Tissue residue depletion of fenbendazole after oral administration in turkeys.

The objectives of this study were to determine tissue depletion of fenbendazole in turkeys and estimate a withdrawal interval (WDI). Forty-eight 9-week-old turkeys were fed fenbendazole at 30 mg/kg of feed for 7 consecutive days. Three hens and 3 toms were sacrificed every 2 days from 2 to 16 days post-treatment, and tissues were collected to determine fenbendazole sulfone (FBZ-SO2) concentrations using mass spectrometry. At all timepoints, FBZ-SO2 concentrations in liver and skin-adherent fat were above the limit of quantification (1 ppb), with higher concentrations than those in kidney and muscle. Two turkeys had detectable FBZ-SO2 concentrations in kidney at 16 days. No detectable FBZ-SO2 concentrations were found in muscle at 14 and 16 days. Fenbendazole residues depleted very slowly from the liver and a WDI of at least 39 days should be observed under the conditions of this study, in order to comply with Canadian regulatory agencies.

Déplétion du fenbendazole pour les résidus tissulaires après l'administration orale chez les dindons. Les objectifs de cette étude consistaient à déterminer la déplétion du fenbendazole dans les tissus chez les dindons et d'estimer un délai d'attente (DA). Du fenbendazole a été administré à quarante-huit dindons âgés de 9 semaines, à raison de 30 mg/kg d'aliments pendant 7 jours consécutifs. Trois dindes et 3 dindons ont été sacrifiés tous les deux jours pendant les jours 2 à 16 après le traitement et les tissus ont été prélevés pour déterminer les concentrations de fenbendazole sulfone (FBZ-SO2) en utilisant la spectrométrie de masse. À tous les moments de prélèvement, les concentrations de FBZ-SO2 dans le foie et le gras adhérent à la peau étaient supérieures à la limite de quantification (1 ppm), avec des concentrations supérieures à celles présentes dans les reins et les muscles. Deux dindes avaient des concentrations de FBZ-SO2 détectables dans les reins à 16 jours. Aucune concentration détectable de FBZ-SO2 n'a été trouvées dans les muscles à 14 et à 16 jours. Les résidus de fenbendazole se résorbaient très lentement du foie et un DA d'au moins 39 jours devrait être observé conformément aux conditions de cette étude afin de satisfaire aux exigences des agences réglementaires canadiennes.(Traduit par Isabelle Vallières).

A randomized trial of the effects of early cardiac serum marker availability on reperfusion therapy in patients with acute myocardial infarction: the serial markers, acute myocardial infarction and rapid treatment trial (SMARTT).

OBJECTIVES: The purpose of this study was to assess whether the immediate availability of serum markers would increase the appropriate use of thrombolytic therapy. BACKGROUND: Serum markers such as myoglobin and creatine kinase, MB fraction (CK-MB) are effective in detecting acute myocardial infarction (AMI) in the emergency setting. Appropriate candidates for thrombolytic therapy are not always identified in the emergency department (ED), as 20% to 30% of eligible patients go untreated, representing 10% to 15% of all patients with AMI. Patients presenting with chest pain consistent with acute coronary syndrome were evaluated in the EDs of 12 hospitals throughout North America. METHODS: In this randomized, controlled clinical trial, physicians received either the immediate myoglobin/CK-MB results at 0 and 1 h after enrollment (stat) or conventional reporting of myoglobin/CK-MB 3 h or more after hospital admission (control). The primary end point was the comparison of the proportion of patients within the stat group versus control group who received appropriate thrombolytic therapy. Secondary end points included the emergent use of any reperfusion treatment in both groups, initial hospital disposition of patients (coronary care unit, monitor or nonmonitor beds) and the proportion of patients appropriately discharged from the ED. RESULTS: Of 6,352 patients enrolled, 814 (12.8%) were diagnosed as having AMI. For patients having AMI, there were no statistically significant differences in the proportion of patients treated with thrombolytic therapy between the stat and control groups (15.1% vs. 17.1%, p = 0.45). When only patients with ST segment elevation on their initial electrocardiogram were compared, there were still no significant differences between the groups. Also, there was no difference in the hospital placement of patients in critical care and non- critical care beds. The availability of early markers was associated with more hospital admissions as compared to the control group, as the number of patients discharged from the ED was decreased in the stat versus control groups (28.4% vs. 31.5%, p = 0.023). CONCLUSIONS: The availability of 0- and 1-h myoglobin and CK-MB results after ED evaluation had no effect on the use of thrombolytic therapy for patients presenting with AMI, and it slightly increased the number of patients admitted to the hospital who had no evidence of acute myocardial necrosis.

Increased expression of major histocompatibility antigens in the liver as a result of cholestasis.

Increased expression of major histocompatibility complex (MHC) antigens may occur following liver transplantation. The mechanism by which this occurs is unclear. Postoperative complications may result in cholestasis. We have investigated the possibility that cholestasis may cause increased expression of MHC antigens in the liver. Cholestasis was induced in rat livers by bile duct ligation and transection. Total serum bilirubin rose markedly postoperatively and remained elevated over a period of 21 days. Samples of bile taken from rats were shown to remain sterile during the study period and there was no evidence of viral infection. Liver tissue taken 1, 3, 7, and 21 days postobstruction showed a marked increase in the expression of rat class I MHC antigens but not class II antigens. We suggest that cholestasis itself can induce increased MHC class I antigens in the liver. Therefore, if cholestasis occurs postoperatively in the human liver transplant recipient this might lead to increased expression of human class I MHC antigens and add to the overall cellular immune activity in a rejection reaction, although cholestasis probably cannot initiate rejection.

Acute thromboscintigraphy with (99m)Tc-apcitide: results of the phase 3 multicenter clinical trial comparing 99mTc-apcitide scintigraphy with contrast venography for imaging acute DVT. Multicenter Trial Investigators.

UNLABELLED: (99m)Tc-apcitide (formerly known as (99m)Tc-P280) is a radiolabeled peptide that binds with high affinity and specificity to the glycoprotein IIb/IIIa receptors expressed on the activated platelets that are involved in acute thrombosis. The purpose of the phase 3 multicenter clinical trials was to compare (99m)Tc-apcitide scintigraphy with contrast venography for imaging acute deep venous thrombosis (DVT). METHODS: A total of 280 patients were enrolled in 2 clinical trials conducted in North America and Europe. Patients were to be within 10 d of onset of signs and symptoms of acute DVT or within 10 d of surgery associated with a high risk of DVT. (99m)Tc-apcitide scintigraphy and contrast venography were to be performed within 36 h. Planar scintigraphic images were obtained at 10, 60, and 120-180 min after injection. (99m)Tc-apcitide scintigrams and contrast venograms were read with masking and also by the institutional investigators. RESULTS: Of a total of 243 patients who were evaluable, 61.7% were receiving heparin at the time of imaging. Masked reading of (99m)Tc-apcitide scintigraphy, compared with masked reading of contrast venography, had a sensitivity, specificity, and agreement of 73.4%, 67.5%, and 69.1%, respectively, which met the prospectively defined target efficacy endpoint in both trials. Institutional reading of (99m)Tc-apcitide scintigraphy, compared with institutional reading of contrast venography, had a sensitivity, specificity, and agreement of 75.5%, 72.8%, and 74.0%, respectively. However, the entire trial population included patients with a history of DVT who may have had old, nonacute venous thrombi that could confound the venography results. Therefore, data from patients having no history of DVT or pulmonary embolism and who presented within 3 d of onset of signs and symptoms (n = 63), i.e., patients for whom a venogram would be expected to be positive only if acute DVT were present, also were analyzed as a subset. In these patients, institutional reading of (99m)Tc-apcitide scintigraphy, compared with institutional reading of contrast venography, had a sensitivity, specificity, and agreement of 90.6%, 83.9%, and 87.3%, respectively. CONCLUSION: (99m)Tc-apcitide scintigraphy is a new diagnostic modality that is highly sensitive for imaging acute DVT.

Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule.

OBJECTIVE: To develop a clinical prediction rule to identify patients who can be safely discharged one hour after the administration of naloxone for presumed opioid overdose. METHODS: Patients who received naloxone for known or presumed opioid overdose were formally evaluated one hour later for multiple potential predictor variables. Patients were classified into two groups: those with adverse events within 24 hours and those without. Using classification and regression tree methodology, a decision rule was developed to predict safe discharge. RESULTS: Clinical findings from 573 patients allowed us to develop a clinical prediction rule with a sensitivity of 99% (95% CI = 96% to 100%) and a specificity of 40% (95% CI = 36% to 45%). Patients with presumed opioid overdose can be safely discharged one hour after naloxone administration if they: 1) can mobilize as usual; 2) have oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; 4) have a temperature of >35.0 degrees C and <37.5 degrees C; 5) have a heart rate >50 beats/min and <100 beats/min; and 6) have a Glasgow Coma Scale score of 15. CONCLUSIONS: This prediction rule for safe early discharge of patients with presumed opioid overdose performs well in this derivation set but requires validation followed by confirmation of safe implementation.

Electron contamination of large cobalt 60 photon beams.

Experimental results are presented of the electron contamination of cobalt 60 gamma photon beams from the Mobaltron MS80, over a range of SSD's from 60 cm to 3.5 m. In the absence of an electron filter, the skin dose can exceed the dose at 4 mm depth by up to 1.6 times due to the high level of electron emission from the depleted uranium collimators. 4 mm of perspex effectively removes these electrons, and in the filtered beam, the skin dose cannot exceed the 4 mm dose. The electron contamination of a 6 MV X-ray beam is compared.

Effects of short term cold exposure on the digestion of milk replacer by young preruminant calves.

Two groups, totalling 29, of 24-day-old Friesian bull calves were offered 0.6 kg milk replacer reconstituted in 2.5 litres warm water once daily and were housed for a period of 14 days at a temperature of either 3 +/- 2 degrees C (cold) or 18 +/0 0.5 degrees C (warm). Mean daily liveweight gains of the groups exposed to cold or warmth were 0.26 and 0.36 +/- 0.04 kg per day respectively (P less than 0.05). Apparent digestibility coefficients of dry matter, nitrogen and fat of the milk replacer were not affected by exposure of the calves to cold and were 0.95 +/- 0.01, 0.92 +/- 0.01 and 0.77 +/- 0.02 respectively for both groups. Water intake and urine volume were significantly (P less than 0.05) reduced by 1.77 and 0.56 litres per day respectively whereas faecal water excretion was increased ty 0.06 litres per day in the cold exposed calves. Over the 10-day period the warm exposed calves were estimated to make a net water retention while there was a net loss of 0.35 litres per day for the group exposed to cold.

Effects of the inclusion of yeast culture (Saccharomyces cerevisiae plus growth medium) in the diet of dairy cows on milk yield and forage degradation and fermentation patterns in the rumen of steers.

The effects of including yeast culture (YC; Saccharomyces cerevisae plus growth medium; 5 x 10(9) organisms/g) in diets for ruminants was examined in two experiments. In Exp. 1, 32 multiparous Friesian dairy cows were fed between wk 7 to 12 of lactation one of four completely mixed diets based on either hay or straw plus rolled barley (mixed to give concentrate:forage ratios of either 50:50 or 60:40, respectively) with or without 10 g YC/d in a 2(3) factorial design. Supplementation with YC increased DM intake of the cows by a mean of 1.2 kg/d (P less than or equal to .062) and increased milk yield by 1.4 liters/d (corrected to 4% butterfat; P less than or equal to .05). There was an interaction (P less than .05) between diet composition and YC addition; effects of YC were greatest in diets containing 60:40 (concentrate:forage) ratio. In Exp. 2, three steers were fed a diet of 50% hay and 50% rolled barley (DM basis). Hay was available for the major part of the day but barley was fed in two meals/d. Addition of YC to the diet increased (P less than .05) ruminal pH for 4 h after the barley meal. This elevation in pH probably was due to a reduction (P less than or equal to .01) in the concentration of L-lactate in the ruminal liquor of steers given YC (1.43 vs 3.55 mM; P less than or equal to .01). Peak ruminal L-lactate concentration (7.75 mM) in the controls coincided with time of minimum pH values (2 h after the meal of barley); this peak was absent in steers given YC. YC had no effect on the concentration of VFA in ruminal liquor, but the ratio of acetate to propionate was reduced (P less than or equal to .01) from 3.3:1 to 2.8:1 in steers given YC. The extent of DM degradation of hay incubated in the rumen of steers fed the hay and rolled barley diet was increased (P less than .05) in the presence of YC at 12 h of incubation, but degradation was similar in all treatment groups after 24 h of incubation. Presence of yeast culture in the rumen had effects on ruminal stoichiometry. An increased rate of forage degradation may have increased forage intake and productivity of these dairy cows.

Sudden death of a young hockey player: case report of commotio cordis.

Despite the use of protective gear, a 15-year-old hockey player died when he was struck in the chest by a puck. This is the fifth recorded hockey death related to so-called commotio cordis, that is, blunt chest injury without myocardial structural damage. In light of inadequacies of commercial chest protectors currently in use for hockey, the authors hope to educate players and coaches about the danger of blocking shots with the chest. Physicians should be aware that commotio cordis represents a distinctive pathological condition, in the event of which immediate recognition, precordial thump, CPR, and defibrillation are potentially lifesaving. Appropriate medical supervision at amateur hockey games, 911 telephone access, and on-site automated external defibrillators are issues that deserve careful consideration.

An unusual cause of abdominal pain and shock in pregnancy: case report and review of the literature.

A near fatal case of spontaneous uterine rupture resulting from placenta percreta is presented. Placenta accreta refers to all conditions in which placental villi attach to, invade, or penetrate the myometrium. Placenta percreta is the most extreme form of morbid placental attachment and is said to exist when the uterine wall is completely breached by invading placental villi. Although uncommon, placenta percreta is an important entity of which the emergency physician should be aware because of its propensity to cause uterine rupture and catastrophic bleeding. This article reviews the pathophysiology, presentation, diagnosis, and emergency department management of placenta accreta, increta, and percreta.

Low-molecular-weight heparin in the emergency department treatment of venous thromboembolism.

Accepted initial therapy for deep vein thrombosis (DVT) is intravenous heparin infusion, which requires hospitalization, inhibits patient ambulation, consumes nursing time, and generates laboratory cost. The effects of heparin are unpredictable, and maintaining optimal anti-coagulation requires careful laboratory monitoring. Many patients are underdosed and 5-20% of heparin-treated patients suffer hemorrhagic complications. Low-molecular-weight (LMW) heparins have a predictable anticoagulant response, require no laboratory monitoring, and can be administered once or twice daily by subcutaneous injection, thus facilitating outpatient treatment. LMW heparins are at least as safe and effective as standard intravenous heparin for the treatment of uncomplicated DVT. LMW heparin use is associated with decreased admission rates, shorter lengths of stay, decreased nursing time, better patient quality of life, and lower laboratory costs. In our emergency department, we have adopted a LMW heparin protocol for the outpatient treatment of suspected or proven DVT.

Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines.

Procedural sedation and analgesia are core skills in emergency medicine. Various specialty societies have developed guidelines for procedural sedation, each reflecting the perspective of the specialty group. Emergency practitioners are most likely to embrace guidelines developed by people who understand emergency department (ED) skills, procedures, conditions, and case mix. Recognizing this, the Canadian Association of Emergency Physicians (CAEP) determined the need to establish guidelines for procedural sedation in the ED. In March, 1996, a national emergency medicine (EM) working committee, representing adult and pediatric emergency physicians, was established. This committee teleconferenced with representatives of the Canadian Anesthetic Society (CAS) to identify problems, perspectives, and controversial issues, and to define a process for guideline development. The EM committee subsequently reviewed existing literature, determined levels of evidence, and developed the document, which evolved based on feedback from the CAS and CAEP Standards Committees. The final version was approved by the CAEP Standards Committee and the CAEP Board of Directors, then submitted for peer review. These guidelines discuss the goals, definitions, and principles of ED sedation, and make recommendations for pre-sedation preparation, patient fasting, physician skills, equipment and monitoring requirements, and post-sedation care. The guidelines are aimed at non-anesthesiologists practicing part-time or full-time emergency medicine. They are applicable to ED patients receiving parenteral analgesia or sedation for painful or anxiety-provoking procedures. They are intended to increase the safety of procedural sedation in the ED.

Ketorolac versus acetaminophen-codeine in the emergency department treatment of acute low back pain.

Acute low back pain is a common problem in the emergency department (ED). Effective management of acute pain enhances early rehabilitation and recovery. Given the importance of inflammatory mediators in pain generation and the adverse effects associated with opioids, it is logical to expect that a non-opioid agent with antiinflammatory and analgesic properties would provide excellent analgesia with fewer adverse effects. This double-blind, randomized, multicenter clinical trial, performed in six university and community hospital EDs, compares the analgesic efficacy and adverse effects of ketorolac to those of acetaminophen-codeine in ED patients with acute musculoskeletal low back pain. Our hypothesis was that ketorolac would provide superior analgesia with fewer adverse effects. One hundred twenty-three patients with acute low back pain were randomized to receive ketorolac (KET, N = 63) or acetaminophen-codeine (ACOD, N = 60). Most (79%) were males, and the mean age was 34.5 years. After baseline clinical assessment, patients were treated with ketorolac (10 mg every 4 to 6 h as needed, up to four daily doses) or acetaminophen-codeine (600 mg-60 mg, respectively, every 4 to 6 h as needed, up to six daily doses) and followed for one week. Pain intensity was assessed on visual analogue and categorical scales. Functional capacity, overall pain relief, and overall medication rating were assessed on categorical scales. Adverse events were documented. Primary outcomes included: 1) Pain intensity differences, based on visual analogue scores, for the 0 to 6 h treatment phase. 2) Incidence of adverse events. Secondary outcomes included analgesic efficacy, functional capacity, and overall subjective drug evaluation at one week. Both drugs provided substantial pain relief, with maximal effect 2.2 h after oral dosing. There were no significant differences in analgesic efficacy, functional capacity, or overall pain relief between the two groups. Sixteen patients (10 KET vs. 6 ACOD, NS) withdrew prematurely because of drug inefficacy. Patients in the ACOD group reported significantly more adverse drug events and serious adverse drug events. Seven patients--all in the ACOD group--withdrew from the study because of adverse drug events. Based on comparable efficacy and a superior adverse event profile, ketorolac was preferable to acetaminophen with codeine for the treatment of acute low back pain in the ED.

Effect of immunological castration on sexual and production characteristics in male cattle.

Ten male Friesian calves were actively immunised against luteinising hormone releasing hormone and their production compared with 10 Friesian steer calves. Five of the immunised calves responded poorly (group 1); the other five responded well (group 2), resulting in high antibody titres, low serum testosterone levels, involuted testes, reduced libido and semen production, and docile behavior. The castration effect lasted approximately six months before reversion to near normal male status. This temporary immunocastration failed to affect seriously performance until slaughter, and liveweight gain was substantially better in this group than in the steers. Carcase traits were similar in groups 1 and 2, but the lean content in both was considerably greater than in the steer carcases.

Outcome in colorectal adenocarcinoma: two seven-year studies of a population.

OBJECTIVE: To record every patient with proved colorectal adenocarcinoma presenting from a defined population over two years in 1968-9 and during 1980-2, and to compare treatment and outcome over seven years. DESIGN: Retrospective in 1968-9 and prospective in 1980-2. SETTING: Aberdeen general hospitals. SUBJECTS: Every patient presenting to the four general surgical units with histological proof of colorectal adenocarcinoma. MAIN FINDINGS: On average, one new patient presented each week per 100,000 population. The proportion of patients aged 65 and over rose from 67% to 71%. An operation was performed on 385 patients in 1968-9 and on 399 during 1980-2. At laparotomy the proportion of patients who seemed to be curable and had a radical operation rose slightly, from 56% to 61%, and operative mortality fell from 9% to 5%. In all there were 421 survivors of curative surgery, and seven years later three quarters were either alive (51%) or had died without recurrence (25%). In both studies some 40% of patients were considered incurable when they presented, but the number who had a palliative resection rose from 59% to 85%. CONCLUSIONS: The contribution of radical surgery to the treatment of colorectal adenocarcinoma is substantial, with three quarters of patients so treated showing no evidence of recurrence after seven years. Operative mortality in an elderly population is now low, and improvement in late outcome is more likely to come from developments in adjuvant therapy than in operative technique. A continuing problem is that 40% of patients are not curable when they present, although palliative resection can now be offered to over 80%.

Do emergency physicians know the costs of medical care?

OBJECTIVES: To estimate the level of knowledge that Canadian emergency physicians have of the costs of common diagnostic tests and interventions in the emergency department (ED). METHODS: In a cross-sectional survey, 75 emergency physicians from 7 community and academic EDs were asked to estimate the cost of 60 of the most commonly ordered imaging modalities, laboratory tests and pharmaceuticals. Their estimates were compared to actual costs obtained from hospital finance departments. For each test or pharmaceutical, physician error was calculated as a percentage of the actual value, using the formula [(actual - estimated) / actual] yen 100. For each item, the proportion of responses that were underestimates, the proportion that were overestimates and the proportion that were accurate within 25% were reported. RESULTS: Mean error of the physicians' estimates was 40% (95% confidence interval [CI], 35%-45%) for imaging studies, 153% (95% CI, 128%-178%) for lab investigations, and 218% (95% CI, 179%-257%) for pharmaceutical costs. Rates of underestimation vs. overestimation were 68% vs. 16% for imaging modalities, 23% vs. 56% for laboratory tests, and 21% vs. 64% for pharmaceuticals. CONCLUSIONS: Emergency physicians have a limited knowledge of the costs of the tests and interventions they use on a daily basis. They tend to overestimate lab and pharmaceutical costs but underestimate imaging costs. Cost-awareness programs for emergency physicians are most likely to be beneficial if they focus on imaging modalities.

A consensus-based process to define standard national data elements for a Canadian emergency department information system.

Canadian hospitals gather few emergency department (ED) data, and most cannot track their case mix, care processes, utilization or outcomes. A standard national ED data set would enhance clinical care, quality improvement and research at a local, regional and national level. The Canadian Association of Emergency Physicians, the National Emergency Nurses Affiliation and l'Association des médecins d'urgence du Québec established a joint working group whose objective was to develop a standard national ED data set that meets the information needs of Canadian EDs. The working group reviewed data elements derived from Australia's Victorian Emergency Minimum Dataset, the US Data Elements for Emergency Department Systems document, the Ontario Hospital Emergency Department Working Group data set and the Canadian Institute for Health Information's National Ambulatory Care Reporting System data set. By consensus, the group defined each element as mandatory, preferred or optional, and modified data definitions to increase their relevance to the ED context. The working group identified 69 mandatory elements, 5 preferred elements and 29 optional elements representing demographic, process, clinical and utilization measures. The Canadian Emergency Department Information System data set is a feasible, relevant ED data set developed by emergency physicians and nurses and tailored to the needs of Canadian EDs. If widely adopted, it represents an important step toward a national ED information system that will enable regional, provincial and national comparisons and enhance clinical care, quality improvement and research applications in both rural and urban settings.

Emergency physicians' attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort.

OBJECTIVES: To determine Canadian emergency physicians' estimates regarding the safety and efficiency of chest discomfort management in their emergency department (ED), and their attitudes toward and perception of the need for a chest discomfort clinical prediction rule that identifies very low risk patients who are safe to discharge after a brief ED assessment. METHODS: 300 members of the Canadian Association of Emergency Physicians (CAEP) were randomly selected to receive a confidential mail survey, which invited them to provide information on current disposition of patients with chest discomfort and their opinions regarding the value of a clinical prediction rule to identify patients with chest discomfort who are safe to discharge after a brief (approximately 2 hour) assessment. RESULTS: Of the 300 physicians selected, 288 were eligible for the survey and 235 (82%) responded. Only 5% follow discharged patients to measure safe practice. Overall, 165 (70%) felt the proposed prediction rule would be very useful and 43 (18%) felt it would be useful. Almost all (94%) believed a prediction rule would be useful if it identified patients safe for discharge without increasing the current rate of missed acute myocardial infarction (estimated at 2%). Most respondents (59%) believed that a clinical prediction rule should suggest a course of action, while 30% felt it should convey a probability of disease. CONCLUSIONS: Canadian emergency physicians support the concept of a clinical prediction rule for the early discharge of patients with chest discomfort. Most believe that such a rule would be useful if it identified patients who are safe for discharge after a brief assessment, while maintaining current levels of safety. Future research should be aimed at deriving a clinical prediction rule to identify low risk patients who can be safely discharged after a limited emergency department evaluation.

Development, implementation and reliability assessment of an emergency physician performance evaluation tool.

UNLABELLED: Evaluation of physician practice is necessary, both to provide feedback for self-improvement and to guide department heads during yearly evaluations. OBJECTIVE: To develop and implement a peer-based performance evaluation tool and to measure reliability and physician satisfaction. METHODS: Each emergency physician in an urban emergency department evaluated their peers by completing a survey consisting of 21 questions on effectiveness in 4 categories: clinical practice, interaction with coworkers and the public, nonclinical departmental responsibilities, and academic activities. A sample of emergency nurses evaluated each emergency physician on a subset of 5 of the questions. Factor analysis was used to assess the reliability of the questions and categories. Intra-class correlation coefficients were calculated to determine inter-rater reliability. After receiving their peer evaluations, each physician rated the process's usefulness to the individual and the department. RESULTS: 225 surveys were completed on 16 physicians. Factor analysis did not distinguish the nonclinical and academic categories as distinct; therefore, the survey questions fell into 3 domains, rather than the 4 hypothesized. The overall intra-class correlation coefficient was 0.43 for emergency physicians, indicating moderate, but far from perfect, agreement. This suggests that variability exists between physician evaluators, and that multiple reviewers are probably required to provide a balanced physician evaluation. The intra-class correlation coefficient for emergency nurses was 0.11, suggesting poor reliability. Overall, 11 of 15 physicians reported the process valuable or mostly valuable, 3 of 15 were unsure and 1 of 15 reported that the process was definitely not valuable. CONCLUSION: Physician evaluation by a single individual is probably unreliable. A useful physician peer evaluation tool can be developed. Most physicians view a personalized, broad-based, confidential peer review as valuable.

The NARC (nonsteroidal anti-inflammatory in renal colic) trial. Single-dose intravenous ketorolac versus titrated intravenous meperidine in acute renal colic: a randomized clinical trial.

OBJECTIVES: Intravenous (IV) opioid titration is an accepted method of relieving acute renal colic. Studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective in this setting. Our objective was to compare single-dose ketorolac and titrated meperidine, both administered intravenously, with respect to speed and degree of analgesia, adverse effects and functional status. Our primary hypothesis was that these agents provide equivalent analgesia within 60 minutes. Our secondary hypotheses were that ketorolac-treated patients would experience fewer adverse effects and would be better able to resume usual activity. METHODS: This was a multicentre, double-blind randomized equivalence trial in a convenience sample of patients age 18-65 with moderate or severe renal colic, documented by intravenous pyelogram, ultrasound or stone passage. Meperidine-treated patients received 50 mg IV meperidine at 0 minutes, then 25-50 mg every 15 minutes as needed for ongoing pain. Ketorolac-treated patients received 30 mg IV ketorolac at 0 minutes and placebo injections every 15 minutes as needed. Pain levels and adverse effects were assessed every 15 minutes, and functional status was evaluated at 60 minutes. Our primary outcome was the proportion of patients with mild or no pain at 60 minutes. RESULTS: Overall, 49 of 77 meperidine-treated patients (64%; 95% confidence interval [CI], 53%-75%) and 47 of 65 ketorolac-treated patients (72%; 95% CI, 61%-83%) achieved successful pain relief at 60 minutes (p value for equivalence = 0.002). Ten percent of meperidine-treated patients and 44% of ketorolac-treated patients were able to resume usual activity at 60 minutes (p = 0.001). CONCLUSIONS: In the doses studied, single-dose IV ketorolac is as effective as titrated IV meperidine for the relief of acute renal colic and causes less functional impairment.