Live vaccine strain Francisella tularensis is detectable at the inoculation site but not in blood after vaccination against tularemia.

INTRODUCTION: Live vaccine strain (LVS) Francisella tularensis is a live, attenuated investigational tularemia vaccine that has been used by the US Army for decades to protect laboratory workers. Postvaccination bacterial kinetic characteristics of LVS at the inoculation site and in the blood are unknown and, therefore, were assessed in a prospective study. LVS vaccination of laboratory workers provided the opportunity to compare culture with polymerase chain reaction (PCR) for the detection of F. tularensis in human clinical samples. METHODS: Blood and skin swab samples were prospectively collected from volunteers who received the LVS tularemia vaccine at baseline (negative controls) and at 5 specified time points (days 1, 2, 7 or 8, 14 or 15, and 35 after vaccination). Bacterial culture and PCR of whole blood samples (17 volunteers) and inoculation site swabs (41 volunteers) were performed. RESULTS: The culture and PCR results of all blood samples were negative. Results of real-time PCR from the inoculation site samples were positive for 41 (100%) of 41 volunteers on day 1, for 40 (97.6%) of 41 volunteers on day 2, for 24 (58.5%) of 41 on day 7 or 8, for 6 (16.7%) of 36 on day 14 or 15, and for 0 (0%) of 9 on day 35. Positive results of bacterial cultures of the inoculation site samples occurred significantly less frequently, compared with PCR testing, with 4 (9.8%) of 41 volunteers having positive results on day 1 (P<.001) and 4 (9.8%) of 41 on day 2 (P<.001); all results from subsequent days were negative. CONCLUSIONS: F. tularensis LVS genomic DNA was detected in the majority of samples from the inoculation site up to 1 week after LVS vaccination, with real-time PCR being more sensitive than culture. Our data suggest that bacteremia does not occur after LVS vaccination in normal, healthy human volunteers.

Do medications affect vital signs in the prehospital treatment of acute decompensated heart failure?

INTRODUCTION: Prehospital treatment of patients with acute decompensated heart failure (ADHF) has been shown to decrease mortality and morbidity. Vital sign changes have been proposed as clinical endpoints in the evaluation of prehospital treatment for this condition. OBJECTIVE: To examine the effect of prehospital treatments on vital signs among patients with ADHF. METHODS: Records of an urban emergency medical services system from September 1, 2002, through September 1, 2003, were queried for patients who had a paramedic impression of shortness of breath or respiratory distress and had received nitroglycerin and/or furosemide. Demographics, initial and repeat vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation), and medications and doses were collected. RESULTS: Three hundred nineteen patients were included; the average age was 77 (+/-12) years and 47% were male. Treatments administered to these patients included nitroglycerin, 296 (93%); furosemide, 194 (61%); albuterol, 189 (59%); aspirin, 57 (18%); morphine, 20 (6%); and prehospital intubation, 15 (5%). Patients were initially hypertensive [mean +/- standard deviation of systolic blood pressure (SBP) was 167 +/-37 mm Hg], tachycardic (heart rate 106 +/- 24 beats/min), tachypneic (respiratory rate 33 +/- 7 breaths/min), and hypoxic (pulse oximetry 88% +/- 9.5%). After treatment, mean changes included decreases (95% confidence interval) in (SBP), -10.6 mm Hg (-14.1 to -7.1), heart rate, -2.3 beats/min (-4.0 to -0.7), and respiratory rate, -3.0 (-3.6 to -2.3), and an increase in oxygen saturation, +8.2 (7.1 to 9.3). Changes in blood pressure and oxygen saturation after treatment correlated with initial values. There was no independent association of either nitroglycerin, furosemide, albuterol, or morphine with improvement in vital signs. CONCLUSION: Prehospital patients with ADHF are a heterogeneous group of patients with significant variability in vital signs. The change in systolic blood pressure or oxygen saturation after treatment depends greatly on the patient's starting point. There was no association of either nitroglycerin or other medications with the improvement in vital signs.

Performance of a bedside C-reactive protein test in the diagnosis of community-acquired pneumonia in adults with acute cough.

PURPOSE: To evaluate the performance of a rapid, bedside whole blood C-reactive protein test as a diagnostic test for pneumonia in adults. METHODS: We enrolled consecutive adults who presented with acute cough (duration < or =3 weeks). A fingerstick blood specimen for C-reactive protein level was obtained. Patients also provided information about demographic characteristics and symptoms. Physical examination findings, diagnoses, and treatments were abstracted from the medical record; illness duration and subsequent office visits were determined with follow-up telephone calls. A clinical prediction rule for pneumonia was calculated for each patient and compared with C-reactive protein levels. RESULTS: Twenty (12%) of the 168 patients in the study had radiographic evidence of pneumonia. Median C-reactive protein levels were significantly higher for patients with pneumonia than in the remaining patients (60 mg/L vs. 9 mg/L, P <0.0001). The area under the receiver operating characteristic (ROC) curve for C-reactive protein level as a predictor of pneumonia was 0.83. C-reactive protein level and the clinical prediction rule were independently associated with pneumonia, yielding a combined area under the ROC curve of 0.93. C-reactive protein level was not associated with hospitalization or resolution of symptoms. CONCLUSION: C-reactive protein levels could be a valuable addition to clinical prediction rules for pneumonia. A C-reactive protein level > or =100 mg/L might be a useful indication for chest radiography or empiric antibiotic therapy when the diagnosis of pneumonia is in doubt.

Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes.

STUDY OBJECTIVE: The causes of syncope are usually benign but are occasionally associated with significant morbidity and mortality. We derive a decision rule that would predict patients at risk for short-term serious outcomes and help guide admission decisions. METHODS: This prospective cohort study was conducted at a university teaching hospital and used emergency department (ED) patients presenting with syncope or near syncope. Physicians prospectively completed a structured data form when evaluating patients with syncope. Serious outcomes (death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid hemorrhage, significant hemorrhage, or any condition causing a return ED visit and hospitalization for a related event) were defined at the start of the study. All patients were followed up to determine whether they had experienced a serious outcome within 7 days of their ED visit. Univariate analysis was performed with chi2 and nonparametric techniques on all predictor variables. kappa Analysis was performed on variables requiring interpretation. Variables with kappa more than 0.5 and a P value less than.1 were analyzed with recursive partitioning techniques to develop a rule that would maximize the determination of serious outcomes. RESULTS: There were 684 visits for syncope, and 79 of these visits resulted in patients' experiencing serious outcomes. Of the 50 predictor variables considered, 26 were associated with a serious outcome on univariate analysis. A rule that considers patients with an abnormal ECG, a complaint of shortness of breath, hematocrit less than 30%, systolic blood pressure less than 90 mm Hg, or a history of congestive heart failure has 96% (95% confidence interval [CI] 92% to 100%) sensitivity and 62% (95% CI 58% to 66%) specificity. If applied to this cohort, the rule has the potential to decrease the admission rate by 10%. CONCLUSION: The San Francisco Syncope Rule derived in this cohort of patients appears to be sensitive for identifying patients at risk for short-term serious outcomes. If prospectively validated, it may offer a tool to aid physician decision making.

Suturing versus conservative management of lacerations of the hand: randomised controlled trial.

OBJECTIVE: To assess the difference in clinical outcome between lacerations of the hand closed with sutures and those treated conservatively. DESIGN: Randomised controlled trial. SETTING: Emergency department in a tertiary hospital. PARTICIPANTS: Consecutive patients presenting between 16 February and 30 November 2000 with uncomplicated lacerations of the hand (full thickness <2 cm; without tendon, joint, fracture, or nerve complications) who would normally require sutures. 154 patients were eligible, 58 refused, and 5 were missed; 91 patients with 95 lacerations were enrolled. INTERVENTION: Participants were randomised to suturing or conservative treatment. MAIN OUTCOME MEASURES: Primary outcome was cosmetic appearance after three months, rated on a previously validated visual analogue scale. Duration of treatment, pain during treatment, patients' assessment of their outcome, and the time for patients to resume normal activities were also measured. RESULTS: Participants treated with sutures and those treated conservatively did not differ significantly in the assessment of cosmetic appearance by independent blinded doctors after three months: 83 mm v 80 mm, (mean difference 3 (95% confidence interval -1 to 8) mm) on the visual analogue scale. The mean time to resume normal activities was the same in both groups (3.4 days). Patients treated conservatively had less pain (difference 18 (12 to 24) mm) and treatment time was 14 (10 to 18) min shorter. CONCLUSION: Similar cosmetic and functional outcomes result from either conservative treatment or suturing of small uncomplicated lacerations of the hand, but conservative treatment is faster and less painful.