Delayed manipulation after collagenase clostridium histolyticum injection for Dupuytren contracture.

BACKGROUND: Collagenase clostridium histolyticum (CCH) injection for Dupuytren contracture was approved in the USA in 2010. Current FDA guidelines stipulate that finger manipulation occurs the day following injection. To investigate the safety and efficacy of delaying manipulation to 2 or 4 days following CCH injection, we conducted a prospective, randomized trial at two sites. METHODS: Patients with Dupuytren contracture involving the metacarpophalangeal (MCP) joint ≥20° caused by a palpable cord participated. All patients received one dose of CCH (0.58 mg/0.25 ml) and were followed for 90 days. The primary end point was the percent of patients maintaining clinical success (reduction of contracture to 0°-5°) at 90 days post-injection. Adverse events and change in Michigan Hand Questionnaire (MHQ) score were recorded as secondary end points. RESULTS: Thirty-seven patients enrolled; 13 were manipulated on day 1, 11 on day 2, and 13 on day 4. At 30 days after injection, the percentage of patients obtaining reduction of contracture to <0°-5° extension was 92, 82, and 85 % in groups 1, 2, and 3, respectively, with no significant difference. At 90 days follow-up, the percentage of patients maintaining 0°-5° extension was 91, 82, and 83 % in groups 1, 2, and 3, respectively, with no significant difference. Adverse events were comparable to rates in prior studies. There were no serious adverse events. There was no statistical difference in MHQ scores between groups at any time point. CONCLUSIONS: Delaying manipulation to day 2 or 4 following CCH injection for MCP joint contractures does not increase adverse events or result in loss of efficacy. LEVEL OF EVIDENCE: Therapeutic, Level II.

The "vertical response time": barriers to ambulance response in an urban area.

BACKGROUND: Ambulance response time is typically reported as the time interval from call dispatch to arrival on-scene. However, the often unmeasured "vertical response time" from arrival on-scene to arrival at the patient's side may be substantial, particularly in urban areas with high-rise buildings or other barriers to access. OBJECTIVES: To measure the time interval from arrival on-scene to the patient in a large metropolitan area and to identify barriers to emergency medical services arrival. METHODS: This was a prospective observational study of response times for high-priority call types in the New York City 9-1-1 emergency medical services system. Research assistants riding with paramedics enrolled a convenience sample of calls between 2001 and 2003. RESULTS: A total of 449 paramedic calls were included, with a median time from call dispatch to arrival on-scene of 5.2 minutes. The median on-scene to patient arrival interval was 2.1 minutes, leading to an actual response interval (dispatch to patient) of 7.6 minutes. The median on-scene to patient interval was 2.8 minutes for residential buildings, 2.7 minutes for office complexes, 1.3 minutes for private homes (less than four stories), and 0.5 minutes for outdoor calls. Overall, for all calls, the on-scene to patient interval accounted for 28% of the actual response interval. When an on-scene escort provided assistance in locating and reaching the patient, the on-scene to patient interval decreased from 2.3 to 1.9 minutes. The total dispatch to patient arrival interval was less than 4 minutes in 8.7%, less than 6 minutes in 28.5%, and less than 8 minutes in 55.7% of calls. CONCLUSIONS: The time from arrival on-scene to the patient's side is an important component of overall response time in large urban areas, particularly in multistory buildings.

The relationship of plasma glucose and HbA1c Levels among emergency department patients with no prior history of diabetes mellitus.

OBJECTIVES: Patients without a history of diabetes mellitus may be incidentally found to be hyperglycemic in the emergency department (ED). If the hyperglycemia is due to undiagnosed diabetes, then an opportunity for detection exists. Hemoglobin A1c (HbA1c) provides a weighted average of blood glucose levels over the past several months; high HbA1c levels could indicate diabetes. The objective of this study was to determine whether hyperglycemia in ED patients without a history of diabetes was associated with higher HbA1c levels. METHODS: This was a prospective nonconsecutive case series of adults aged 18 years or older presenting to the ED with acute illness for whom a plasma glucose sample was drawn for clinical management. A history of diabetes/hyperglycemia or current symptoms of diabetes excluded patients. HbA1c levels were analyzed for a glucose cutoff of 110 mg/dL; the data were further analyzed using additional glucose cutoffs. Based on the Third National Health and Nutrition Examination Survey outpatient screening data, an HbA1c level > or =6.2% was considered elevated (sensitivity of 63% and specificity of 97% for identifying diabetes). RESULTS: There were 541 patients enrolled; the glucose level correlated with the HbA1c level (r = 0.60, p < 0.001). Among the 331 patients with a glucose level > or =110 mg/dL, 22.4% had an elevated HbA(1c) level; among the 210 patients with a glucose level < 110 mg/dL, 7.6% had an elevated HbA1c level. There were few patients (n = 13) with a glucose level > or =200 mg/dL, but most (85%) had an elevated HbA1c level. Among the 140 patients with a mildly elevated glucose level (110-125 mg/dL), 16.4% had an elevated HbA(1c) level. CONCLUSIONS: Elevated HbA1c levels are found in ED patients with elevated random plasma glucose values. ED patients with hyperglycemia may warrant referral for diabetes testing.