Cerebral air embolism in asthmatic scuba divers in a swimming pool.

Significant shallow-water injuries can occur in scuba divers, even in swimming pools. Two asthmatic patients are presented who sustained cerebral air emboli during Scuba classes in a swimming pool. Such injuries may be more common in asthmatics. Asthma is a contraindication to Scuba diving.

Perestroika and health care in the USSR: innovations in state financing.

The budget of the USSR Ministry of Health has steadily been shrinking during the period 1960-1985 as a proportion of the standard measure of national productivity. In the age of perestroika, however, the Ministry of Health and various units within it have instituted a number of innovative attempts to increase available funds and resources on one hand, and make facilities operate more efficiently on the other. Some of these strategies include the expansion of pay polyclinics and hospitals, the institution of self-financing and cost accounting procedures, the initiation of health insurance forms of reimbursement, more control over the budget at lower levels, and the geographical reorganization of health care facilities. There are concerns about the effectiveness of these innovations, and the issue of quality of care. It is not clear which if any of these innovations will achieve the desired goals.

Fixing EMTALA: what's wrong with the Patient Transfer Act.

Congress primarily enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986 to prevent the denial of care to uninsured patients in emergency departments. The final version of EMTALA lacks specific protection for indigent patients and saddles hospitals and physicians with more liability than Congress initially intended. Loopholes in the law allow denial of care to patients when temporarily stabilized. Congress should ameliorate these problems through amendment of the law.

Scholarship support for Indian students in the health sciences: an alternative method to address shortages in the underserved area.

The University of New Mexico Area Health Education Center was established in conjunction with the Navajo Health Authority to begin health manpower development immediately in the Navajo Nation and surrounding areas (a territory approximately the size of West Virginia). To this end, a student support program was established at the Navajo Health Agency to recruit and support Indian students with scholarships, to provide them with culturally based counseling, and to reinforce the students' intentions of ultimately returning to serve Indian people. No payback penalties or other forms of coercion were used in this program to encourage students to return to the underserved Indian areas.From October 1973 through September 1977, 124 students graduated with 125 degrees or certificates in all aspects of health care. Of these 124 students, 76 were employed. The remaining were continuing their education, unemployed, untraceable, or deceased. Of the 76 employed, 61 were from tribes within the Navajo Nation; of these 61, 56 returned to their area to serve Indians. This return rate to an underserved area is substantially better than anticipated from a review of programs that employ a variety of coercive methods to encourage recipients of loans to settle in specific underserved areas after the necessary training.

Varying presentations of methemoglobinemia: two cases.

The cases of two patients with methemoglobin levels approaching 30% are presented. No history of exposure to an oxidant was ever determined for the first case; the second patient had taken amyl nitrate orally along with alcohol as well as a self-injected narcotic and antihistamine. Due to their symptomatology, both patients were treated with methylene blue with good results; however, the patient described in case one had a brief episode of symptoms and pulse oximetry changes, not previously emphasized, consistent with the administration of methylene blue. The pathophysiology of methemoglobinemia, the utility of bedside diagnostic techniques, and the use of pulse oximetry are discussed.

Pulmonary embolism with ST segment elevation in leads V1 to V4: case report and review of the literature regarding electrocardiographic changes in acute pulmonary embolism.

A 62-year-old man presented to the Emergency Department (ED) after having three short syncopal episodes earlier that day soon after experiencing acute onset of shortness of breath. He had no significant past medical history and was a nonsmoker. Initially in the Emergency Department he was without any complaints, but then became acutely short of breath and hemodynamically unstable and died despite resuscitative efforts. His electrocardiogram showed ST segment elevations in leads V1 to V4, which is consistent with an anteroseptal myocardial infarction. Autopsy revealed that this patient did not have a myocardial infarction, but rather died of a pulmonary embolism (PE). This case demonstrates how a PE can mimic an anteroseptal myocardial infarction on electrocardiogram. This patient's lack of risk factors for PE also makes this case unusual.

Emerging public health issues in Alaska: occupational and environmental health.

The principal purpose of this article is to examine selected Alaskan occupational and environmental health problems and associated issues. Specifically, we focus on two traditional areas of interest in occupational and environmental health: 1) Job-related injuries, illnesses, and fatalities, and 2) accidental spills and uncontrolled waste sites involving hazardous materials. In 1986 the Alaska Department of Labor reported 13,154 recordable occupational injuries and illnesses among workers in the private sector. The injury rate for private sector workers was 10.2 cases per 100, compared to a rate of 7.9 for the U.S. private sector as a whole. There are approximately 550 known hazardous waste sites in Alaska identified by military, other federal, or state sources. One study documents 1,330 hazardous materials incidents in Alaska during a one year period. Effective public health policy for these occupational and environmental health hazards requires the development of an adequate database and a specific plan of action for the future.

Acceptance of the physician assistant by nonphysician health professionals in the Indian Health Service.

A survey of 55 licensed practical nurses, registered nurses and pharmacists in the Indian Health Service was conducted to determine attitudes about the use of physician assistants (PAs). The results tend to support findings of similar studies reported in the literature, but performed in other settings. Overall the PAs appear to have gained general acceptance among nonphysician health professionals. There are significant differences between the responses of LPNs and RNs, with the latter perceiving more conflict with PAs and being less supportive of the emergence of the role. Separation of the responses of LPNs and RNs, at least in this setting, appears to be an important distinction in the analysis and understanding of staff acceptance. Pharmacists were generally approving of the skill levels the PAs demonstrated in areas related to pharmacy, and tended to be intermediate in their response rates relative to LPNs and RNs in overall acceptance of the PA role.

A novel microtubule protein in the marginal band of human blood platelets.

A characterization is reported of the major cytoskeletal protein, called IEF (isoelectric focusing)-51K, of marginal band microtubule coils from human blood platelets (Kenney, D. M. and Linck, R. W. (1985) J. Cell Sci. 78, 1-22). IEF-51K is a unique biochemical species which is distinguishable from platelet and mammalian neuronal alpha-tubulin and beta-tubulin by 1) its faster mobility on discontinuous sodium dodecyl sulfate electrophoresis corresponding to an apparent Mr 51,000; 2) its more alkaline relative isoelectric point at pH 5.7 compared with that of alpha- and beta-tubulin at pH 5.3 and 5.5, respectively; 3) lack of coincidence in peptide maps prepared with chymotrypsin or Staphylococcus aureus V8 protease; and 4) lack of immunochemical cross-reactivity of polyclonal anti-IEF-51K with alpha- and beta-tubulin and of monoclonal anti-alpha-tubulin and anti-beta-tubulin with IEF-51K. In contrast to its chemical uniqueness, IEF-51K is tubulin-like in some of its properties. IEF-51K is localized in the marginal band of intact platelets by immunofluorescence; it undergoes cycles of microtubule disassembly/reassembly both in vitro and in vivo. Furthermore, IEF-51K was not extracted from isolated Taxol-stabilized marginal band microtubules by elevated NaCl concentrations (to 0.45 M), conditions that do not disrupt the polymeric structure of alpha- and beta-tubulin. These results indicate that IEF-51K together with alpha-tubulin and beta-tubulin are the major structural polypeptides of platelet marginal band microtubules. The unusual subunit composition of the platelet marginal band microtubule may be related to specialization(s) of microtubule structure and function in the marginal band coil of platelets.

Treatment of a cluster headache patient in a hyperbaric chamber.

A patient with severe cluster headaches was treated in a hyperbaric chamber on two occasions. Her symptoms had been refractory to other treatment modalities including conventional oxygen therapy. On both occasions her pain was promptly relieved while breathing 100% oxygen at two atmospheres of pressure. This is the first known reported case of a cluster headache treated with hyperbaric oxygen. A prospective study is needed to substantiate the efficacy of this treatment modality for cluster headaches.

Employee Retirement Income Security Act and managed care: current issues and their impact on medical practice.

BACKGROUND: Managed care organizations (MCOs) routinely make decisions regarding utilization of health services, with an expectation of protection from liability through the Employee Retirement Income Security Act of 1974 (ERISA). An MCO decision to deny services to a patient may expose the physician to liability, while ERISA often shields the MCO from liability. A recent United States Supreme Court decision, New York State Conference of Blue Cross and Blue Shield Plans v Travelers, as well as legislation on the state and federal levels, may resolve this area of friction between physicians and MCOs. METHODS: We reviewed federal and state laws, as well as relevant case law and legal commentaries. RESULTS: The Travelers decision raised the threshold for ERISA preemption, decreasing the protection once afforded to MCOs. The American Medical Association, many state legislatures, and some members of Congress have recognized ERISA preemption and its protection of MCOs as a source of potential risk to patient care and increased liability for physicians. CONCLUSION: The problems created by the interaction of ERISA and managed care appear headed for a legislative resolution on the federal and state levels. This will significantly affect the interaction of MCOs with patients and physicians.

Methemoglobin levels following sublingual nitroglycerin in human volunteers.

Sublingual nitroglycerin 0.8 mg every five minutes for a total of 4.8 mg was administered to 11 healthy volunteers. One volunteer had to withdraw due to a hypotensive bradycardic reaction after 2.4 mg. In the remaining subjects, methemoglobinemia over the next hour never significantly increased from baseline levels, reaching a peak of only 0.71%. We conclude that commonly used doses of sublingual nitroglycerin do not induce significant methemoglobinemia and that nitroglycerin would not be useful in the treatment of cyanide poisoning.

Central embolization of needle fragments: a complication of intravenous drug abuse.

Central embolization is a known complication of catheter and needle fragments that enter the intravenous space. These events are associated with a number of complications including sepsis, thrombus formation with embolization, arrhythmia, and sudden death. This report reviews the case of a drug abuser who sought medical attention in the emergency department after breaking a needle in her left supraclavicular area. Initial efforts to explore the region were delayed. The delay resulted in embolization of the needle fragment to the lung periphery. This case illustrates the complications of central drug abuse and prompts a review of existing techniques to remove intravascular foreign bodies nonsurgically.

The development of a water rescue unit in an urban EMS system.

A river rescue unit was developed in Pittsburgh in March 1986. From its time of inception through December 31, 1987, the unit responded 572 times (325 times in 1987); this included 144 medical calls. Many of the other calls were police related, false alarms, routine patrols, or public service calls. We present a description of the service, type of training necessary, costs involved, and administrative aspects of running a marine emergency medical services system and its integration into an urban EMS system.

The incidence of myoglobinuria in patients with pneumatic trousers.

The possible association between the use of pneumatic trousers and myoglobinuria was investigated. One hundred and four victims of multiple trauma were entered into a study over a three-month period. Patients who suffered serious injuries to two or more organ systems qualified for entrance into the study. Patients who arrived at the emergency department with inflated pneumatic trousers served as the test population (n = 50), and patients who did not have pneumatic trousers served as the controls (n = 54). Urine specimens were obtained from all patients just before the completion of their treatment in the emergency department. No patients in the control group had myoglobinuria 0%), and only one patient in the test group had myoglobinuria 2%). The results were not statistically significant. Myoglobinuria is not an acute complication of the use of pneumatic trousers. The presence of pneumatic trousers on a multiple-trauma patient is not an indication for routine screening for myoglobinuria in the emergency department.

Effects of alpha-1-acid glycoprotein on the cardiovascular toxicity of nortriptyline in a swine model.

Tricyclic antidepressant toxicity is a frequently encountered and life-threatening problem in emergency medicine. This trial investigated the effect of alpha-1-acid glycoprotein (AAG), an acute phase reactant with a high affinity for basic drugs, on the clinical and pharmacological manifestations of nortriptyline (NT) toxicity. Fourteen pentobarbital-anesthetized swine (10-13 kg) were given a 10-min loading dose followed by a 45-min maintenance infusion of NT to achieve a plasma level of approximately 1000 ng/ml. At the end of the infusion, 7 control (C) animals were given 50 ml of 0.9% saline and 7 AAG animals were given 50 ml of 10% AAG, both over 15 min. Heart rate, QRS duration, QTc interval, blood pressure, temperature, arterial blood gases, albumin, and plasma-free and plasma-bound NT levels were measured at baseline and at every hour for 4 h. One death was noted in the AAG group and none in the C group (p = NS). Mean total NT levels after infusion in the C group was 1240 +/- 1118 ng/ml and in the AAG group 804 +/- 194 ng/ml (p = NS). No significant differences were found in the plasma-free fractions between groups at any time interval. However, significantly shorter QTc intervals were found during treatment with AAG compared to controls (P = 0.02). A trend toward increased systolic blood pressure (p = 0.09) and shorter QRS duration (p = 0.09) was noted during AAG treatment. No significant changes were shown between groups with respect to heart rate, arterial blood gases, or albumin measurements.(ABSTRACT TRUNCATED AT 250 WORDS)

Methemoglobin levels following intravenous lidocaine administration.

Methemoglobin levels were obtained before and after administration of IV lidocaine in 40 cardiac patients. Patients were given a 1-mg/kg bolus of IV lidocaine hydrochloride, started on a maintenance infusion at 2.0 mg/min, and given a second bolus of lidocaine of 0.5 mg/kg 15 minutes after the initial bolus. The maintenance infusion was adjusted from 1 to 4 mg/min according to clinical needs. Methemoglobin levels were drawn at zero, one, and six hours, and lidocaine levels were drawn at one and six hours after the initial bolus. Elevation of methemoglobin levels after lidocaine administration was statistically significant (P less than .05), but not clinically significant. The highest methemoglobin level obtained was 1.2%. Only one other patient had a level above 1%. No patient developed either signs of lidocaine toxicity or toxic levels of methemoglobin. Routine determination of methemoglobin levels is not clinically indicated following routine lidocaine administration. It may have some as-yet-undetermined value in lidocaine-toxic patients.

Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation.

A retrospective evaluation of magnetic resonance (MR) imaging for the detection of avascular necrosis (AVN) of the femoral head was performed in 49 patients (85 hips) with clinical suspicion of AVN. Positive findings at bone biopsy or evidence on plain radiographs was considered proof of AVN. Absence of clinical symptoms and of radiographic findings for a minimum of 18 months after MR imaging was considered evidence of the absence of AVN. All patients were studied with plain radiography and technetium-99m methylene diphosphonate bone scintigraphy. Five hips had negative MR images, positive findings at bone marrow biopsy, positive bone pressure measurement (BMP), and positive bone scans. A comparison between MR images and bone scans showed MR imaging to be superior, with a sensitivity of 88.8% (vs. 77.5%) and a specificity of 100% (vs. 75%). BMP was the most sensitive (92%) but least specific test (57%).