Primary cytomegalovirus infectious colitis complicating Crohn's disease successfully treated with oral valganciclovir.

Most cases of cytomegalovirus (CMV) colitis that develop in patients with inflammatory bowel disease (IBD) are caused by reactivation of a latent virus. Primary CMV infections are rare in adult patients. Treatment with immunosuppressive agents increases the infection risk in patients with IBD. We present a 26 year old lady with primary CMV colitis, superimposed on underlying Crohn's colitis. The diagnosis was confirmed by a viral-like prodrome, a positive CMV IgM titer, presence of low avidity IgG antibodies to CMV, high CMV DNA titers in the plasma, and immunohistological detection of CMV positive cells in her colonic mucosa. The patient responded to initial treatment with intravenous ganciclovir with a fall in plasma levels of CMV DNA, treatment was completed with oral valganciclovir until plasma CMV DNA levels became undetectable.

A comparison of methods for assessing penetrating trauma on retrospective multi-center data.

OBJECTIVE: TraumaSCAN-Web (TSW) is a computerized decision support system for assessing chest and abdominal penetrating trauma which utilizes 3D geometric reasoning and a Bayesian network with subjective probabilities obtained from an expert. The goal of the present study is to determine whether a trauma risk prediction approach using a Bayesian network with a predefined structure and probabilities learned from penetrating trauma data is comparable in diagnostic accuracy to TSW. METHODS: Parameters for two Bayesian networks with expert-defined structures were learned from 637 gunshot and stab wound cases from three hospitals, and diagnostic accuracy was assessed using 10-fold cross-validation. The first network included information on external wound locations, while the second network did not. Diagnostic accuracy of learned networks was compared to that of TSW on 194 previously evaluated cases. RESULTS: For 23 of the 24 conditions modeled by TraumaSCAN-Web, 16 conditions had Areas Under the ROC Curve (AUCs) greater than 0.90 while 21 conditions had AUCs greater than 0.75 for the first network. For the second network, 16 and 20 conditions had AUCs greater than 0.90 and 0.75, respectively. AUC results for learned networks on 194 previously evaluated cases were better than or equal to AUC results for TSW for all diagnoses evaluated except diaphragm and heart injuries. CONCLUSIONS: For 23 of the 24 penetrating trauma conditions studied, a trauma diagnosis approach using Bayesian networks with predefined structure and probabilities learned from penetrating trauma data was better than or equal in diagnostic accuracy to TSW. In many cases, information on wound location in the first network did not significantly add to predictive accuracy. The study suggests that a decision support approach that uses parameter-learned Bayesian networks may be sufficient for assessing some penetrating trauma conditions.

Pelvic fractures.

Pelvic fractures are associated with significant morbidity and mortality. Despite advances in emergency, radiologic, surgical, and ICU care that have improved survival during the past decade, the morbidity and the mortality remain significantly high. This article focuses on the recent developments in the initial management of pelvic fractures including the use of external pelvic binders, radiographic imaging, interventional radiology, and extraperitoneal packing.

A review of police pursuit fatalities in the United States from 1982-2004.

BACKGROUND: High-speed police pursuits are common in the United States (US). Most states do not gather statistics on police pursuits, pursuit crashes, injuries or fatalities for annual review. OBJECTIVE: The objective of this study is to determine the number of pursuit fatalities to officers, those in the chased vehicle, and those uninvolved in pursuits from 1982-2004. METHODS: A review of police pursuit fatalities reported to the National Highway Traffic Safety Administration (NHTSA) Fatality Analysis Reporting System (FARS) database from 1982-2004. The data was reviewed for fatalities, demographic data, alcohol involvement, road surface type (rural versus urban) and mechanism of collision leading to a pursuit fatality. RESULTS: From 1982-2004, 881,733 fatal crashes were reported to NHTSA, leading to 987,523 fatalities. Of fatal crashes, 6,336 (0.7%) were secondary to pursuits, leading to 7,430 (0.8%) fatalities, a mean of 323 per year. Among these fatalities, chased vehicle occupants accounted for 5,355 (72%); police for 81 (1%); those uninvolved for 1994 (27%). Of fatalities, 6074 (82%) were male, 2,092 (28%) were children and adolescents. Mean age of death was 24 years. African-Americans 1,154 (24%) and Native Americans 101 (2%) died at a higher proportion than their percentage of the US population. Collisions with solid objects accounted for 3,175 (59%) of fatalities in the chased vehicles. Collisions with other moving vehicles accounted for 1,434 (80%) of fatalities of vehicular occupants uninvolved in pursuits. Most fatal crashes, 3,130 (62%), occurred on urban roadways. Alcohol was involved in 4,628 (62%) fatalities. Of police fatalities, 20 (25%) were intoxicated. CONCLUSIONS: Police pursuits results in a small yet significant number of fatal motor vehicular crashes and fatalities. All states should record the total number of police pursuits, pursuit crashes, injuries and fatalities for annual review. The findings in this study have important operational implications for EMS care.

Evaluating the discriminatory power of a computer-based system for assessing penetrating trauma on retrospective multi-center data.

OBJECTIVE: To evaluate the discriminatory power of TraumaSCAN-Web, a system for assessing penetrating trauma, using retrospective multi-center case data for gunshot and stab wounds to the thorax and abdomen. METHODS: 80 gunshot and 114 stab cases were evaluated using TraumaSCAN-Web. Areas under the Receiver Operator Characteristic Curves (AUC) were calculated for each condition modeled in TraumaSCAN-Web. RESULTS: Of the 23 conditions modeled by TraumaSCAN-Web, 19 were present in either the gunshot or stab case data. The gunshot AUCs ranged from 0.519 (pericardial tamponade) to 0.975 (right renal injury). The stab AUCs ranged from 0.701 (intestinal injury) to 1.000 (tracheal injury).

The United States twenty-year experience with bombing incidents: implications for terrorism preparedness and medical response.

BACKGROUND: Terrorist bombings remain a significant threat in the United States. However, minimal longitudinal data exists regarding the medical and public health impact because of bombings. METHODS: We conducted a retrospective analysis of the number of incidents, injuries, and deaths because of explosive, incendiary, premature, and attempted bombings from January 1983 to December 2002. Morbidity and mortality by motives, target locations, and materials used were evaluated. RESULTS: In the United States, 36,110 bombing incidents, 5,931 injuries, and 699 deaths were reported. There were 21,237 (58.8%) explosive bombings, 6,185 (17.1%) incendiary bombings, 1,107 (3.1%) premature bombings, and 7,581 (21.0%) attempted bombings. For explosive bombings with known motives, 72.9% of injuries and 73.8% of deaths were because of homicide. For incendiary bombings with known motives, 68.2% of injuries were because of extortion and revenge, and 53.5% of deaths were due to homicide. Private residences accounted for 29.0% of incidents, 31.5% of injuries, and 55.5% of deaths. Government installations accounted for 4.4% of incidents but were the site of 12.7% of injuries and 25.5% of deaths. In bombings with known materials, nitrate-based fertilizers accounted for 36.2% of injuries and 30.4% of deaths, and smokeless powder and black powder accounted for 33.2% of injuries and 27.1% of deaths. CONCLUSIONS: Illegal bombings and related injuries commonly occur in the United States. Because of the easy availability of bombing materials, government agencies and healthcare providers should prepare for potential mass-casualty bombings.

A patient education intervention does not improve satisfaction with emergency care.

STUDY OBJECTIVE: We determine whether a patient education intervention based on a previously validated model increases satisfaction with emergency department (ED) care. METHODS: A single-page patient education form was distributed on alternating 2-week time blocks for 8 weeks at the triage desk of a single academic ED. Alert, discharged patients were administered an exit interview assessing satisfaction on a 5-point ordinal scale. Secondary outcomes included patient satisfaction measured on a bivariate scale, willingness to return, and process of care indicators previously demonstrated to be associated with satisfaction. Exclusion criteria included air or ground transport to the ED, inability to speak English or Spanish, and refusal to participate. Differences in patient satisfaction and other outcomes were adjusted for predefined covariates, including age, sex, triage severity, race, language, location in ED, total ED length of stay, and time to room, using multivariable logistic regression. RESULTS: Of 1,934 patients discharged during study periods, 1,233 (64%) were approached and 860 (44%) were enrolled. There were no important covariate differences between the control and intervention groups. There was no important correlation between intervention and patient satisfaction on univariate (odds ratio [OR] 0.840; 95% confidence interval [CI] 0.650 to 1.086) and multivariate analysis (OR 0.874; 95% CI 0.672 to 1.136). There were no important correlations between the intervention and secondary outcomes on multivariate analysis. CONCLUSION: A triage-based, patient education intervention did not significantly improve patient satisfaction or performance on predictors of satisfaction at the study site.

Drug resistance is uncommon in pregnant women with low viral loads taking zidovudine monotherapy to prevent perinatal HIV transmission.

Zidovudine monotherapy is used to reduce perinatal HIV transmission in women with low viral loads. There are few data on the risk of drug resistance in this select cohort of women. We determined the prevalence of newly acquired mutations conferring reduced sensitivity to zidovudine after exposure during pregnancy, and found that the development of mutations was uncommon and was restricted to women treated before 1998 who had higher baseline viral loads than those currently recommended monotherapy.