Poor association between 13-valent pneumococcal conjugate vaccine-induced serum and mucosal antibody responses with experimental Streptococcus pneumoniae serotype 6B colonisation.

BACKGROUND: Pneumococcal carriage is the primary reservoir for transmissionand a prerequisite for invasive pneumococcal disease. Pneumococcal Conjugate Vaccine 13 (PCV13) showed a 62% efficacy in protection against experimental Streptococcus pneumoniae serotype 6B (Spn6B) carriage in a controlled human infection model (CHIM) of healthy Malawian adults. We, therefore, measured humoral responses to experimental challenge and PCV-13 vaccination and determined the association with protection against pneumococcal carriage. METHODS: We vaccinated 204 young, healthy Malawian adults with PCV13 or placebo and nasally inoculated them with Spn6B at least four weeks post-vaccination to establish carriage. We collected peripheral blood and nasal lining fluid at baseline, 4 weeks post-vaccination (7 days pre-inoculation), 2, 7, 14 and > 1 year post-inoculation. We measured the concentration of anti-serotype 6B Capsular Polysaccharide (CPS) Immunoglobulin G (IgG) and IgA antibodies in serum and nasal lining fluid using the World Health Organization (WHO) standardised enzyme-linked immunosorbent assay (ELISA). RESULTS: PCV13-vaccinated adults had higher serum IgG and nasal IgG/IgA anti-Spn6B CPS-specific binding antibodies than placebo recipients 4 to 6 weeks post-vaccination, which persisted for at least a year after vaccination. Nasal challenge with Spn6B did not significantly alter serum or nasal anti-CPS IgG binding antibody titers with or without experimental pneumococcal carriage. Pre-challenge titers of PCV13-induced serum IgG and nasal IgG/IgA anti-Spn6B CPS binding antibodies did not significantly differ between those that got experimentally colonised by Spn6B compared to those that did not. CONCLUSION: This study demonstrates that despite high PCV13 efficacy against experimental Spn6B carriage in young, healthy Malawian adults, robust vaccine-induced systemic and mucosal anti-Spn6B CPS binding antibodies did not directly relate to protection.

The effect of working serial night shifts on the cognitive functioning of emergency physicians.

STUDY OBJECTIVE: We sought to determine whether working 5 serial night shifts in the emergency department results in a decline in physician performance as measured with an intelligence test. METHODS: This study compared the cognitive functioning of emergency physicians who worked the day shift (7 AM to 5 pm) with those who worked 5 consecutive night shifts (11 pm to 7 am). The Fluid Scale of the Kaufman Adolescent and Adult Intelligence Test (KAIT) was administered to 16 emergency medicine residents. Half of the residents (group A) were tested while working day shifts, and the other half (group B) were tested after working 5 consecutive night shifts. After a minimum interval of 2 months, the residents were retested in reverse order, with group A tested after working night shifts and group B tested while working day shifts. RESULTS: A total of 16 emergency medicine residents were tested. A paired t test was used to determine whether day-shift KAIT scores are different from night-shift KAIT scores. The mean day-shift KAIT score was 119.1 (SD=7.7), and the mean night-shift KAIT score was 107.2 (SD=10.2). This difference was significant (mean difference=11.9; 95% confidence interval 7.0 to 16.8; P <.001), with the day-shift scores being statistically higher than the night-shift scores. CONCLUSION: Working a series of 5 night shifts results in a substantial decline in cognitive performance in physicians working in the ED.

A prospective study comparing i.m. ketorolac with i.m. meperidine in the treatment of acute biliary colic.

Ketorolac is a nonsteroidal anti-inflammatory medication that is used widely for pain management. Its effects are mediated through the inhibition of prostaglandins, which makes it uniquely different from opioids in relieving pain. We conducted a randomized, prospective, double blind study of patients presenting to our Emergency Department (ED) with a diagnosis of acute biliary colic. Study patients were randomized into one of two treatment groups, meperidine 1.5 mg/kg with a maximum dose of 100 mg or ketorolac 60 mg given intramuscularly (i.m.). The patients rated their pain before and 30 min after medication on a scale of 1 to 10 using a Visual Analog Pain Scale. Overall pain relief was compared between the two groups using a two-sample t test. Thirty patients were enrolled in the study, 16 in the ketorolac group and 14 in the meperidine group. Patients ranged in age from 18 to 71 years and 6 (20%) were male. The average pain score at time 0 was 7.6 for the ketorolac group and 7.3 for the meperidine group. Pain relief at time 30 min was 3.8 in the ketorolac group and 3.9 in the meperidine group, which was not statistically different. The mean global pain score and need for an emergency cholecystectomy were similar in the two groups. Rescue medication for additional analgesia at 30 min was needed in 4 patients in the meperidine group and in 2 patients in the ketorolac group (28.6% versus 12.5%, respectively; NS). In this study of patients with acute biliary colic there was no significant difference in the pain relief achieved by using either ketorolac or meperidine.

The efficacy of sublingual hyoscyamine sulfate and intravenous ketorolac tromethamine in the relief of ureteral colic.

A prospective, randomized, open-label, single-dose study was conducted in an emergency department (ED) of a tertiary care teaching hospital to evaluate the efficacy of hyoscyamine sulfate as compared to ketorolac tromethamine for the reduction of pain from ureteral colic in the ED. Patients were included if they were at least 18 years of age and presented to the ED with an initial history and physical examination consistent with ureteral colic. Ureteral calculi were confirmed by ultrasound or intravenous urogram. Consecutive patients were randomized to either a single sublingual dose of 0.125 mg of hyoscyamine sulfate or a single intravenous dose of 30 mg of ketorolac tromethamine given over 1 minute. After 30 minutes, if analgesia was inadequate, patients were given rescue medication. Baseline pain scores were obtained using a horizontal, 100-mm visual analog scale. Additional pain scores were obtained at 10-minute intervals for 30 minutes. Upon completion of the study, both patients and physicians completed a global assessment score questionnaire. Fifty-four evaluable patients were randomized. Demographics and baseline pain scores were similar for each group. Decreasing trends in pain over time were observed for both treatment groups, with significantly greater pain reduction observed with ketorolac tromethamine as compared to hyoscyamine sulfate. Global evaluations of pain relief revealed better results in the ketorolac tromethamine group than in the hyoscyamine sulfate group, although this result was not statistically significant.

A 10-year experience in the use of air medical transport for medical scene calls.

OBJECTIVE: The objective of this retrospective descriptive study was to evaluate the use of air medical services in response to medical scene calls for transport to tertiary care in the rural setting. METHODS: This study is a retrospective descriptive review of all medical scene calls during a 10-year study period. The cases were analyzed for demographics, transport time, medical indication, procedures, role of ground EMS services, effects on community hospitals, and patient outcomes. A case-by-case review by emergency medicine (EM) physicians was conducted to determine necessity of air medical transport. RESULTS: A total of 8106 medical flights were conducted during the study period. Of these, 103 were scene calls for which 85 charts were available for review. The breakdown of medical scene calls is cardiac (29%), poisoning (17%), co poisoning (11%), neurologic (11%), and other (32%). Ground EMS was involved in 80% of the cases; ground advanced life support (ALS) was present in 58%. In 86% of the flights reviewed, an EM resident was aboard the helicopter. Of the 85 patients whose charts were available, 41 required admission to the ICU, five required hyperbaric oxygen (HBO) treatment, and 14 died before admission. CONCLUSION: Evacuation of the rural patient with a medical emergency accounts for an extremely small percentage of an air medical service's use. ALS services, including emergency procedures at the scene and rapid transport to a tertiary care, were provided. Seventy-one percent of the flights reviewed required transport to a tertiary care facility, indicating that air medical transport was appropriate. Physician guidelines to ensure effective and cost-efficient use of these services should be developed. Responding for victims in cardiopulmonary arrest appears to provide little benefit with respect to outcome.

Emergency department presentation of patients with conversion disorder.

OBJECTIVE: To describe the presenting symptoms and other features of ED patients diagnosed as having conversion disorder. METHODS: A retrospective chart review was carried out on the records of ED patients who had had final ED or in-hospital diagnoses of conversion disorder. Cases from 1982 to 1992 at a 566-bed rural tertiary care hospital with a residency program in emergency medicine were reviewed for patient age and gender, presenting signs and symptoms, ED diagnostic evaluation, disposition, and comorbidity. RESULTS: Of 42 patients who had conversion disorder diagnoses, 24 were women and 18 were men. Twenty-one (50%) of the patients were diagnosed in the ED, and of those patients, ten were released home from the ED. Patient age ranged from 5 to 70 years, with a mean age of 33 years for women and 34 years for men. Most clinical symptoms mimicked neurologic disorder (weakness, pain, seizure-like activity, loss of consciousness, etc). Thirty patients (71%) received laboratory studies in the ED and two others received laboratory studies on admission. Seventeen (40%) patients had computed tomography of the head and five (12%) patients had magnetic resonance imaging of the head. Twelve (29%) patients had previous histories of psychiatric disorders, four (10%) had histories of alcohol and drug abuse, two (5%) had prior conversion reactions, three (7%) had chronic illnesses, and four (10%) had been victims of previous head trauma. CONCLUSION: Patients with conversion disorder in the ED usually present with neurologic symptoms and undergo multiple diagnostic tests. Comorbidity is common. Early psychiatric evaluation may assist in the diagnosis and evaluation of patients with suspected conversion disorder in the ED.

Patient outcome using medical protocol to limit "lights and siren" transport.

INTRODUCTION: Emergency medical services vehicle collisions (EMVCs) associated with the use of warning "lights and siren" (L&S) are responsible for injuries and death to emergency medical services (EMS) personnel and patients. This study examines patient outcome when medical protocol directs L&S transport. DESIGN: During four months, all EMS calls initiated as an emergency request for service and culminating in transport to an emergency department (ED) were included. Medical criteria determined emergent (L&S) versus non-emergent transport. Patients with worsened conditions, as reported by EMS providers, were reviewed. SETTING: Countywide suburban/rural EMS system. RESULTS: Ninety-two percent (1,495 of 1,625) of patients were transported nonemergently. Thirteen (1%) of these were reported to have worsened during transport, and none of them suffered any worsened outcome related to the non-L&S transport. CONCLUSION: This medical protocol directing the use of warning L&S during patient transport results in infrequent L&S transport. In this study, no adverse outcomes were found related to non-L&S transports.

The 'ring sign': is it a reliable indicator for cerebral spinal fluid?

STUDY OBJECTIVE: To study the development of a ring sign when blood is mixed with various fluids. METHODS: One drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the specimens were examined after ten minutes for the development of a ring. A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. RESULTS: All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. The type of filter paper did not affect the development of a ring. CONCLUSION: In this experimental setting, the ring or halo sign is reliable for detecting cerebrospinal fluids but is not exclusive for cerebrospinal fluid.

Duodenal obstruction by a nondeflating Foley catheter gastrostomy tube.

We report the case of a 36-year-old mentally retarded man who presented to our emergency department after one day of vomiting and one episode of coffee-ground emesis. The Foley catheter used as his gastrostomy tube was found to be obstructing the duodenum, and the balloon could not be deflated. Removal was accomplished by rupturing the balloon by endoscopy. Our case illustrates one of many possible complications of feeding gastrostomy tubes.

Vascular injury following disc surgery.

The case of a patient who suffered a vascular injury following lumbar disk surgery is presented. She presented to the emergency department for evaluation of hypotension and congestive heart failure, which occurred acutely several days after her surgery. At angiography, a large A:V fistula was demonstrated between the aorta and vena cava. The diagnosis and pathophysiology of this complication of lumbar disc surgery is discussed.

Detectability of drug tablets and capsules by plain radiography.

This study was undertaken to determine the detectability of drugs in tablet or capsule form by plain radiography. A total of 459 drugs in tablet or capsule form were radiographed in water with parameters commonly used in routine upper abdominal films. Detectability was judged subjectively by radiologist's readings and objectively by the use of a densitometer. Of the total, 6.3% were as radiopaque as a ferrous sulfate control tablet, 29.6% were moderately radiopaque, but less than control values, and 64% were essentially nondetectable. Potential benefits of this information in the clinical setting are discussed.

Rural interhospital helicopter transport of motor vehicle trauma victims: causes for delays and recommendations.

One hundred twenty-six consecutive ACS Category I motor vehicle trauma patients transported by helicopter from 25 hospitals to a regional trauma center in rural Pennsylvania during a 14-month period were reviewed retrospectively. The overall mortality was 13%. Average round-trip distance was 79 miles. Interventions by the medical flight team (emergency physician/nurse) included endotracheal intubation, tube thoracostomy, and/or central venous access in 42 patients (33%) prior to lift-off. Ground time at the referring facility, from landing to lift-off, when no interventions were required of the flight team, averaged 31.2 minutes (baseline). Ground time when major therapeutic interventions were required (principally airway management), however, averaged 57.4 minutes, an 84% increase over baseline (P less than .01). A major cause of the excessive ground times was the lack of standardized diagnostic workup and stabilization of patients prior to arrival of the flight team. Recommendations for standardized emergency department preparation of trauma victims requiring aeromedical evacuation are made.

Rapid flow rates for the resuscitation of hypovolemic shock.

Nine dogs were hemorrhaged to approximately 40% of their blood volume and then were resuscitated with a crystalloid solution (Normosol) at various flow rates. Three study groups with three dogs in each group were resuscitated at 15 mL/min/kg (Group 1), 6 mL/min/kg (Group 2), and 4 mL/min/kg (Group 3). Central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), mean arterial pressure, and cardiac output (CO) were monitored during the hemorrhage and the resuscitation from shock. During the infusion of fluids, Group 1 animals demonstrated an elevation of the PAWP of 31 mm Hg and elevation of CVP to 23.2 mm Hg; CO rose to 8.4 L/min. In Group 2 animals CO rose to 6.1 L/min; CVP was 10.5 mm Hg; and PAWP was 25 mm Hg. Group 3 animals had a rise in CO to 5 L/min; CVP and PAWP rose to 4.5 mm Hg and 6.8 mm Hg, respectively. In this experimental shock study, infusion of crystalloids at 6 mL/min/kg appeared to result in an improved physiologic response, although no statistical difference was demonstrated. Further studies are necessary to demonstrate the optimum flow rate for resuscitation of hypovolemic shock using crystalloids.

Degloving injury of the mandible.

A young boy fell off his bicycle, striking his face on the pavement. On arrival in the emergency department, his only apparent injuries were facial abrasions; however, further examination of his oral cavity revealed that the soft tissues overlying the mandible had been stripped from the bone. Oral Surgery was consulted and the patient was taken to the operating room, where debridement and primary closure of the wound was performed under general anesthesia. Soft tissue injuries that result from a shearing or stripping force are termed degloving injuries, which are described best in relation to injuries of the hand, although other body parts can be involved. We report the case of a degloving injury of the mandible, an injury that has not been reported previously.

The scavenger device for nitrous oxide administration.

Nitrous oxide levels of 300 to 500 ppm occur when nitrous oxide is administered in the emergency department using the Nitronox machine without use of the scavenger device, which traps expired nitrous oxide gases and vents them to the outside environment. A scavenger device that can limit nitrous oxide gas to zero ppm in the emergency department setting has been developed. We think that development of the scavenger device is a significant advance for the safe administration of nitrous oxide in the emergency department.

Traumatic disruption of the brachiocephalic artery.

We report the case of a patient presenting with blunt chest and head injuries. Initial emergency department evaluation revealed a pulmonary contusion and suspected closed head injuries. Computed tomographic scan of the head was unremarkable. An angiogram performed to further investigate the nature of his head injuries revealed a disruption of the brachiocephalic artery. The lesion was surgically repaired in the operating room and the patient was moved to the intensive care unit, where he remained comatose and died from complications of his head and chest injuries on the seventh post-operative day. The pathophysiology and clinical manifestations of injuries to the brachiocephalic artery are discussed.

The rural interhospital disaster plan: some new solutions to old problems.

The rural area is not immune to multi-casualty incidents, and the complete rural EMS System reported here includes a plan to deal with one. The Susquehanna Valley Health Care Consortium was developed with this in mind, and addresses the points pertinent to the rural setting, including the large area served, available medical care, prehospital transport, and communications. Six hospitals in five counties participate. New approaches to these problems, which emerged after three field tests, are: participants must be organized for successful triage and resuscitation; crowd and traffic control by police is mandatory; an overall commander is necessary; two-way communication by several methods must be available; an administrator should track all victims; and air evacuation capability should be arranged.

Nitrous oxide levels in the emergency department.

Levels of nitrous oxide were monitored in the emergency department during the use of a Nitronox machine after four and eight minutes of breathing gas. Levels near the user's head were found to be 800 to 1,200 parts per million. Levels at the center of the room peaked at 300 ppm after eight minutes of use, and spot checks in the emergency department hall adjacent to the test room were less than 10 ppm. Ventilation was measured in the test room and was found to influence the peak level of nitrous oxide and the rapidity of washout of the gas from the room. The results of this study should prompt the development of guidelines for the use of nitrous oxide in the emergency department setting.