matched control group was composed of randomly chosen subjects without respiratory complaints or a history of asthma. The control group was also screened by urine toxicology for cocaine and its metabolite, benzoylecgonine. Results: In the asthma group, 21/59 (36%) had a urine toxicologic screen positive for cocaine metabolite (benzoylecgonine). Of the 21 with a positive screen for cocaine, 8 denied illicit drug abuse. Among the 13 patients reporting drug use, 10 said that they smoked crack and 3 snorted cocaine. In the control group, 8/53 (15%) were positive. Multivariate logistic regression analysis, with adjustment for age and sex, indicated that the use of cocaine was associated with a 3‐fold higher prevalence of new‐onset bronchospasm or recrudescence of asthma (OR = 3.28, 95% CI: 1.26 to 8.50).

Conclusions: There appears to be an association between cocaine use and new‐onset bronchospasm or recrudescence of asthma in this inner‐city ED population. Further study is necessary to determine the basis for this association.
Differences between Chest Pain Observation Service Patients and Admitted “Rule‐out Myocardial Infarction” Patients
Authors: Dallara John , Severance Harry W. , Davis Barbara , Schulz Gail
Published: September 2008

Objective: To compare and contrast the patient characteristics of ED patients at low risk for acute cardiac ischemia who were assigned to a chest pain observation service vs those admitted to a monitored inpatient bed for “rule‐out acute myocardial infarction” (R/O MI).

Methods: This was a retrospective, cross‐sectional comparison of adult patients considered at relatively low risk for cardiac ischemia and who were evaluated in 1 of 2 settings: a short‐term observation service and an inpatient monitored bed. All patients had an ED final diagnosis of “chest pain,” “R/O MI,” or “unstable angina” during the 7‐month study period. Demographic features and presenting clinical features were examined as a function of site of patient evaluation.

Results: Of 531 study patients, 265 (50%) were assigned to the observation service. Younger age (OR = 1.75, 95% CI 1.26, 2.44, for each decrement of 20 years), the complaint of “chest pain” (OR = 2.35, 95% CI 1.34, 4.12), and the absence of prior known coronary artery disease (OR = 1.64, 95% CI 1.13, 2.38) were the principal independent factors associated with assignment to a chest pain observation service bed. Conclusions: Patients evaluated in a chest pain observation service appear to have different clinical characteristics than other individuals admitted to a monitored inpatient bed for “R/O MI.” Investigators should address differences in clinical characteristics when making outcome comparisons between these 2 patient groups.