Is bigger better? A comparison of growth restriction rates using the crown-rump length derived due date from the smaller versus larger twin.

BACKGROUND: Although the smaller twin's crown-rump length is most accurate in establishing the estimated due date in dichorionic gestations, societal guidelines favor the use of the larger twin measurements based on concern for missing a diagnosis of fetal growth restriction. OBJECTIVE: This study aimed to compare the accuracy of the diagnosis of early- and late-onset fetal growth restriction in dichorionic twin gestations conceived by assisted reproductive technology using the estimated due date as established by the crown-rump length of the smaller vs larger twin. STUDY DESIGN: This was a 10-year retrospective cohort study of nonanomalous, dichorionic gestations conceived with assisted reproductive technology at 2 institutions. The incidence of early-onset (<32 weeks of gestation) and late-onset (≥32 weeks of gestation) growth restriction derived from the Hadlock formula using the smaller and larger crown-rump length estimated due date was compared with the true estimated due date by assisted reproductive technology. Statistical significance was determined using the Fisher exact test. The incidence of missed fetal growth restriction cases, false-positive rate, and error were calculated along with the relative risk for a missed diagnosis using the smaller crown-rump length. RESULTS: A total of 176 subjects were screened: 81 had a fetal growth ultrasound at 24 to <32 weeks of gestation, and 58 had a fetal growth ultrasound at ≥32 weeks of gestation. There was a significant difference in the incidence of fetal growth restriction using the 3 dating strategies in both gestational age ranges (P<.001) with the smaller crown-rump length estimated due date more closely approximating the true rate. Before 32 weeks of gestation, the smaller crown-rump length estimated due date missed 2.5% of fetal growth restriction cases, whereas the larger crown-rump length estimated due date missed 0.6% of fetal growth restriction cases, with false-positive and error rates of 1.2% and 3.7% and 5.5% and 6.2%, respectively. After 32 weeks of gestation, the smaller crown-rump length estimated due date missed 1.8% of cases, whereas the larger crown-rump length estimated due date missed 0% of cases, with false-positive and error rates of 2.6% and 4.4% and 5.3% and 5.3%, respectively. The relative risk for a missed diagnosis of fetal growth restriction using the smaller crown-rump length estimated due date was 1.77 for early-onset growth restriction and 1.22 for late-onset growth restriction. CONCLUSION: Using the estimated due date derived from the smaller twin led to a more accurate detection of fetal growth restriction at a cost of a higher missed diagnosis rate.

Establishing the Most Accurate Due Date in Dichorionic Twin Gestations by First and Second Trimester Ultrasound.

OBJECTIVE: To determine the optimal sonographic dating of dichorionic gestations. MATERIALS AND METHODS: We reviewed dichorionic pregnancies conceived with assisted reproductive technologies (ART) at 2 institutions between 2006-2016, excluding fetuses with major anomalies. Gestational age was calculated with smaller, larger, and mean of the crown-rump lengths (CRL) and biometry midgestation and compared to the ART age. The mean and mean absolute deviation of the observed gestational age from the ART age was calculated to assess accuracy, precision, and presence of bias. The incidence of small for gestational age using the smaller and larger CRLs was compared to the ART age via McNemar's test. RESULTS: Based on 140 ultrasounds, the CRL from the smaller twin best approximates the true gestational age with least bias compared to the larger twin or average (mean absolute deviation: 2.8, mean deviation: -0.1 [95% CI: -0.4, 0.2] versus 2.7, -0.9 [-1.1, -0.6] and 2.9, -1.5 [-1.8, -1.3], in days, respectively). Based on 165 ultrasounds, biometry from the smaller fetus is least accurate compared to the larger or mean (11.8, 2.5 [1.5, 3.6] versus 11.7, 0.8 [-0.3, 1.8] and 11.9, -1.0 [-2.0, 0.04], respectively). The incidence of small for gestational age neonates did not differ from the true rate using either the CRL from the larger or smaller twin (p > .05). CONCLUSION: In ART dichorionic gestations, ultrasound of the smaller fetus is most accurate in establishing gestational age in the first trimester but least accurate in the second, though all methods performed well with little clinical difference.

Contrast-Enhanced MRI Evaluation of Bone-Patellar Tendon-Bone and Hamstring ACL Autograft Healing in Humans: A Prospective Randomized Study.

BACKGROUND: Gadopentetate dimeglumine-enhanced magnetic resonance imaging (MRI), or gadolinium-enhanced MRI, was used to prospectively study the postoperative course of bone-patellar tendon-bone (BPTB) and combined semitendinosus and gracilis (STG) tendon autografts following arthroscopically assisted reconstruction of the anterior cruciate ligament (ACL) in humans. Gadopentetate dimeglumine is a contrast agent that has been shown to enhance the signal of vascularized tissue when examined by MRI. PURPOSE: To prospectively determine and compare the pattern and timing of autograft revascularization following arthroscopically assisted ACL reconstruction by BPTB or STG autografts. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 73 patients (63 males, 10 females) with ACL tears who were scheduled to undergo reconstruction consented to participate in this study. The patients were randomized to receive arthroscopically assisted reconstruction of the ACL employing either BPTB or STG autografts. Gadolinium-enhanced MRI scans were scheduled at 3-month intervals during the first postoperative year to assess the integrity, timing, and pattern of enhancement of the ACL graft. The temporal sequence and morphologic characteristics of imaged signals were compared for both types of ACL reconstructions. RESULTS: Based on all knees with 1 exception, there were no statistically significant differences in gadopentetate dimeglumine-mediated graft enhancement grade observed between BPTB and STG autografts. CONCLUSION: The results suggest that autograft revascularization probably varies in intensity and location during the time course of graft healing. The interval signal changes observed 3 to 9 months, but especially 6 to 9 months, postoperatively are due to increased contrast uptake as a reflection of ongoing neovascularization during the process of ligamentization.

Comparison of Temporal Artery Versus Rectal Temperature in Emergency Department Patients Who Are Unable to Participate in Oral Temperature Assessment.

INTRODUCTION: In the emergency department, pediatric and geriatric patients who present with illnesses and are unable to participate in oral evaluation of temperature must undergo a rectal temperature (RT) assessment. This study asks if a temporal artery temperature (TAT) measure can supplant the RT measure. METHODS: A convenience sample, using a within-subject design, was used to evaluate the efficacy of TAT compared with RT in patients ≤ 3 and ≥ 65 years of age, who were unable to participate in oral temperature assessments. RESULTS: Instrument reliability of the TAT is adequate for both the pediatric and geriatric populations. An unadjusted TAT did not provide acceptable temperature measurements. We also found that adjusting a TAT reading by adding -17.22°C (1° F) rendered the TAT average (either mean or median) adequately similar to RT averages for research purposes for both pediatric and geriatric groups. DISCUSSION: No influence was detected on the differences between RT and TAT due to age, sex, or emergency severity index (ESI) score in patients or due to profession, years of education, or years of experience in caregivers for either the pediatric or geriatric groups. Furthermore, the adjusted TAT reading could detect fever in individual patients adequately in both the pediatric and geriatric groups. However, the adjusted TAT readings were too frequently divergent from RT readings to be used to measure temperature in individual patients for both pediatric and geriatric groups.

Single Versus Multiple Hyperbaric Sessions for Carbon Monoxide Poisoning in a Murine Model.

Hyperbaric oxygen (HBO) has been advocated for treatment of acute carbon monoxide (CO) poisoning. There exists considerable debate as to whether HBO prevents delayed neurologic sequelae (DNS) due to CO poisoning. Additionally, existing data in the literature supporting HBO efficacy do not identify an optimal number of HBO treatments. We sought to determine in a mouse model whether there is a difference between one versus multiple HBO sessions for the prevention of DNS. Fifty mice were randomized into five groups of ten mice each: (1) control, receiving no CO exposure or treatment; (2) CO poisoned, receiving no treatment (CO group); (3) CO poisoned, receiving normobaric oxygen for 58 min following the end of exposure (CO + NBO group); (4) CO poisoned, followed by one session of HBO(CO + HBO1); and (5) CO poisoned, followed by three HBO treatment sessions, one every 6 h (CO + HBO3). Prior to poisoning, all animals were trained in step-down latency (SDL) and step-up latency (SUL) tasks. One week after exposure and treatment, all five groups were retested to evaluate the retention of this training. There was no difference detected among groups in SDL (p = 0.67 among all groups) when evaluated using a Kruskal-Wallis test. There was a significant difference among groups in SUL (p = 0.027 among all groups) when evaluated using a Kruskal-Wallis test. When individual groups were compared using a Wilcoxon signed-rank test with Bonferroni correction, there were no statistically significant differences in either SDL or SUL. There was no difference between groups treated with either one or three HBO sessions. One possibility to explain this might be that HBO sessions administered some time after a CO exposure may enhance the lipid peroxidation cascade and worsen neurologic outcomes; alternatively, HBO may simply impart no benefit when compared to NBO.

A comprehensive model for correcting RNFL readings of varying signal strengths in cirrus optical coherence tomography.

PURPOSE: To develop a model for the Cirrus HD-OCT that allows for the comparison of retinal nerve fiber layer (RNFL) thickness measurements with dissimilar signal strengths (SS) and accounts for test-retest variability. METHODS: Retinal nerve fiber layers were obtained in normals using the Cirrus optic disc cube 200 × 200 protocol during a single encounter. Five RNFL scans were obtained with a SS of 9 or 10. Diffusion lens filters were used to degrade SS to obtain five scans at each SS group of 7 or 8, 5 or 6, and 3 or 4. The relationship between average RNFL thickness and SS was established, and an equation was developed to allow for adjustment of an RNFL measurement had it been a SS of 7. Intravisit interclass correlation coefficient (ICC) and coefficient of variation (CV) parameter estimates for each SS group were calculated. Repeatability and upper tolerance limit were calculated as 1.96 × âˆš2 × within-subject standard deviation (Sw) and 1.645 × âˆš2 × Sw, respectively. RESULTS: There was a linear relationship between average RNFL and SS. RNFLadj = RNFL - 1.03*SS + 7.21 allows for the adjustment of RNFL readings to the same SS. Interclass correlation coefficients and CVs were good for all measurements down to SS of 3 or 4. Repeatability and upper tolerance limit were 5.24 and 4.40 µm, respectively. CONCLUSIONS: Our model adjusts RNFL readings based on SS and includes an upper tolerance limit of 5 µm. If validated, this model could improve the detection of real RNFL changes. Further study to validate this model should be performed before widespread use is adopted.

Ondansetron compared with doxylamine and pyridoxine for treatment of nausea in pregnancy: a randomized controlled trial.

OBJECTIVE: To evaluate whether ondansetron or the combination of doxylamine and pyridoxine was superior for the treatment of nausea and vomiting of pregnancy. METHODS: This was a double-blind, randomized, controlled trial in which women with nausea and vomiting of pregnancy were assigned to 4 mg of ondansetron plus a placebo tablet or 25 mg pyridoxine plus 12.5 mg of doxylamine for 5 days. The primary outcome was an improvement in nausea as reported on a 100-mm visual analog scale (VAS). Secondary outcomes were a reduction in vomiting on the VAS and the proportion of patients reporting sedation or constipation while using either study regimen. RESULTS: Thirty-six women (18 in each group) were randomized to either ondansetron or pyridoxine and doxylamine, of whom 13 (72%) and 17 (94%) completed follow-up, respectively. There were no differences among the groups with regard to demographic characteristics or baseline nausea. Patients randomized to ondansetron were more likely to have an improvement in their baseline nausea as compared with those using pyridoxine and doxylamine over the course of 5 days of treatment (median VAS score decreased 51 mm [interquartile range 37-64] compared with 20 mm [8-51]; P=.019). Furthermore, women using ondansetron reported less vomiting (median VAS decreased 41 [interquartile range 17-57] compared with 17 [-4 to 38]; P=.049). There was no significant difference between the groups regarding sedation or constipation. CONCLUSION: Our investigation showed ondansetron to be superior to the combination of pyridoxine and doxylamine in the treatment of nausea and emesis in pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01668069. LEVEL OF EVIDENCE: : I.

Intravenous lidocaine for the emergency department treatment of acute radicular low back pain, a randomized controlled trial.

BACKGROUND: Acute radicular back pain is a frequent complaint of patients presenting to the Emergency Department. STUDY OBJECTIVE: Determine the efficacy of intravenous lidocaine when compared to ketorolac for the treatment of acute radicular low back pain. METHODS: Randomized double-blind study of 41 patients aged 18-55 years presenting with acute radicular low back pain. Patients were randomized to receive either 100 mg lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60 minutes. Changes in [median] VAS scores were compared over time (within groups) by the signed-rank test and between groups by the rank-sum test. A 5-point Pain Relief Scale (PRS) was administered at the conclusion of the study (60 min) and again at 1 week by telephone follow-up; [median] scores were compared between groups by rank-sum. RESULTS: Forty-four patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac). Initial VAS scores were not significantly different between the lidocaine and ketorolac groups (83; 95% confidence interval [CI] 74-98 vs. 79; 95% CI 64-94; p = 0.278). Median VAS scores from baseline to 60 min significantly declined in both groups (lidocaine [8; 95% CI 0-23; p = 0.003]; ketorolac [14; 95% CI 0-28; p = 0.007]), with no significant difference in the degree of reduction between groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine, compared to 50% receiving ketorolac. No significant change in PRS between groups was found at the conclusion or at the follow-up. CONCLUSION: Intravenous lidocaine failed to clinically alleviate the pain associated with acute radicular low back pain.

Comparison of laparoscopic sleeve gastrectomy to laparoscopic Roux-en-Y gastric bypass for morbid obesity in a military institution.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance in the bariatric community as a definitive weight loss procedure; however, longitudinal data remain limited. The objective of this study was to compare weight loss results of LSG with laparoscopic Roux-en-Y gastric bypass (LRYGB) up to 5 years postoperatively using anthropometric measurements. METHODS: Prospectively collected bariatric database at the Naval Medical Center San Diego was retrospectively reviewed from 2005-2011 . Anthropometric factors, including weight and hip circumference were measured during standard yearly follow-up appointments. Surgical outcomes were tested by the Student t test and demographic variables by Fisher's exact and Wilcoxon rank-sum tests. RESULTS: Follow-up was achieved in 147/226 LRYGB versus 130/208 LSG at year 1, 92/195 versus 81/151 at year 2, 64/145 versus 50/100 at year 3, 32/81 versus 18/54 at year 4, and 12/42 versus 14/15 at year 5. The excess weight loss (EWL) for LRYGB versus LSG was 72% versus 64.7% at 1 year (P = .002), 71.3% versus 65.5% at 2 years (P = .113), and 68.3% versus 57.4% at 5 years (P = .252), respectively. Similarly, the body mass index (BMI) decrease was statistically significant at 1 year (P = .001) but not on subsequent annual visits. Mean percent body adiposity index (BAI) decrease was 28.4% for LRYGB versus 26.8% for LSG at 1 year (P = .679) and 21.8% versus 29.8% at 2 years (P = .134), respectively. Weight loss measured in terms of %EWL and decrease in BMI and BAI did not show significance between LRYGB and LSG 2 years after surgery. CONCLUSION: Our study provides similar long-term weight loss between LSG and LRYGB, and therefore, LSG is a viable option as a definitive bariatric procedure.

Negative predictive value of acetaminophen concentrations within four hours of ingestion.

OBJECTIVES: The objective was to ascertain whether acetaminophen (APAP) concentrations less than 100 µg/mL obtained between 1 and 4 hours after acute ingestion accurately predict a nontoxic 4-hour concentration. METHODS: The authors performed a multicenter, prospective cohort study involving five emergency departments (EDs) participating in the ToxIC Research Network. Data were collected from May 2009 to December 2011. Patients with APAP concentrations <100 µg/mL drawn between 1 and 4 hours after acute ingestions, and concentrations drawn 4 or more hours after ingestions, were included in the study. Exclusion criteria included initial concentration >100 µg/mL, initial APAP concentration drawn prior to 1 hour, two undetectable APAP concentrations, the second concentration drawn prior to 4 hours, and unknown time of ingestion. Toxic concentrations 4 or more hours after ingestion were defined as concentrations that plotted above the 150 µg/mL line on the Rumack-Matthew nomogram. RESULTS: Data were collected on 83 patients who met inclusion criteria. Of the 83 patients with APAP concentrations <100 µg/mL between 1 and 4 hours, one patient (1.2%) had a ≥ 4-hour toxic concentration. Negative predictive value (NPV) for an APAP concentration <100 µg/mL obtained between 1 and 4 hours after an acute ingestion was 98.8% (95% confidence interval [CI] = 93.5% to 99.8%). CONCLUSIONS: An APAP concentration of <100 µg/mL obtained between 1 and 4 hours after ingestion has a high NPV for excluding toxic ingestion. We do not recommend reliance on concentrations obtained between 1 and 4 hours to exclude toxicity, because of a potential false-negative rate of 6.5%.

A comparison of ultrasound-guided and landmark-based approaches to saphenous nerve blockade: a prospective, controlled, blinded, crossover trial.

BACKGROUND: Blockade of the saphenous nerve is often used for surgeries below the knee. Depending on the approach, success rates vary widely ranging from 33% to 88%. In this prospective volunteer study, we compared 2 ultrasound-guided techniques, the modified vastus medialis and perifemoral saphenous nerve block with a below the knee field block. METHODS: Twenty volunteer adults, in a single-blinded, crossover, prospective trial underwent 3 different saphenous nerve blocks. The primary end point of block success was loss of sensation in the distal two-thirds distribution of the saphenous nerve. Secondary variables included time to perform the block, time to sensory loss, pain during block, and motor weakness. RESULTS: Compared with the below the knee field block success rate (30%), both the modified vastus medialis and perifemoral techniques had significantly higher success rates (80%, difference 50% with confidence interval [CI], 23%-77%, P = 0.009, and 100%, difference 70% with CI, 41%-91%, P < 0.001, respectively). However, the difference when comparing the perifemoral ultrasound technique against the modified vastus medialis ultrasound technique did not show significance (difference 20% with CI, -7% to 49%, P = 0.125). Also, no statistical differences were found with the other variables measured, except the perifemoral technique showed faster block performance times than below the knee field block (P = 0.007). CONCLUSION: In our prospective study, we have demonstrated that ultrasound-guided above the knee saphenous nerve blocks have higher success rates than a below the knee field block and are easily performed in a short amount of time.

Resource utilization in the emergency department of a tertiary care university-based hospital in Tokyo before and after the 2011 Great East Japan earthquake and tsunami.

INTRODUCTION: The objective of this study was to determine the resource utilization of a tertiary care Japanese emergency department (ED) that was not immediately adjacent to the area of the 2011 Great East Japan earthquake and tsunami. METHODS: A retrospective chart review was performed at a tertiary care university-based urban ED located approximately 290 km from the primary site of destruction secondary to an earthquake measuring 9.0 on the Richter Scale and the resulting tsunami. All patients who presented for a period of twelve days before and twelve days after the disaster were included. Data were collected using preformed data collection sheets, and stored in an Excel file. Abstracted data included gender, time in the ED, intravenous fluid administration, blood transfusion, oxygen, laboratories, electrocardiograms (ECGs), radiographs, ultrasound, diagnoses, surgical and medical referrals, and prescriptions written. Ten percent of the charts were reviewed for accuracy, and an error rate reported. Data were analyzed using 2-tailed t-tests, Fisher's exact tests or rank sum tests. Bonferroni correction was used to adjust P values for multiple comparisons. RESULTS: Charts for 1193 patients were evaluated. The error rate for the abstracted data was 3.2% (95% CI, 2.4%-4.1%). Six hundred fifty-seven patients (53% male) were evaluated in the ED after the earthquake, representing a 23% increase in patient volume. Mean patient time spent in the ED decreased from 61 minutes to 52 minutes (median decrease from 35 minutes to 32 minutes; P = .005). Laboratory utilization decreased from 51% to 43% (P = .006). The percentage of patients receiving prescriptions increased from 48% to 54% (P = .002). There was no change in the number of patients evaluated for surgical complaints, but there was an increase in the number treated for medical or psychiatric complaints. CONCLUSION: There was a significant increase in the number of people utilizing the ED in Tokyo after the Great East Japan earthquake and tsunami. Time spent in the ED was decreased along with laboratory utilization, possibly reflecting decreased patient acuity. This information may help in the allocation of national resources when planning for disasters.

Acute bacterial osteoarticular infections: eight-year analysis of C-reactive protein for oral step-down therapy.

BACKGROUND: One of the most important decisions in the treatment of osteoarticular infections is the time at which parenteral therapy can be changed to oral therapy. C-reactive protein (CRP) is an acute inflammatory indicator with a half-life of 19 hours and thus can be helpful in assessing the adequacy of therapy for bacterial infections. At our institution, a combination of CRP and clinical findings is used to determine the transition to oral therapy. METHODS: A search of 8 years of electronic records identified children with osteoarticular infections. Only children with culture-positive acute bacterial arthritis (ABA) or acute bacterial osteomyelitis (ABO) were studied further. A primary chart review of demographic and clinical data was conducted, and a secondary chart review of complicated outcomes was performed. RESULTS: Of 194 total patients, complicated outcomes occurred in 40, of which 35 were prolonged therapy. Only 1 microbiologic failure occurred, presumably due to a retained intra-articular fragment of infected bone. CRP was highest initially among patients with simultaneous ABO + ABA and among those with complicated outcomes, and was lower at the transition to oral therapy in the complicated outcome group (1.5 vs 2.1 mg/dL; P = .012). CONCLUSIONS: The combination of clinical findings and CRP is a useful tool to transition children with osteoarticular infections to oral therapy. Complicated outcomes were associated with higher early CRP at diagnosis and lower CRP at the end of parenteral therapy, suggesting that clinicians were more conservative with prolonged initial parenteral therapy in this group.

Bedside method to estimate actual body weight in the Emergency Department.

BACKGROUND: Actual body weight (ABW) is important for accurate drug dosing in emergency settings. Oftentimes, patients are unable to stand to be weighed accurately or clearly state their most recent weight. OBJECTIVE: Develop a bedside method to estimate ABW using simple anthropometric measurements. METHODS: Prospective, blinded, cross-sectional convenience sampling of adult Emergency Department (ED) patients. A multiple linear regression equation from Derivation Phase (n = 208: 121 males, 87 females) found abdominal and thigh circumferences (AC and TC) had the best fit and an inter-rater correlation of 0.99 and 0.96, respectively: Male ABW (kg) = -47.8 + 0.78 ∗ (AC) + 1.06 ∗ (TC); Female ABW = -40.2 + 0.47 ∗ (AC) + 1.30 ∗ (TC). RESULTS: Derivation phase: Number of patients (%) with a body weight estimation (BWE) > 10 kg from ABW for males/females were: 7 (6%)/1 (1%) for Patients, 46 (38%)/28 (32%) for Doctors, 38 (31%)/24 (27%) for Nurses, 75 (62%)/43 (49%) for 70 kg/60 kg convention, and 14 (12%)/8 (9%) using the anthropometric regression model. For validation phase (55 males, 44 females): Gold standard ABW mean (SD) male/female = 83.6 kg (14.3)/71.5 kg (18.9) vs. anthropometric regression model = 86.3 kg (14.7)/73.3 kg (15.1). R(2) = 0.89, p < 0.001. The number (%) for males/females with a BWE > 10 kg using the anthropometric regression model = 8 (15%)/11 (27%). CONCLUSIONS: For male patients, a regression model using supine thigh and abdominal circumference measurements seems to provide a useful and more accurate alternative to physician, nurse, or standard 70-kg male conventional estimates, but was less accurate for use in female patients.

The effect of bedside presentations in the emergency department on patient satisfaction.

BACKGROUND: Due to increasing time constraints, the use of bedside presentations in resident education has declined. We examined whether patient satisfaction in the emergency department is affected when first-year residents present at the bedside with attendings. METHODS: We performed an observational, prospective, nonblinded study in the emergency department of a military teaching hospital. We alternately assigned first-year residents to present a convenience sample of 248 patients to the attending physician at the patient's bedside or away from the patient. We measured patient satisfaction by using the Patient Satisfaction Questionaire-18 (PSQ-18), a validated survey instrument that utilizes a Likert scale, and additional nonvalidated survey questions involving Likert and visual analog scales. RESULTS: While the median PSQ-18 score of 74 (95% confidence interval [CI], 72-76) was higher for patient satisfaction when residents made bedside presentations than that for standard presentations, 72 (95% CI, 70-74), the difference did not reach statistical significance (P  =  .33). CONCLUSION: There was no significant difference in overall patient satisfaction between residents' bedside presentations and presentations to attendings away from the patient. Although not significant, the differences noted in PSQ-18 subscales of communication, general satisfaction, and interpersonal manner warrant further investigation. Patients did not appear to be uncomfortable with having their care discussed and with having subsequent resident education at the bedside. Future research on patient satisfaction after implementation of standardized bedside teaching techniques 5 help further elucidate this relationship.

Bedside estimation of patient height for calculating ideal body weight in the emergency department.

BACKGROUND: Ideal body weight (IBW), which can be calculated using the variables of true height and sex, is important for drug dosing and ventilator settings. True height often cannot be measured in the emergency department (ED). OBJECTIVES: Determine the most accurate method to estimate IBW using true height-based IBW that uses true height estimated by providers or patients compared to true height estimated by a regression formula using measured tibial length, and compare all to the conventional 70 kg male/60 kg female standard IBW. METHODS: Prospective, observational, double-blind, convenience sampling of stable adult patients in a tertiary care ED from September 2004 to April 2006. Derivation set (215 patients) had blinded provider and patient true height estimates and tibial length measurements compared to gold-standard standing true height. A validation set (102 patients) then compared the accuracy of IBW using true height calculated from the regression formula vs. IBW using gold-standard true height. Regression formula for men tibial length-IBW (kg) = 25.83 + 1.11 × tibial length; for women tibial length-IBW = 7.90 + 1.20 × tibial length; R(2) = 0.89, p < 0.001. Inter-rater correlation of tibial length was 0.94. RESULTS: Derivation set: percent within 5 kg of true height-based IBW for men/women = PATIENT: 91.1%:/85.7%; Physician: 66.1%/45.1%; Nurse: 65.7%/ 47.3%; tibial length: 66.1%/63.7%; and 70 kg male/60 kg female standard 46%/75%. Validation set: tibial length-IBW estimates were within 5 kg of true height-ideal body weight in only 56.2% of men and 42.2% of women. CONCLUSIONS: PATIENT-reported height is the best bedside method to estimate true height to calculate ideal body weight. Physician and nurse estimates of true height are substantially less accurate, as is true height obtained from a regression formula that uses measured tibial length. All methods were more accurate than using the conventional 70 kg male/60 kg female IBW standard.

Oxygen saturation is not clinically useful in the exclusion of bacterial pneumonia in febrile infants.

BACKGROUND: Acute respiratory infection remains a common presentation to Emergency Departments. Oxygen saturations (Sao(2)) may be useful in determining which febrile infants require chest x-rays (CXR) in investigation for bacterial pneumonia (PNA). This study aimed to determine whether Sao(2) is clinically useful in excluding bacterial PNA in febrile infants <24 months. METHODS: A febrile infant registry was instituted at a tertiary care military hospital (55,000 annual patients, 27% children) from December 2002-December 2003. Eligible patients consisted of infants <3 months with temperature ≥38°C or 3-24 months with temperature ≥39°C. Bacterial PNA was defined in this cohort by a CXR revealing a 'lobar infiltrate' by a board-certified radiologist. Descriptive statistics are presented on groups who received CXR versus groups who did not, and on infants who had bacterial PNA versus those who did not. Student t tests were used to compare maximum temperature (Tmax), RR, and Sao(2). Logistic regression for PNA was performed using age, sex, Tmax, RR, HR and Sao(2). A Receiver Operator Characteristic (ROC) curve was created to show Sao(2) cut-off points as related to sensitivity and specificity. RESULTS: 985 patients (55% boys; median age: 12 months) met entry criteria. 790 underwent CXR and 82 were diagnosed with bacterial PNA. Sao(2) was lower in infants with bacterial PNA (96.6%±2.5% vs 97.7%±1.8%, p<0.001). Sao(2) was also predictive of bacterial PNA by logistic regression (p=0.017) but the ROC curve yielded a poor sensitivity/specificity profile (area under curve (AUC) of 0.6786). CONCLUSIONS: In febrile infants, Sao(2) was not found to be clinically useful for excluding bacterial PNA.

B-type natriuretic peptide: perioperative patterns in congenital heart disease.

OBJECTIVE: B-type natriuretic peptide (BNP) has diagnostic, prognostic, and therapeutic roles in adults with heart failure. BNP levels in children undergoing surgical repair of congenital heart disease (CHD) were characterized broadly, and distinguishable subgroup patterns delineated. DESIGN: Prospective, blinded, observational case series. SETTING: Academic, tertiary care, free-standing pediatric hospital. PATIENTS: Children with CHD; controls without cardiopulmonary disease. Interventions. None. MEASUREMENTS: Preoperative cardiac medications/doses, CHD lesion types, perioperative BNP levels, intraoperative variables (lengths of surgery, bypass, cross-clamp), postoperative outcomes (lengths of ventilation, hospitalization, open chest; averages of inotropic support, central venous pressure, perfusion, urine output; death, low cardiac output syndrome (LCOS), cardiac arrest; readmission; and discharge medications). RESULTS: Median BNP levels for 102 neonatal and non-neonatal controls were 27 and 7 pg/mL, respectively. Serial BNP measures from 105 patients undergoing CHD repair demonstrated a median postoperative peak at 12 hours. The median and interquartile postoperative 24-hour average BNP levels for neonates were 1506 (782-3784) pg/mL vs. 286 (169-578) pg/mL for non-neonates (P < 0.001). Postoperative BNP correlated with inotropic requirement, durations of open chest, ventilation, intensive care unit stay, and hospitalization (r = 0.33-0.65, all P < 0.001). Compared with biventricular CHD, Fontan palliations demonstrated lower postoperative BNP (median 150 vs. 306 pg/mL, P < 0.001), a 3-fold higher incidence of LCOS (P < 0.01), and longer length of hospitalization (median 6.0 vs. 4.5 days, P= 0.01). CONCLUSIONS: Perioperative BNP correlates to severity of illness and lengths of therapy in the CHD population, overall. Substantial variation in BNP across time as well as within and between CHD lesions limits its practical utility as an isolated point-of-care measure. BNP commonly peaks 6-12 hours postoperatively, but the timing and magnitude of BNP elevation demonstrates notable age-dependency, peaking earlier and rising an order of magnitude higher in neonates. In spite of higher clinical acuity, non-neonatal univentricular CHD paradoxically demonstrates lower BNP levels compared with biventricular physiologies.

Urinalysis is not reliable to detect a urinary tract infection in febrile infants presenting to the ED.

OBJECTIVE: Urinary tract infections are a common source of serious bacterial infections in febrile infants younger than 2 years. Our objective was to compare urinalysis with urine culture in the emergency department evaluation of febrile infants. METHODS: A febrile infant registry was instituted at a tertiary care hospital treating an average of 55000 patients annually (27% children), from December 2002 to December 2003. Patients were eligible if they were younger than 3 months and had a temperature of at least 38 degrees C or if they were between 3 and 24 months of age and had a temperature of at least 39 degrees C. Data abstracted included age, sex, and temperature. Urinalysis (UA) and urine culture (UCx) results were obtained from electronic hospital archives. RESULTS: Nine hundred eighty-five patients were entered into the febrile infant registry. Male patients comprised 55%. The mean age of patients was 12.6 months; median was 12 months. Four hundred thirty-five (78% of eligible patients) had both a UA and UCx from the same specimen, and there were 45 (10.3%) positive UCx result. Females accounted for 33 (73%) of 45 positive results. The sensitivity of UA for predicting a positive UCx result was 64% (95% confidence interval [CI], 49%-78%), whereas the specificity was 91% (95% CI, 88%-94%). The positive predictive value was 46% (95% CI, 31%-53%), with a negative predictive value of 96% (95% CI, 93%-97%). CONCLUSION: Urinalysis is not reliable for the detection of urinary tract infections in febrile infants when compared with urine cultures.