Congenital malaria in a hyperendemic area.

The prevalence of Plasmodium falciparum malaria was evaluated in all near-term pregnant women and their newborns at the Macha Hospital in the Southern Province of Zambia during part of the rainy season, when malaria prevalence is at its peak. Peripheral parasitemia was noted in 19 (29%) of 65 newborns and in 40 (63%) of 63 mothers. All but one of the infected neonates had an infected mother, and 17 of 40 infected mothers gave birth to infected newborns. The parasite densities measured were uniformly low (less than 25,000/cc), and only seven of 19 infected neonates had fever within 48 hours of delivery suggestive of malaria infection. Parasitized newborns had a 469-gm lower average birthweight, but they did not have a higher incidence of prematurity or preterm delivery compared with uninfected newborns. In addition, the Apgar scores of infected and uninfected newborns were not significantly different. There was no correlation between neonatal parasitemia and either the sex of the child or the parity of the mother. Maternal chloroquine prophylaxis did not appear to be effective in preventing infection in the fetus or the gravida, and the emergence of chloroquine resistance may explain, in part, the greater prevalence of congenital malaria in endemic areas in recent years.

Depletion of O6-alkylguanine-DNA alkyltransferase activity in mammalian tissues and human tumor xenografts in nude mice by treatment with O6-methylguanine.

We have previously shown that exposure of cells in culture to O6-methylguanine significantly reduces their level of the repair protein, O6-alkylguanine-DNA-alkyltransferase (AGT), thus rendering cells more sensitive to the cytotoxic effects of chemotherapeutic chloroethylating agents. Experiments were carried out in mice to determine whether the AGT content of tissues and tumors could be reduced by in vivo treatment with O6-methylguanine. There was a dose-dependent decrease in AGT activity in liver tissues of CD-1 mice to 24% of basal levels after four hourly intraperitoneal injections of O6-methylguanine (110 mg/kg). Although the decline in AGT activity in the liver was reversible, the activity remained at 75% of basal levels for up to 25 h after the final injection. The effect of O6-methylguanine treatment on AGT activity was measured in mouse tissues as well as human colonic carcinoma tumors (HT29 and BE) grown in Swiss athymic nude mice. The activity in the liver, kidney, and spleen of these mice decreased to 33%-35% of control levels, whereas the activity in HT29 tumors was likewise diminished to 25% of control levels after four hourly injections of O6-methylguanine (100 mg/kg). There was no enhancement of the tumoricidal effectiveness of chloroethylating agents on the HT29 tumor after O6-methylguanine treatment, probably due to a disproportionately higher level of AGT in human tissue than in murine tissue. However, these studies suggest that O6-methylguanine can be given in vivo to examine the role of the AGT protein in protecting against the toxic and carcinogenic effects of alkylating agents.

Effectiveness of ignition interlock devices in reducing drunk driving recidivism.

OBJECTIVE: To determine if ignition interlock devices reduce driving while intoxicated (DWI) recidivism. SEARCH STRATEGIES: Cochrane Collaboration search strategies were used. SELECTION CRITERIA: Studies for selection examined the effectiveness of interlock programs in a defined population. Studies were required to have a clear description of the program and outcomes evaluated, to have a comparison group and to provide interpretable data. DATA COLLECTION AND ANALYSIS: A total of 31 studies were found. Ten studies met the selection criteria. Three of these studies were eliminated from further analysis because they did not contain original data. A fourth study was eliminated due to methodologic weaknesses, leaving six studies for final review and analysis. Pooled analyses were not done because studies did not follow similar methods over comparable time periods. MAIN RESULTS: Five of the six studies found interlocks were effective in reducing DWI recidivism while the interlock was installed in the car. In the five studies demonstrating a significant effect, participants in the interlock programs were 15%-69% less likely than controls to be re-arrested for DWI. The only reported randomized, controlled trial demonstrated a 65% reduction in re-arrests for DWI in the interlock group, compared with the control group. CONCLUSIONS: Alcohol ignition interlock programs appear to be effective in reducing DWI recidivism during the time period when the interlock is installed in the car. Future studies should attempt to control for exposure (i.e., number of miles driven) and determine if certain sub-groups are most benefited by interlock programs.

Behçet's disease in patients of west African and Afro-Caribbean origin.

AIM: To report the presence of Behçet's disease with ocular involvement in patients of west African or Afro-Caribbean origin. METHODS: Case series of eight patients reporting to a tertiary uveitis service. RESULTS: Eight patients with typical features of the disease are presented. Six of the eight patients were tested and found to be HLA-B51 negative. CONCLUSION: Behçet's disease has only been reported in sporadic case reports in the indigenous west African and Afro-Caribbean populations, in whom the incidence of HLA B51 is also very low. A series of patients from the London region presented with the typical symptoms and signs of disease, most of whom were also HLA B51 negative. The presence of disease in this population, when absent in the indigenous population, suggests either that ascertainment of disease is poor in the indigenous population or that acquired factors may be important in the aetiology of the disease.

Evaluating professionalism in emergency medicine: clinical ethical competence.

While the teaching and assessing of technical skills have been an integral part of residency training, the demonstration of ethical and humanistic skills has been more or less left to chance. Only in the last two decades has the formal teaching of bioethics become an accepted component of Western medical education. In spite of the many ethics lectures, discussions, conferences, and courses, the clinical impact of this educational paradigm shift remains unclear. Most ethics assessments to date are conducted retrospectively by risk managers and attorneys. The few prospective evaluations of trainees have focused on single-researcher observations or student attitude surveys that are fraught with observer and recall biases, respectively. More reliable and valid methods of identifying clinical ethical competence are needed. This paper reviews a variety of evaluative tools and suggests a three-level approach to monitoring the ethical knowledge, capacity, and real-time performance of emergency medicine residents.

Ethics seminars: case studies in "futility"-challenges for academic emergency medicine.

The concept of "futility" and its determination in emergency medicine pose unique challenges to emergency physicians, patients, and society. The term "futility," although commonly used, is problematic in its scope, meaning, and interpretation. To bridge this gap in understanding, the authors suggest the construct of clinically nonbeneficial interventions (CNBI), instead of "futility. " This language better informs discussions of nonbeneficial interventions across the risk spectrum of emergency medical practice, while retaining the focus on the patient's interests. Two cases are presented, which underscore the need for prudence and empathetic communication when addressing issues of CNBI. Determinations of expected benefit should be based on established scientific evidence, and the goals and values of patients, not on individual biases regarding quality of life or other subjective matters. While physicians are under no ethical obligation to provide treatments that they judge have no realistic likelihood of clinical benefit, the context in which these determinations take place is of critical importance. When certain interventions are appropriately withheld, concerted efforts should be made to maintain effective communication, comfort, support, and counseling for patients, friends, and families. In all aspects of clinical decision making, the value of various interventions and therapies must be based on expected risks and benefits to the patients, first and foremost.

Ethics seminars: beyond authorship requirements-ethical considerations in writing letters of recommendation.

Letters of recommendation may serve a number of vital functions related to the evaluation, selection, and promotion of candidates. The lure of academic celebrity or the desire of an individual candidate for a flattering letter must not threaten the veracity of the content. Letters of recommendation should be appropriately authored to meet the needs of the institution or individual requesting the letter, while keeping authenticity paramount. Length and content should be complete but not overly verbose. Relevant elements suggested by standardized formats should typically be included, such as nature of contact with the applicant, commitment to emergency medicine, work ethic, ability to develop a differential and treatment plan, personality, interpersonal interactions, and an overall comparative ranking. The seven cardinal elements of an exemplary letter of recommendation are that it should be: 1) authentic (based on adequate first-hand knowledge of the candidate's skills); 2) honest (accurate; avoiding exaggeration or hyperbole); 3) explicit (avoidance of veiled omissions); 4) balanced (taking care to incorporate both strengths and weaknesses); 5) confidential (avoiding unnecessary or unanticipated disclosure); 6) of appropriate detail and length (content relevant to the institutional or individual requests); and 7) technically clear (avoidance of unnecessary abbreviations and jargon). The implied duty to future students, colleagues, researchers, and patients who might come in contact with the applicant should motivate authors to write honest, explicit, appropriate, and complete letters.

Research ethics: ethical issues of data reporting and the quest for authenticity.

The search for truth and its unbiased reporting are ultimate goals of conducting scientific research. Ideally, the reporting of research data ought to be an objective task. In practice, however, it is fraught with numerous statistical and ethical pitfalls, seldom addressed in formal emergency medicine training. The lure of academic celebrity and related influences may persuade researchers to report results in ways that make data appear more interesting, or worthy of publication. Several examples of potentially misleading data reporting are illustrated, including using inappropriate statistical tests, neglecting negative results, omitting missing data points, failing to report actual numbers of eligible subjects, using inappropriate graph labels or terminology, data dredging, and others. Although potentially inaccurate or inflated methods of data reporting may not constitute overt scientific misconduct, the intentional misrepresentation of data is a form of fraud or deception. Publicly funded academic inquiry is a privilege and honor enjoyed by a trusted few. Regardless of outcome, every effort should be made to report data in the most scientifically accurate method. To this end, the Society for Academic Emergency Medicine Code of Conduct and American College of Emergency Physicians Code of Ethics provide important guidance toward the accurate, compassionate, competent, impartial, and honest conduct of scientific research. Accuracy and authenticity in data reporting are first and foremost a matter of individual integrity, and are crucial to the preservation of academic credibility, the protection of future patients, and the public's trust in the medical research enterprise.

Doing unto others? Emergency medicine residents' willingness to be treated by moonlighting residents and nonphysician clinicians in the emergency department.

OBJECTIVE: Contentious moonlighting policies and the proliferation of nonphysician clinicians (NPCs) in academic emergency departments (EDs) send conflicting messages to emergency medicine (EM) residents regarding appropriate ED staffing patterns. The objective was to assess EM resident (EMR) views on the ED utilization of unsupervised residents and NPCs from their perspectives as both physicians and prospective patients. METHODS: A survey was mailed to a random sample of senior EMRs (sampling fraction, 68%) from the Emergency Medicine Residents Association membership list. Respondents were instructed to assume the role of patient when presented with hypothetical clinical scenarios of increasing severity; outcomes included provider preferences and the impacts of medical urgency, time delays, costs, and supervision on those preferences. Survey items asked about willingness to see residents, nurse practitioners (CRNPs), and physician assistants (PAs), and perceived impact of NPCs on professional identity. RESULTS: A total of 251 EMRs responded. Senior EMRs are more willing to have their care handled by residents as opposed to mid-level providers. For a moderate illness or injury scenario, 54% agreed to be seen by a resident alone compared with only 17% and 24% willing to be seen by a CRNP and PA, respectively. Only a small fraction of the residents (22.7%) would allow another resident to treat them for a major injury or illness. Residents are more willing to be seen by mid-level providers if a savings in time can be realized but showed little interest in using NPCs to save money. Approximately one-third (34%) of the residents view mid-level providers as a professional threat, but logistic regression reveals this perception to be 2.25 (1.3, 4.0) times higher in male EMRs and 1.94 (1.1, 3.4) times higher in those with higher household incomes (> or =$75,000). CONCLUSIONS: When assuming the patient role, senior EMRs have preferences for ED care that are consistent with restrictive EMR moonlighting and NPC staffing policies.

Professionalism in emergency medicine. SAEM Ethics Committee. Society for Academic Emergency Medicine.

The Society for Academic Emergency Medicine (SAEM), with the support and participation of the American Board of Emergency Medicine (ABEM), the Council of Residency Directors (CORD), the American College of Emergency Physicians (ACEP), the Emergency Medicine Residents Association (EMRA), the American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM), initiated a project entitled Professionalism in Emergency Medicine. Its concepts were developed by the SAEM Ethics Committee, and are intended to describe proper behaviors and attitudes of the successful practitioner of emergency medicine. The behaviors described are not primarily scientific or technical, since those are defined by the core curriculum for residency training and are tested through certification examinations. This document identifies attitudes and behaviors that enhance trust by placing the patient's interest above other interests. This concept serves as the operative definition of professionalism. The purpose of this article is to clarify the professional attitudes and knowledge that are important to the emergency physician (EP). While no physician is likely to meet idealized standards, all EPs must meet basic standards while striving for the ideal. Awareness of these standards must begin early in the socialization process of emergency medical professionals. The standards must be integrated into residency training as well as the clinical practice of all EPs.

Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department.

The determination of decision-making capacity (DMC) is an essential component of securing voluntary informed consent, for either treatment or refusal of care. Decision-making capacity should be determined on some level during each patient encounter. Decision-making capacity includes the ability to receive, process, and understand information, the ability to deliberate, the ability to make choices, and the ability to communicate those preferences. For patients in whom DMC may be uncertain, a more explicit approach to determination of DMC is recommended. However, DMC determination must neither compromise patient safety nor delay needed care. When DMC determination is challenging, or when the ramifications of a decision are serious, the assistance of a third party (such as a surrogate, a consultant, or another clinician) may be valuable in discerning the most appropriate action. In addition to the obvious clinical utility of DMC assessment, the steps taken in the very establishment of DMC may promote patient trust, professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion and respect we have for our patients must be unconditional.

Patients' perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia.

OBJECTIVE: There is a commonly held belief among health care providers that patients respond better to parenteral nonsteroidal anti-inflammatory drugs (NSAIDs) than to oral forms by virtue of the patients' belief that getting an injection means they are receiving "stronger" medicine. To the authors' knowledge, this effect has never been adequately documented in the literature. The objective of this study was to compare the effects of a placebo analgesic injection vs placebo oral analgesia on patients with acute musculoskeletal pain. METHODS: A convenience sample of emergency department (ED) patients with acute musculoskeletal pain secondary to trauma were enrolled. Patients received 225 mL of orange-flavored drink containing 800 mg of ibuprofen. Patients then received either a physiologically inactive starch tablet resembling ibuprofen 800 mg in taste and appearance or a physiologically inactive saline intramuscular (IM) injection resembling ketorolac 60 mg. Both patients and research nurses were blinded to the addition of ibuprofen to the drink and the inactive nature of subsequent medication. Pain was evaluated at time 0 and at 30, 60, 90, and 120 minutes on a 10-mm visual analog scale (VAS). RESULTS: Sixty-four patients completed the study protocol. The VAS scores between groups did not differ significantly at baseline or at each subsequent interval (p = 0.86). CONCLUSIONS: These results contradict the belief that parenteral medications confer a selective placebo effect stemming from patients' beliefs regarding route of administration and efficacy. Therefore, the routine use of IM administration of NSAIDs for suspected enhanced analgesia appears unwarranted.

The Emergency Medical Treatment and Labor Act as a federal health care safety net program.

Despite the greatest economic expansion in history during the 1990s, the number of uninsured U.S. residents surpassed 44 million in 1998. Although this number declined for the first time in recent years in 1999, to 42.6 million, the current economic slow-down threatens once again to increase the ranks of the uninsured. Many uninsured patients use hospital emergency departments as a vital portal of entry into an access-impoverished health care system. In 1986, Congress mandated access to emergency care when it passed the Emergency Medical Treatment and Labor Act (EMTALA). The EMTALA statute has prevented the unethical denial of emergency care based on inability to pay; however, the financial implications of EMTALA have not yet been adequately appreciated or addressed by Congress or the American public. Cuts in payments from public and private payers, as well as increasing demands from a larger uninsured population, have placed unprecedented financial strains on safety net providers. This paper reviews the financial implications of EMTALA, illustrating how the statute has evolved into a federal health care safety net program. Future actions are proposed, including the pressing need for greater public safety net funding and additional actions to preserve health care access for vulnerable populations.

Ethical issues of managed care.

In a competitive, monetized medical system, a clash of principles is inevitable; however, amid the tumult in the medical marketplace, the underlying tenets of emergency medical ethics remain inviolate. Although the goals of providing excellent and cost-effective care are not mutually exclusive, the conflicts encountered can only be resolved by appeal to a higher goal: the good of the patient. Both MCOs and EPs must function as agents of individual patients first and foremost. The enterprise of healthcare rests on fidelity, integrity, and trust; therefore, physicians and MCOs must accept and take seriously their important moral, legal, and social obligations to patients and society. Otherwise, third-party cost considerations and provider greed irreversibly could pervert the practice of medicine and destroy the last vestiges of fidelity in the patient-physician relationship.

Giant urethral calculus: a rare cause of acute urinary retention.

We present a case of a 98-yr-old woman with acute urinary retention secondary to a large urethral calculus. This is a unique cause of obstructive uropathy for several reasons. First, urethral calculi are extremely rare in American-born Caucasian females. Second, urethral stones in females are nearly always associated with underlying genitourinary pathology; however, subsequent work up failed to reveal any strictures, diverticula, or related processes that may have predisposed this patient to urethral calculus formation. The epidemiology, pathogenesis, clinical presentation, and emergency management of large urethral calculi are reviewed.

Resource utilization in the emergency department: the duty of stewardship.

As the pool of available health care resources continues to evaporate, emergency physicians will be increasingly required to guard against the provision of expensive, unnecessary, and marginally beneficial care. This article proposes that emergency physicians embrace the ethic of prudent resource stewardship to ensure the continued availability of emergency services to all who need them. When making resource allocation decisions, emergency physicians must consider the likelihood, magnitude, and duration of benefits to patients, the urgency of the condition, and the cost and burdens of treatment to patients, payers, and society. These considerations go beyond professional duties to individual patients and suggest that ignoring the burdens of emergency department microallocation decisions is socially and morally irresponsible.

Airbag-mediated corneal injury.

This is the first report of airbag-induced facial and corneal abrasions associated with several weeks of blurred vision in a patient without previous visual or ocular problems. Similar episodes of minor trauma from airbags are becoming commonplace, reflecting the increasing popularity of these lifesaving devices. Nonetheless, airbag-associated injuries, especially facial and ocular injuries, should be monitored and reported to both increase physician awareness and to determine if further airbag design improvements are necessary.

A randomized, double-blind, comparative study of the efficacy of ketorolac tromethamine versus meperidine in the treatment of severe migraine.

STUDY OBJECTIVE: To evaluate the relative efficacy of ketorolac tromethamine and meperidine hydrochloride in the emergency department treatment of severe migraine. DESIGN: Prospective, randomized, double-blind trial. SETTING: University hospital ED. PARTICIPANTS: Patients presenting to the ED with an isolated diagnosis of common or classic migraine. INTERVENTIONS: Subjects were randomized to receive a single intramuscular injection of either 30 mg ketorolac or 75 mg meperidine. MEASUREMENTS AND MAIN RESULTS: Of the 31 patients completing the trial, 15 received ketorolac and 16 received meperidine. The demographic characteristics of both groups were comparable. At one hour, ketorolac was significantly less effective than meperidine in reducing headache pain (P = .02) and in improving clinical disability (P = .01). Ketorolac also was less effective at reducing nausea, photophobia, and the need for rescue medication (P less than .05). Sustained headache relief was experienced by 44% of the patients treated with meperidine at 12- to 24-hour follow-up, compared with 13% of the patients treated with ketorolac (P = NS). No significant side effects were observed for either group. CONCLUSION: IM ketorolac tromethamine is less effective than meperidine in the ED treatment of severe migraine.