Polyamine inhibitors for treatment of feline oral squamous cell carcinoma: a proof-of-concept study.

This study assessed proof-of-concept for use of polyamine inhibitor 2-diluoromethylornithine (DFMO) as a treatment for oral squamous cell carcinoma (SCC) in client-owned cats. Polyamine levels in tumor tissue and normal oral mucosa were quantified before and after treatment. DFMO was administered orally to 14 client-owned cats with histologically confirmed oral SCC. Patients were monitored for gastrointestinal, dermatologic, auditory, hematological, and biochemical abnormalities. Total polyamine levels in tumor tissue decreased after treatment, as did the specific polyamine putrescine in both tumor tissue and normal mucosa. Ototoxicity was observed in 5 of 6 cats receiving pre- and post-treatment brainstem auditory evoked potential tests. Subclinical thrombocytopenia was observed in 6 of 14 cats. One cat showed mild post-anesthetic tremors that resolved without treatment. Oral administration of DFMO at doses used in this study resulted in significantly decreased tumor polyamine levels without life-threatening clinical or hematological toxicities. Further studies are warranted to explore pathophysiology of polyamine biochemistry and use of polyamine inhibitors in treatment of cats with oral SCC.

Dacarbazine as single-agent therapy for relapsed lymphoma in dogs.

BACKGROUND: Multidrug resistance is the most common cause of treatment failure in dogs with multicentric lymphoma. 5-(3,3-Dimethyl-1-triazeno)-imidazole-4-carboxamide (DTIC) is an atypical alkylator used as standard treatment in human Hodgkin's lymphoma, and has been effective in combination treatment to treat resistant lymphoma in dogs. However, no data are available on the use of DTIC as a single agent in the treatment of relapsed canine lymphoma. HYPOTHESIS: Single-agent DTIC is effective and safe in treating dogs with lymphoma that relapsed or failed to respond to previous chemotherapy. ANIMALS: Forty client-owned dogs with relapsed lymphoma. METHODS: Dogs were eligible for the retrospective study if they had a histologically or cytologically confirmed diagnosis of lymphoma and had relapsed. Dogs received DTIC (800-1,000 mg/m(2) every 2-3 weeks as a 4-5-hour IV infusion) and were evaluated for response rate and duration. Hematologic and gastrointestinal toxicity was assessed. RESULTS: The overall response rate for dogs being treated with DTIC was 35% (14 dogs) with a median progression-free interval of 43 days. Thirteen dogs had a partial response and 1 dog had a complete response. Stable disease was achieved in 3 dogs. Mild gastrointestinal toxicity was reported in 3 dogs posttreatment. Thrombocytopenia was the principal toxicity observed 7-14 days after the treatment. Treatments were delayed because of thrombocytopenia. CONCLUSIONS: DTIC, when used alone, is effective in the treatment of dogs with relapsed lymphoma.

Evaluation of adjuvant doxorubicin-based chemotherapy for the treatment of feline mammary carcinoma.

BACKGROUND: Feline mammary carcinomas (FMC) are locally invasive and highly metastatic tumors. Because of the high metastatic potential, patients often are treated with adjuvant doxorubicin-based chemotherapy, but little data exist to evaluate the effect of this strategy. HYPOTHESIS: Adjuvant doxorubicin-based chemotherapy improves outcome for FMC compared with surgery alone. ANIMALS: Cats with naturally occurring, biopsy-confirmed FMC treated with either surgery alone (Sx) or with surgery plus adjuvant doxorubicin-based chemotherapy (Sx + Chemo). METHODS: Retrospective cohort study. Clinical data were collected and compared to identify differences between groups. Outcome results were determined and compared. Prognostic factors for disease-free survival (DFS) and overall survival were evaluated. RESULTS: Seventy-three cats were evaluated, of which 37 were in the Sx group and 36 in the Sx + Chemo group. No differences in clinical data were found between Sx and Sx + Chemo groups. Median DFS times for the Sx and Sx + Chemo groups were 372 and 676 days, respectively (P= .15) and median survival times (ST) were 1,406 and 848 days, respectively (P= .78). For cats that underwent a unilateral radical mastectomy, ST was significantly longer for the Sx + Chemo compared with the Sx group (1,998 versus 414 days, respectively; P= .03). CONCLUSIONS AND CLINICAL IMPORTANCE: This study did not find a benefit to adjuvant doxorubicin-based chemotherapy in cats with FMC. Additional studies are required to determine whether patient subgroups with negative prognostic factors may benefit from adjuvant chemotherapy.

Clinical characterization of cardiovascular abnormalities associated with feline mucopolysaccharidosis I and VI.

OBJECTIVE: The purpose of this study was to define the cardiovascular abnormalities present in young and adult cats affected with the lysosomal storage diseases mucopolysaccharidosis (MPS) I and MPS VI. METHOD: Eighteen cats affected with MPS I and 10 cats affected with MPS VI were evaluated by physical examination, electrocardiography and echocardiography. Electrocardiography (ECG) was performed on all MPS I and 9 of the MPS VI cats. Twelve unaffected cats underwent complete examinations for comparison purposes. RESULTS: No cardiovascular abnormalities were noted on physical examination. Measured ECG intervals were normal in affected cats; however, sinus arrhythmia was noted more frequently than in the unaffected cats. Significant echocardiographic abnormalities included aortic valve thickening, regurgitation and aortic root dilation. Significant mitral valve thickening was also noted. The severity of changes increased in older affected cats. CONCLUSION: As affected animals increased in age, more cardiac abnormalities were found with increasing severity. Significant lesions included the mitral and aortic valves and ascending aorta, but myocardial changes were not recognized. MPS I and MPS VI cats have similar cardiovascular findings to those seen in children and constitute important models for testing new MPS therapies.

Secondary intracranial neoplasia in the dog: 177 cases (1986-2003).

BACKGROUND: This study investigates the frequency, location, and clinical findings associated with 177 secondary brain tumors in dogs. HYPOTHESIS: Secondary intracranial neoplasia is more common than primary intracranial neoplasia in dogs during the time period studied, and hemangiosarcoma (HSA) is the most common secondary intracranial tumor. ANIMALS: One hundred and seventy-seven client-owned dogs presented to the Matthew J. Ryan Veterinary Hospital between 1986 and 2003. METHODS: Medical records were searched for a diagnosis of intracranial neoplasia in dogs who underwent complete postmortem examination. Of these dogs, those with a diagnosis of primary intracranial neoplasia were excluded. RESULTS: Of the 177 secondary brain tumors, 51 (29%) were HSAs, 44 (25%) were pituitary tumors, 21 (12%) were lymphosarcomas, and 21 (12%) were metastatic carcinomas. The average age at diagnosis was 9.6 +/- 3.0 years. Most tumors were located in the cerebrum, and a mentation change was the most common presenting clinical sign. On postmortem examination, the same tumor that was in the brain was also present in the lung in 84 cases (47%), in the kidney in 62 cases (35%), and in the heart in 55 cases (31%). CONCLUSIONS AND CLINICAL IMPORTANCE: Secondary intracranial neoplasia in dogs was more common than primary intracranial neoplasia during the time period studied. Many of these dogs had related disease in other body systems that was apparent on diagnostic tests such as thoracic radiography.

Complications and radiographic findings following cemented total hip replacement: a retrospective evaluation of 97 dogs.

Cemented total hip replacement (cTHR) is commonly performed to treat intractable coxofemoral pain in dogs. While owners generally perceive a good outcome after the procedure, the longevity of the implant may be limited by complications such as infection and aseptic loosening. The objective of this retrospective study was to identify the prevalence of complications and radiographic changes following cTHR, and to identify factors that may predispose to a need for revision surgery. Medical records and radiographs from 97 dogs that underwent cTHR were evaluated for signalment, preoperative degree of osteoarthritis, technical errors, intra-operative culture results, and the post-operative radiographic appearance of the implant. The complications occurring in the intra-operative and short-term (eight week) time period were recorded. Mean (+/- SD) follow-up time was 1.1 +/- 1.6 years (range: 0-7.7 years). Seven dogs had a short-term complication and a revision surgery was performed in eleven dogs. Osseous or cement changes were radiographically detectable in the majority of cTHR. Eccentric positioning of the femoral stem and the presence of radiolucent lines at the femoral cement-bone interface were positively associated with the occurrence of revision surgery. The clinical significance of the periprosthetic radiographic changes is unclear and further investigation is warranted.

Postvaccinal sarcomas in the cat: epidemiology and electron probe microanalytical identification of aluminum.

An increase in fibrosarcomas in a biopsy population of cats in the Pennsylvania area appears to be related to the increased vaccination of cats following enactment of a mandatory rabies vaccination law. The majority of fibrosarcomas arose in sites routinely used by veterinarians for vaccination, and 42 of 198 tumors were surrounded by lymphocytes and macrophages containing foreign material identical to that previously described in postvaccinal inflammatory injection site reactions. Some of the vaccines used have aluminum-based adjuvants, and macrophages surrounding three tumors contained aluminum oxide identified by electron probe microanalysis and imaged by energy-filtered electron microscopy. Persistence of inflammatory and immunological reactions associated with aluminum may predispose the cat to a derangement of its fibrous connective tissue repair response, leading to neoplasia.

Risk stratification of emergency department patients with acute coronary syndromes using P-selectin.

OBJECTIVES: We compared the predictive properties of P-selectin to creatine kinase, MB fraction (CK-MB) for detecting acute myocardial infarction (AMI), acute coronary syndromes (ACS) and serious cardiac events upon emergency department (ED) arrival. BACKGROUND: Practioners detecting early diagnosis of ACS have focused on cardiac markers of myocardial injury. Plaque rupture/platelet aggregation precedes myocardial ischemia. Therefore, markers of platelet aggregation may detect ACS earlier than cardiac markers. METHODS: Consecutive patients with potential ACS presenting to an urban university ED were identified by research assistants who screened all ED patients between November 12, 1997 and January 31, 1998. Whole blood was drawn at presentation and 1 h later and rapidly stained and fixed for membrane P-selectin assay and plasma was separated for soluble P-selectin assay. Creatine kinase, MB fraction values were determined using standard immunoassay techniques. Clinical history and hospital course were followed daily. Outcomes were AMI, ACS (AMI and unstable angina) and serious cardiac events. Receiver operator characteristic curves were derived for CK-MB, and soluble and membrane-bound P-selectin to determine the optimal cutoff values. Predictive properties were calculated with 95% confidence intervals. RESULTS: A total of 263 patients were enrolled. They had a mean age of 56.5+/-14 years; 52% were male. There were 22 patients with AMI; 87 patients with ACS and 54 patients with serious cardiac events. Creatine kinase, MB fraction had a higher specificity for detection of AMI, ACS and serious cardiac events than both soluble and membrane-bound P-selectin. At the time of ED presentation, the specificity of CK-MB, and soluble and membrane-bound P-selectin for AMI was 91% versus 76% versus 71%; for ACS, 95% versus 79% versus 71%, and for serious cardiac events, 91% versus 76% versus 72% (p < 0.05). The sensitivities for AMI were 50% versus 45% versus 32%; for ACS, 26% versus 35% versus 30%, and for serious cardiac events, 29% versus 35% versus 36%. CONCLUSIONS: Although theoretically attractive, the use of soluble and membrane-bound P-selectin for risk stratification of chest pain patients at the time of ED presentation does not appear to have any advantages over the use of CK-MB.

Stroke in the Lehigh Valley: risk factors for recurrent stroke.

Age-specific risk of recurrent stroke for various risk factors, calculated independently, was estimated using the first year of data from the Lehigh Valley Stroke Register. The register is based on a population of more than one-half million. Among the risk factors examined, the highest overall risk of recurrent stroke, 41.4, occurred with a history of at least one transient ischemic attack (TIA). After myocardial infarction (MI), the relative risk of a recurrent stroke was 8.0, while with all other heart diseases combined it was 8.4. With diabetes, the relative risk of a recurrent stroke was 5.6; with hypertension, it was 4.5. The relative risk increased with age after TIA and MI, but not for other heart disease, diabetes, and hypertension, except in the 85+-year-old age group.

Adverse effect of splenectomy on the survival of patients with more than one kidney transplant.

Risk factors associated with death were identified in a cohort of patients who received 2 or more kidney transplants. Data on 19 variables were collected by chart review on 774 patients who received allografts between 1973 and 1980 at any one of 3 hospitals in Philadelphia. 124 of the patients received two or more transplants and were followed for a minimum of 1.5 years. Modified life table analyses of single variables indicated that 7 factors--splenectomy, donor source, age, transplant hospital, number of HLA mismatches, donor sex, and survival time of the prior graft--were significantly related to patient survival. Using all 19 variables, the proportional hazards model was fit to the data. The characteristics most related to survival were splenectomy (P less than .001), donor source (P = .0022), and age (P = .0015). The other 4 factors that were significant on univariate analysis were not significant in this multivariate analysis. The relative risk of death was 5.5 for patients who had had a splenectomy compared with those who had not had a splenectomy. Patients who had received more than one transplant were compared with patients who had received only one transplant, and a subset of recipients of primary transplants who returned to dialysis after primary graft failure. Survival of patients who had received one transplant was approximately the same as that of the retransplanted population. When the proportional hazards model was fit to the populations that received one transplant and compared with the model for the retransplanted group, only age and donor source were common to all three models. The effect of splenectomy on survival was significant for the total population of primary transplant recipients but had no effect on the survival of the subset of recipients whose kidney grafts had failed and were returned to hemodialysis. Infection accounted for 45% of the deaths among splenectomized, retransplanted patients. A higher percentage of septic deaths occurred in patients whose grafts were functioning at the time of death when compared with patients who had returned to dialysis after secondary graft failure. Although retransplantation alone is not associated with an increased mortality, retransplantation in splenectomized patients carries a high risk of death.

Chrono-lume and magnesium potentiate aggregation of canine but not human platelets in citrated platelet-rich plasma.

The effects of Chrono-lume (CL) and magnesium sulfate (Mg2+), a component of this luciferin-luciferase reagent, on platelet aggregation were studied in platelet-rich plasma (PRP) obtained from blood anticoagulated with sodium citrate from humans, dogs, cats, horses, and cows. The final added Mg2+ concentration of both solutions ranged from 0.75-3.7 mM. CL and Mg2+ had no effect on maximum aggregation of platelets from humans induced by sub-threshold concentrations of collagen and ADP. In contrast, addition of CL or Mg2+ to canine PRP resulted in a dose-dependent and equal potentiation of platelet aggregation in response to sub-threshold concentrations of collagen, ADP, and thrombin in normal and thrombopathic dogs. The effect of CL on platelet aggregation induced by sub-threshold concentrations of agonists was less pronounced and varied in other species according to the agonist. The reason for the marked difference in sensitivity of human and canine platelets to CL or Mg2+ is not clear, although a difference in releasable cation pools of the platelets from these two species has been recognized. Platelet aggregation studies of animals with suspected thrombopathias should be performed without CL to prevent masking of a platelet function defect.

Violence prevention in the emergency department: clinician attitudes and limitations.

OBJECTIVE: To assess emergency department (ED) clinicians' attitudes and behaviors regarding identification, assessment, and intervention for youth at risk for violence in the ED. DESIGN: Anonymous, cross-sectional written questionnaire. SETTING: The EDs of 3 urban hospitals. SUBJECTS: Emergency medicine residents and faculty, pediatric residents, pediatric emergency medicine fellows and faculty, and ED nurses. RESULTS: A total of 184 (88%) of 208 clinicians completed the questionnaire. Only 15% correctly recognized the lack of existing protocols for addressing youth violence. Clinicians reported being most active in identification of at-risk youth (93% asking context of injury and 82% determining relationships of victim and perpetrator), with pediatricians being more active than general ED clinicians (87% vs 68%; P<.01). Clinicians less often reported performing assessments or referrals of at-risk youth. Nurses and physicians were no different in their reported identification, assessment, or referral behaviors. Barriers identified include concern over upsetting family members, lack of time or skills, and concern for personal safety. Additional clinician training, information about community resources, and specially trained on-site staff were noted by respondents as potential solutions. CONCLUSIONS: Emergency department clinicians recognize the need for evaluation of youth at risk for violence. They are able to identify violently injured youth, but less often perform risk assessment to guide patients to appropriate follow-up resources. Further investigation should address clinician barriers to the complete care of violently injured youth in the ED.

Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation.

OBJECTIVE: To determine the short-term outcome of patients with a known seizure disorder who have a seizure, are evaluated by out-of-hospital care providers, and refuse transport. METHODS: This was a prospective study conducted over a 15-month period. Philadelphia Fire Department paramedics contacted a medical command physician whenever they encountered a patient with a known seizure disorder who had had another seizure and was refusing transport. After confirming that the patient had the mental capacity to refuse care and understood the associated risks, the physician recorded the patient's name, address, and telephone number. Beginning three days later, a registered nurse attempted to reach the patient by telephone and administer a brief questionnaire about his or her medical outcome. Patients not reached by telephone were sent a certified letter. The names of patients lost to follow-up were compared with medical examiner records to confirm that they had not died during the follow-up period. RESULTS: Of 63 patients enrolled in the study, 52 (82.5%) were reached in follow-up. Of these, three (5.8%) had another seizure within 72 hours and recontacted 911. One of these patients (1.9%) was hospitalized. Twenty (38.5%) patients contacted their primary care physicians. There were no deaths, including patients lost to follow-up. CONCLUSIONS: Most patients (94.2%) who were evaluated by out-of-hospital care providers for a seizure and refused transport had no further seizure activity in the subsequent 72 hours. However, because there is a risk of recurrence, out-of-hospital care providers and medical command physicians should ensure that patients understand the risks of refusal.

The short-term outcome of hypoglycemic diabetic patients who refuse ambulance transport after out-of-hospital therapy.

OBJECTIVE: To determine the short-term medical outcome of hypoglycemic insulin-dependent diabetic patients who refuse transport after out-of-hospital therapy and return to baseline mental status. METHODS: Prospective, descriptive, short-term medical outcome data for adult patients were collected between May 1996 and December 1996. Paramedics responding to the aid of hypoglycemic insulin-dependent diabetic patients who refused transport after administration of dextrose solution (D50W) contacted a medical command physician at the University of Pennsylvania. The patients' medical histories, names, addresses, and telephone numbers were recorded. Three days after their hypoglycemic episodes, these patients were contacted by telephone by a registered nurse to determine their medical conditions. RESULTS: Of 132 patients enrolled in the study, 103 (78%) could be contacted by telephone follow-up. Ninety-four (91%) of these patients had no recurrence of symptoms. Nine patients (9%) had recurrence of hypoglycemia and recontacted 911. Eight of these (8%) were transported to a hospital via ambulance and 3 (3%) were admitted, 1 (1%) for a cancer-related illness and 2 (2%) for hypoglycemia, 1 of whom died (1%). The remaining patient refused transport a second time after being treated, despite having the risks of refusal explained to him by a medical command physician. CONCLUSIONS: The practice of treating and releasing most hypoglycemic insulin-dependent diabetic patients who return to normal mental status after D50W administration appears in general to be safe. Patients should be advised of the risks of recurrent hypoglycemia.

Violence between women in an urban emergency department patient population.

OBJECTIVE: To determine what percentage of women presenting to an urban emergency department (ED) for any reason had been the victims of violence committed by another woman in the previous year. METHODS: This was a prospective study of a consecutive sample of female patients of legal age presenting to the ED between 8 AM and 12 midnight over an 11-week period. Patients were asked a series of questions adapted from the George Washington University Universal Violence Prevention Screening Protocol. Non-English-speaking patients, those unable to give informed consent, and those meeting regional criteria for major trauma were excluded. RESULTS: One thousand six hundred seventy-six women participated; 426 (25%) refused. Of the 1,250 women interviewed, 118 (9.4%; 95% CI = 7.8% to 11.1%) reported being assaulted by another woman in the previous 12 months. Compared with the nonvictims, the victims were more frequently younger and single. The most common forms of assault were slapping, grabbing, and shoving (54.7% of victims). These were followed by being choked, kicked, bitten, or punched (46.2%). Eighteen percent of the assaults involved a weapon or an object. Five percent of the victims described being forced to have sex. Thirty-seven percent of the victims contacted the police, 13% required medical attention, 17% pursued legal action, and 10% sought follow-up counseling. CONCLUSIONS: Nine percent of the women in the study sample had been assaulted by another woman in the previous year. Further attention to the recognition and management of violence committed by women against other women may be warranted to ensure that patients receive appropriate treatment and referral.

Characteristics and outcomes of young adults who present to the emergency department with chest pain.

BACKGROUND: Most studies of emergency department (ED) chest pain patients exclude patients <30-40 years old. As a result, the clinical course of these patients is poorly described. OBJECTIVE: To study the clinical characteristics, hospital course, and 30-day outcomes of ED chest pain patients <40 years old. The hypothesis was that patients <40 years old without a cardiac history and with normal electro-cardiograms (ECGs) or no cardiac risk factors would be at a <1% risk for acute coronary syndromes (ACSs) and 30-day adverse cardiovascular (CV) events. METHODS: This was a prospective cohort study of non-cocaine-using ED patients, 24-39 years old, who received an ECG for chest pain between July 9, 1999, and October 23, 2000. Structured data collection at presentation included demographics, chest pain description, history, laboratory, and ECG data. Hospital course was followed daily. Thirty-day follow-up was performed by telephone. The main outcomes were discharge diagnosis and 30-day adverse CV events [acute myocardial infarction (AMI), death, percutaneous intervention (PCI), or coronary artery bypass grafting (CABG)]. RESULTS: A total of 487 patients presented 527 times and comprised the study group. Patients were most often 30-39 years old (71%), female (60%), and African-American (73%). Thirty-two percent were admitted. Five hundred seven of 527 patient visits (96%) had 30-day follow-up. Patients had the following cardiac risk factors: tobacco, 37%; hypertension, 22%; family history, 19%; diabetes mellitus, 6%; cholesterol, 6%; prior angina, 3%; known coronary artery disease, 3%; and prior AMI, 2%. Patients usually had unremarkable ECGs (61% normal, 98% nonischemic). Overall, 11 of 527 patients had adverse CV events (2.1%; 95% CI = 0.9% to 3.3%): 8 AMIs (1.5%), 4 deaths (0.8%), 5 PCIs (0.9%), and no CABG. Twenty-five patients had a final diagnosis of ACS (4.7%; 95% CI = 2.9% to 6.5%). The incidence of ACS in the 210 patients without a cardiac history and without cardiac risk factors was 0.5% (95% CI = 0% to 1.4%). At 30 days, none of these 210 patients had AMI, PCI, CABG, or death (0%, 95% CI = 0% to 1.4%). The incidence of ACS in the 312 patients with normal ECGs and a negative cardiac history was 0.3% (95% CI = 0% to 0.9%). At 30 days, there was no AMI, PCI, or CABG in these 312 patients, and one patient with metastatic cancer died (adverse CV event 0.3%, 95% CI = 0% to 0.9%). CONCLUSIONS: Although young patients, as a whole, have a 4.7% risk of ACSs and a 2.1% risk of adverse CV events at 30 days, those without known cardiac disease or any cardiac risk factors had a <1% risk of ACSs and were free from adverse CV events over 30 days. Likewise, young patients without a cardiac history and with a normal ECG had a <1% risk of ACSs and adverse CV events at 30 days. It may be reasonable to expedite outpatient management and limit unnecessary admissions in these cohorts.

Risk factors for infection in patients with traumatic lacerations.

BACKGROUND: Most of our knowledge of laceration management comes from studies in animal models or patients with closure of sterile postoperative surgical incisions. Traumatic laceration management has not been well studied. OBJECTIVE: To determine which characteristics of traumatic lacerations were associated with the development of wound infection. METHODS: A cross-sectional study of consecutive patients with traumatic lacerations repaired over a four-year period was conducted. Structured closed-question data sheets were prospectively completed at the time of laceration repair and suture removal. Infection was determined at the time of suture removal. Multivariate modeling was used to determine the adjusted odds ratio (OR) of infection. RESULTS: Five thousand five hundred twenty-one patients were enrolled; 195 patients developed an infection (3.5%). An increased likelihood of wound infection was associated with age (adjusted OR per year, 1.01; 95% CI = 1.0 to 1.02); history of diabetes mellitus (adjusted OR 6.7; 95% CI = 1.7 to 26.4); laceration width (adjusted OR 1.05 per mm; 95% CI = 1.02 to 1.08); and presence of foreign body (adjusted OR 2.6; 95% CI = 1.3 to 5.2). Laceration location on the head/neck was associated with a decreased risk of infection (adjusted OR 0.28; 95% CI = 0.18 to 0.45). CONCLUSIONS: Both patient and wound characteristics of traumatic lacerations have an influence on the likelihood of infection. This knowledge may be valuable for determining whether various methods of wound cleansing, debridement, and repair can improve the outcome of patients with traumatic lacerations.

Randomized, double-blind, placebo-controlled trial of diazepam, nitroglycerin, or both for treatment of patients with potential cocaine-associated acute coronary syndromes.

INTRODUCTION: To the authors' knowledge, treatment of patients with cocaine-associated acute coronary syndromes has not been rigorously investigated in symptomatic patients. OBJECTIVE: To perform a randomized double-blind trial of diazepam, nitroglycerin, or both for treatment of patients with potential cocaine-associated acute coronary syndromes. METHODS: Patients with potential cocaine-associated acute coronary syndromes were randomized to treatment with either diazepam, nitroglycerin, or both every 5 minutes or until symptom resolution. Outcomes were chest pain resolution (measured by visual analog scale), and changes in blood pressure, pulse rate, cardiac output (L/min), cardiac index (L/min/m2), stroke volume (mL/beat), and stroke index (mL/beat/m2) over the 15-minute treatment period. To adjust for seven outcomes using the Bonferroni correction, alpha was set at 0.007. RESULTS: Forty patients were enrolled (diazepam, 12; nitroglycerin, 13; both, 15). Patients had a mean age (+/-SD) of 35.4 (+/-7.5) years; 75% were male. They presented a mean of 5 hours and 37 minutes after cocaine use. Baseline demographics, cocaine use patterns, chest pain characteristics, and initial electrocardiograms were similar for all groups. Chest pain severity improved similarly in the three groups [-33.3 mm (+/-8.0); -30.7 mm (+/-7.1); -33.0 mm (+/-7.9); p = 0.6]. The stroke index decreased during the 15-minute treatment period for all groups (diazepam, -8.7 (+/-3.3); nitroglycerin, -3.1 +/- 2.8; both, -1.8 (+/-3.1) mL/beat/m2; p = 0.03). After adjustment for differences between baseline hemodynamic and cardiac profiles and multiple comparisons, there was no difference in any response to therapy over time for the different treatments. CONCLUSIONS: For treatment of patients with potential cocaine-associated acute coronary syndromes, chest pain resolutions and changes in cardiac performance are not different in patients treated with diazepam or nitroglycerin. In this study, the use of both agents did not offer any advantage over either agent alone.

Do quantitative changes in pain intensity correlate with pain relief and satisfaction?

OBJECTIVE: To correlate measured pain intensity (PI) changes with pain relief and satisfaction with pain management. METHODS: A prospective single-group repeated-measures design study. A heterogeneous group of patients were asked to record their levels of PI at initial presentation and at ED release using a numerical descriptor scale (NDS) and a visual analog scale (VAS). At release, a 5-point pain relief scale and a pain management satisfaction survey were also completed. RESULTS: A convenience sample of 81 patients were enrolled over the study period. The average reduction in PI for all patients was 33%. A 5%, 30%, and 57% reduction in PI correlated with "no," "some/partial," and "significant/complete" relief, respectively (p < 0.001). However, when patients were divided into 2 groups based on their initial PI scores, patients with moderate/severe pain (NDS > 5) required a reduction of 35% and 84% in PI to achieve "some/partial" and "significant/complete" relief, respectively. Patients in less pain (NDS < or = 5) needed 25% and 29% reductions in PI for the same categories (p=0.8). Patients were generally satisfied with their pain management. There was a positive association between pain relief and satisfaction with pain management. CONCLUSION: There is a significant association between changes in PI and pain relief. Greater reductions in PI are required for patients presenting with more severe initial pain to achieve relief compared with those who have lesser initial PI. While there is a linear relationship between increasing pain relief and satisfaction, relief of pain appears to only partially contribute to overall satisfaction with pain management.

Assessment of airway visualization: validation of the percentage of glottic opening (POGO) scale.

OBJECTIVE: Research defining optimal methods of intubation has been limited by the lack of a validated outcome measure to assess airway visualization. The objective of this study was to develop a reliable scale for the assessment of airway visualization during endotracheal intubation. METHODS: This prospective study was performed to assess the intra- and interphysician reliabilities of emergency physicians (EPs) for estimating the percentage of glottic opening (POGO) that is visualized during direct laryngoscopy. Using video images of laryngeal views obtained from a commercially available videotape, still slide images were prepared representing glottic openings ranging from 0% to 100%. Five EPs, blinded to study objective, reviewed 25 pairs of airway slides (50 slides total). For each slide, the physicians recorded the POGO and their scores using a modified Cormack-Lehane (MCL) scale, where grade I is a view of the full glottic opening, MCL grade II is a partial view of the glottic opening, and MCL grade III is a view of the epiglottis only. Inter- and intraphysician reliabilities were assessed using the kappa statistic (K) for MCL grade and intraclass correlation coefficient for the POGO scores. RESULTS: For the POGO score, the degree of intrarater reliability was very good, with an intraphysician correlation of 0.85 and an interphysician correlation of 0.74. For the MCL score, the intraphysician concordance had a K of 0.71, and interphysician concordance was also good, with a kappa of 0.59. CONCLUSION: Both the modified version of the Cormack-Lehane grading classification and the POGO score have good interphysician and intraphysician reliabilities. Because the POGO score can distinguish patients with large and small degrees of partial glottic visibility, it might provide a better outcome for assessing the difference between various intubation techniques.