Expression and Molecular Regulation of the Cox2 Gene in Gastroenteropancreatic Neuroendocrine Tumors and Antiproliferation of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs).

BACKGROUND Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) has had a significant increase over the past 4 decades. The pathophysiological role of the cyclooxygenase-2 (cox-2) gene and factors responsible for the expression in GEP-NETs is of clinical value. Current study determined the expression of cox-2 gene in human GEP-NET tissues and corresponding cell lines, investigated the molecular mechanisms underlying the regulation of cox-2 gene expression and assessed the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on both anchorage-dependent and independent growth of GEP-NET cells. MATERIAL AND METHODS GEP-NET tissues and QGP-1, BON, and LCC-18 GEP-NET cell lines were used. The expression of cox-2 gene was analyzed by immunohistochemistry, western blot, RT-PCR, and enzyme immunoassay. Transient transfection and luciferase assays along with electrophoretic mobility shift assays were conducted to explore the regulation of cox-2 gene expression. The effect of COX-inhibitors on GEP-NET cell growth was determined by proliferation assays and colony growth assessment. RESULTS We found 87.8% of GEP-NET tissues stained positive for COX-2. QGP-1 and LCC-18 cells expressed cox-2 gene. PGE2 (prostaglandin E2) amounts quantified in the supernatants of NET cells matched to cox-2 expression level. The CRE-E-box element (-56 to -48 bp) and binding of USF1, USF2, and CREB transcription factors to this proximal promoter element were essential for cox-2 promoter activity in GEP-NET cells. COX-2-specific inhibitor NS-398 potently and dose-dependently inhibited PGE2 release from QGP-1 cells. Interestingly, both NS-398 and acetylic salicylic acid effectively suppressed proliferation of QGP-1 and BON cells in a dose-dependent manner. CONCLUSIONS The majority of GEP-NETs over express cox-2 gene. The binding of CREB and USF-1/-2 transcription factors to a proximal, overlapping CRE-Ebox element is the underlying mechanism for cox-2 gene expression. NSAIDs potently suppressed the proliferations and may offer a novel approach for chemoprevention and therapy of GEP-NETs.

NHAMCS Validation of Emergency Severity Index as an Indicator of Emergency Department Resource Utilization.

INTRODUCTION: Triage systems play a vital role in emergency department (ED) operations and can determine how well a given ED serves its local population. We sought to describe ED utilization patterns for different triage levels using the National Hospital Ambulatory Medical Care Survey (NHAMCS) database. METHODS: We conducted a multi-year secondary analysis of the NHAMCS database from 2009-2011. National visit estimates were made using standard methods in Analytics Software and Solutions (SAS, Cary, NC). We compared patients in the mid-urgency range in regard to ED lengths of stay, hospital admission rates, and numbers of tests and procedures in comparison to lower or higher acuity levels. RESULTS: We analyzed 100,962 emergency visits (representing 402,211,907 emergency visits nationwide). In 2011, patients classified as triage levels 1-3 had a higher number of diagnoses (5.5, 5.6 and 4.2, respectively) when compared to those classified as levels 4 and 5 (1.61 and 1.25). This group also underwent a higher number of procedures (1.0, 0.8 and 0.7, versus 0.4 and 0.4), had a higher ED length of stay (220, 280 and 237, vs. 157 and 135), and admission rates (32.2%, 32.3% and 15.5%, vs. 3.1% and 3.6%). CONCLUSION: Patients classified as mid-level (3) triage urgency require more resources and have higher indicators of acuity as those in triage levels 4 and 5. These patients' indicators are more similar to those classified as triage levels 1 and 2.

Qualitative evaluation of trauma delays in road traffic injury patients in Maringá, Brazil.

BACKGROUND: Road traffic injuries (RTIs) are the eighth leading cause of death worldwide, with an estimated 90% of RTIs occurring in low- and middle-income countries (LMICs) like Brazil. There has been minimal research in evaluation of delays in transport of RTI patients to trauma centers in LMICs. The objective of this study is to determine specific causes of delays in prehospital transport of road traffic injury patients to designated trauma centers in Maringá, Brazil. METHODS: A qualitative method was used based on the Consolidated Criteria for Reporting Qualitative Research (COREQ) approach. Eleven health care providers employed at prehospital or hospital settings were interviewed with questions specific to delays in care for RTI patients. A thematic analysis was conducted. RESULTS: Responses to primary causes of delay in treatment to RTI patients fell into the following categories: 1) lack of public education, 2) traffic, 3) insufficient personnel/ambulances, 4) bureaucracy, and 5) poor location of stations. Suggestions for improvement in delays fell into the categories of 1) need for centralized station/avoid traffic, 2) improving public education, 3) Increase personnel, 4) increase ambulances, 5) proper extrication/rapid treatment. CONCLUSION: Our study found varied responses between hospital and SAMU providers regarding specific causes of delay for RTI patients; SAMU providers cited primarily traffic, bureaucracy, and poor location as primary factors while hospital employees focused more on public health aspects. These results mirror prehospital system challenges in other developing countries, but also provide solutions for improvement with better infrastructure and public health campaigns.

The epidemiology and hotspots of road traffic injuries in Moshi, Tanzania: An observational study.

Road traffic injuries (RTIs) continue to increase with the proliferation of motor vehicles, especially in low-income countries where safe road infrastructure is lacking. Knowing where and why RTIs occur would allow for increased safety and prevention planning. In this study, police records of 300 motor vehicle collisions which occurred between February 2013 and January 2014 in Moshi, Tanzania were reviewed. Analysis of variables including victim age, gender, type of collision, conditions, and use of safety equipment were analyzed. Geographic information system (GIS) analysis was performed to identify areas with the most collisions. Most injuries occurred at four intersections on two main corridor. Car crashes represented 48% of reports while motorcycle collisions were 35% of reports. Victims were predominantly male. The majority (64%) of RTI victims in cars used seatbelts while only 43% of motorcyclists wore helmets; none of those who used the helmet or seatbelt suffered a grievous injury. These data demonstrate that RTIs in Moshi occur in predictable high traffic locations. RTIs injure victims of all backgrounds and safety equipment is not universally utilized. More investment is needed in improved data collection methods, and a greater emphasis on intersection safety is needed to reduce these preventable injuries.

A prospective registry evaluating the epidemiology and clinical care of traumatic brain injury patients presenting to a regional referral hospital in Moshi, Tanzania: challenges and the way forward.

Traumatic brain injury (TBI) is the most common cause of death and disability globally disproportionately affecting low- and middle-income countries where increasing injury rates are compounded by limited quality care. The objective of this study is to describe quality of care for TBI patients who presented to Kilimanjaro Christian Medical Center, Moshi, Tanzania. We evaluated a prospective quality improvement TBI registry that enrolled consecutive patients with acute TBI. Descriptive statistics and qualitative comparative analysis was performed. Overall, 893 TBI patients were enrolled during the study period, with a mean age of 32.1 years and who were mostly (80%) male. 12.9% suffered severe TBI (GCS < 9). Most injuries were road traffic (66%) especially motorcyclists (49%) and 26.8% were alcohol related. One intubation occurred, and 22.9% of hypoxic patients received oxygen. Severe TBI mortality was 47%. TBI affects men 15-45 years old in traffic crashes with high mortality for severe TBI (47%) patients. Care addressing secondary injury, hypoxemia, and hypotension is limited.

Who explicitly requests the ordering of computed tomography for emergency department patients? A multicenter prospective study.

Emergency department (ED) computed tomography (CT) use has increased substantially in recent years, resulting in increased radiation exposure for patients. Few studies have assessed which parties contribute to CT ordering in the ED. The objective of this study was to determine the proportion of CT scans ordered due to explicit requests by various stakeholders in ED patient care. This is a prospective, observational study performed at three university hospital EDs. CT scans ordered during research assistant hours were eligible for inclusion. Attending emergency physicians (EPs) completed standardized data forms to indicate all parties who had explicitly requested that a specific CT be performed. Forms were completed before the CT results were known in order to minimize bias. Data were obtained from 77 EPs regarding 944 CTs. The parties most frequently requesting CTs were attending EPs (82.0 %, 95 % CI 79.4-84.3), resident physicians (28.6 %, 95 % CI 25.8-31.6), consulting physicians (24.4 %, 95 % CI 21.7-27.2), and admitting physicians (3.9 %, 95 % CI 2.9-5.4). In the 168 instances in which the attending EP did not explicitly request the CT, requests most commonly came from consulting physicians (51.2 %, 95 % CI 43.7-58.6), resident physicians in the ED (39.9 %, 95 % CI 32.8-47.4), and admitting physicians (8.9 %, 95 % CI 5.5-14.2). EPs were the sole party requesting CT in 46.2 % of cases while multiple parties were involved in 39.0 %. Patients, families, and radiologists were uncommon sources of such requests. Emergency physicians requested the majority of CTs, though nearly 20 % were actually not desired by them. Admitting, consulting, and resident physicians in the ED were important contributors to CT utilization.

Road Traffic Injury Prevention Initiatives: A Systematic Review and Metasummary of Effectiveness in Low and Middle Income Countries.

BACKGROUND: Road traffic injuries (RTIs) are a growing but neglected global health crisis, requiring effective prevention to promote sustainable safety. Low- and middle-income countries (LMICs) share a disproportionately high burden with 90% of the world's road traffic deaths, and where RTIs are escalating due to rapid urbanization and motorization. Although several studies have assessed the effectiveness of a specific intervention, no systematic reviews have been conducted summarizing the effectiveness of RTI prevention initiatives specifically performed in LMIC settings; this study will help fill this gap. METHODS: In accordance with PRISMA guidelines we searched the electronic databases MEDLINE, EMBASE, Scopus, Web of Science, TRID, Lilacs, Scielo and Global Health. Articles were eligible if they considered RTI prevention in LMICs by evaluating a prevention-related intervention with outcome measures of crash, RTI, or death. In addition, a reference and citation analysis was conducted as well as a data quality assessment. A qualitative metasummary approach was used for data analysis and effect sizes were calculated to quantify the magnitude of emerging themes. RESULTS: Of the 8560 articles from the literature search, 18 articles from 11 LMICs fit the eligibility and inclusion criteria. Of these studies, four were from Sub-Saharan Africa, ten from Latin America and the Caribbean, one from the Middle East, and three from Asia. Half of the studies focused specifically on legislation, while the others focused on speed control measures, educational interventions, enforcement, road improvement, community programs, or a multifaceted intervention. CONCLUSION: Legislation was the most common intervention evaluated with the best outcomes when combined with strong enforcement initiatives or as part of a multifaceted approach. Because speed control is crucial to crash and injury prevention, road improvement interventions in LMIC settings should carefully consider how the impact of improvements will affect speed and traffic flow. Further road traffic injury prevention interventions should be performed in LMICs with patient-centered outcomes in order to guide injury prevention in these complex settings.

Noninvasive ventilation in severe acute asthma.

Noninvasive ventilation (NIV) in severe acute asthma is controversial but may benefit this population by preventing intubation. We report on a 35-year-old male asthma patient who presented to our emergency department via emergency medical services. The patient was responsive, diaphoretic, and breathing at 35 breaths/min on 100% oxygen with bag-mask assistance, with S(pO2) 88%, heart rate 110-120 beats/min, blood pressure 220/110 mm Hg, and temperature 35.8 °C. NIV at 12/5 cm H2O and FIO2 0.40 was applied, and albuterol at 40 mg/h was initiated. Admission arterial blood gas revealed a pH of 6.95, P(aCO2) 126 mm Hg, and P(aO2) 316 mm Hg. After 90 min of therapy, P(aCO2) was 63 mm Hg. Improvement continued, and NIV was stopped 4 h following presentation. NIV tolerance was supported with low doses of lorazepam. The patient was transferred to the ICU, moved to general care the next morning, and discharged 3 days later. We attribute our success to close monitoring in a critical care setting and the titration of lorazepam.

Transcription of the vascular endothelial growth factor receptor-3 (VEGFR3) gene is regulated by the zinc finger proteins Sp1 and Sp3 and is under epigenetic control: transcription of vascular endothelial growth factor receptor 3.

BACKGROUND: In the past, the vascular endothelial growth factor receptor-3 (VEGFR-3) has been linked to the regulation of lymphangiogenesis and the lymphatic spread of solid malignancies. The molecular mechanisms controlling VEGFR3 gene expression have, however, remained poorly understood. Here, we aimed at assessing these mechanisms through VEGFR3 gene promoter analysis and the identification of transcription factors binding to it. In addition, we focussed on epigenetic modifications underlying VEGFR3 transcription regulation. METHODS: 5' Deletion analyses for the identification of functional promoter elements, electrophoretic mobility shift assays, chromatin immunoprecipitations, methylation-specific PCRs, and Trichostatin A (TSA) and 5-Aza desoxycytidine (5-Aza dC) treatments were performed in this study. RESULTS: Following the isolation of a 2 kb stretch of 5'-flanking DNA of VEGFR3, we identified a novel GC-rich element (GRE) spanning -101/-66 sufficient for VEGFR3 transcription and activated by Sp1 and Sp3, respectively. Histone de-acetylase inhibition by TSA led to the accumulation of acetylated histones H3/H4 at the VEGFR3 gene promoter, up-regulation of its mRNA levels, and transactivation of promoter reporter constructs in endothelial cell lines. Similarly, methylation inhibition by 5-Aza dC triggered up-regulation of VEGFR3 mRNA levels and increased promoter activity. TSA and 5-Aza-dC did not influence Sp1/Sp3 binding, but increased the transactivating capacity of both transcription factors, suggesting epigenetic modification as an underlying mechanism. CONCLUSIONS: Here we describe the identification of regulatory elements controlling human VEGFR3 gene expression and show that histone acetylation and CpG methylation are important determinants of VEGFR3 transcription regulation. These findings may facilitate the development of intervention strategies aimed at targeting VEGFR3-based tumor lymphangiogenesis and/or lymphatic tumor spread.

Systematic review and metasummary of attitudes toward research in emergency medical conditions.

Emergency departments are challenging research settings, where truly informed consent can be difficult to obtain. A deeper understanding of emergency medical patients' opinions about research is needed. We conducted a systematic review and meta-summary of quantitative and qualitative studies on which values, attitudes, or beliefs of emergent medical research participants influence research participation. We included studies of adults that investigated opinions toward emergency medicine research participation. We excluded studies focused on the association between demographics or consent document features and participation and those focused on non-emergency research. In August 2011, we searched the following databases: MEDLINE, EMBASE, Google Scholar, Scirus, PsycINFO, AgeLine and Global Health. Titles, abstracts and then full manuscripts were independently evaluated by two reviewers. Disagreements were resolved by consensus and adjudicated by a third author. Studies were evaluated for bias using standardised scores. We report themes associated with participation or refusal. Our initial search produced over 1800 articles. A total of 44 articles were extracted for full-manuscript analysis, and 14 were retained based on our eligibility criteria. Among factors favouring participation, altruism and personal health benefit had the highest frequency. Mistrust of researchers, feeling like a 'guinea pig' and risk were leading factors favouring refusal. Many studies noted limitations of informed consent processes in emergent conditions. We conclude that highlighting the benefits to the participant and society, mitigating risk and increasing public trust may increase research participation in emergency medical research. New methods for conducting informed consent in such studies are needed.

Perinatal implications of motor vehicle accident trauma during pregnancy: identifying populations at risk.

OBJECTIVE: The purpose of this study was to examine the association between restraint use, race, and perinatal outcome after motor vehicle accidents (MVAs) during pregnancy. STUDY DESIGN: The Duke Trauma Registry and medical records were searched for information on pregnant women at >14 weeks' gestation who were involved in an MVA and who received care through the Emergency Department and the Obstetric Units. Between January 1994 and December 31, 2010, 126 women were identified. Variables that were collected included type of trauma, gestational age at presentation, and delivery outcomes. A prognostic study was performed that evaluated the associations between maternal demographics, details of the accident that included restraint use, and maternal treatment that was related to the accident in relationship to perinatal outcome. RESULTS: There was no difference in the mean age or median gravidity or parity by race among pregnant women who were cared for after an MVA. There was no difference in mean age or racial distribution between women who were restrained compared with women who were unrestrained; unrestrained women were more likely to be nulliparous. Unrestrained women were more likely to require nonobstetric surgery that was related to the trauma. The overall rate of placental abruption was 6%. There were 6 intrauterine fetal deaths, 3 each in the unrestrained (25%) and restrained groups (3.5%; P = .018). Airbags deployed in 17 accidents. Among the 7 women with placenta abruption, 4 women (57%) experienced air bag deployment. CONCLUSION: Lack of restraint use during pregnancy is associated with an increased risk of fetal death.

Microarray meta-analysis defines global angiogenesis-related gene expression signatures in human carcinomas.

Angiogenesis is a prerequisite for progression of cancers. The number of genes linked to angiogenesis suggests the existence of complex gene-networks, which remain to be elucidated. To identify angiogenesis genes deregulated in carcinomas, we performed a meta-profiling analysis of published gene expression microarray studies. Own microarray and quantitative RT-PCR data were obtained from a colorectal carcinoma cohort. Applying highly stringent inclusion criteria, 15 cancer array studies were suitable for our analysis. These studies provided 789 tumor specimens and 190 samples of healthy tissues yielding a total of approx. 1,000,000 gene expression measurements. Meta-analysis on the expression of 480 angiogenesis-related genes in 10 cancer types identified a characteristic, entity-independent "global" cancer expression signature of 25 angiogenesis-related genes showing high frequency down-regulation when compared to corresponding healthy tissues. Furthermore, we characterized 25 genes displaying frequent up-regulation, yet less often than the 25 down-regulated genes. Comparative inter-study cross-validation revealed that both signatures discriminate cancers from healthy tissues with high accuracy in independent test sets. Moreover, own microarray data of colorectal carcinomas confirmed the specific and sensitive discriminating potential of both signatures. These results were validated by quantitative RT-PCR for eight genes displaying the highest differences in the microarray analysis. Our study for the first time defines global gene expression signatures linked to angiogenesis in carcinomas. Our findings suggest that gene down-regulation may represent a central aspect of tumor angiogenesis.

Dental visits to a North Carolina emergency department: a painful problem.

BACKGROUND: Emergency departments (EDs) act as the safety net and alternative care site for patients without insurance who have dental pain. METHODS: We conducted a retrospective chart review of visits to an urban teaching hospital ED over a 12-month period, looking at patients who presented with a chief complaint or ICD code indicating dental pain, toothache, or dental abscess. RESULTS: The number of visits to this ED by patients with a dental complaint was 1,013, representing approximately 1.3% of all visits to this ED. Dental patients had a mean age of 32 (+/- 13) years, and 60% of all dental visits were made by African Americans. Dental patients were more likely to be self-pay than all other ED patients (61% versus 22%, P < 0.001). At the vast majority of dental ED visits (97%), the patient was treated and discharged; at most visits (90%) no dental procedure was performed. ED treatment typically consisted of pain control and antibiotics; at 81% of visits, the patient received an opiate prescription on discharge, and at 69% of visits, the patient received an antibiotic prescription on discharge. LIMITATIONS: This retrospective chart review covered a limited period of time, included only patients at a large urban academic medical center, and did not incorporate follow-up analysis. CONCLUSION: Although they make up a small percentage of all ED visits, dental ED visits are more common among the uninsured, seldom result in definitive care or hospital admission, and often result in prescription of an opioid or antibiotic. These findings are cause for concern and have implications for public policy.

Analysis of traumatic injuries presenting to a referral hospital emergency department in Moshi, Tanzania.

BACKGROUND: Injuries represent a significant and growing public health concern in the developing world, yet their impact on patients and the emergency health-care system in the countries of East Africa has received limited attention. This study evaluates the magnitude and scope of injury related disorders in the population presenting to a referral hospital emergency department in northern Tanzania. METHODS: A retrospective chart review of patients presenting to the emergency department at Kilimanjaro Christian Medical Centre was performed. A standardized data collection form was used for data abstraction from the emergency department logbook and the complete medical record for all injured patients. Patient demographics, mechanism of injury, location, type and outcomes were recorded. RESULTS: Ten thousand six hundred twenty-two patients presented to the emergency department for evaluation and treatment during the 7-month study period. One thousand two hundred twenty-four patients (11.5%) had injuries. Males and individuals aged 15 to 44 years were most frequently injured, representing 73.4% and 57.8%, respectively. Road traffic injuries were the most common mechanism of injury, representing 43.9% of injuries. Head injuries (36.5%) and extremity injuries (59.5%) were the most common location of injury. The majority of injured patients, 59.3%, were admitted from the emergency department to the hospital wards, and 5.6%, required admission to an intensive care unit. Death occurred in 5.4% of injured patients. CONCLUSIONS: These data give a detailed and more robust picture of the patient demographics, mechanisms of injury, types of injury and patient outcomes from similar resource-limited settings.

Health care utilization before and after an outpatient ED visit in older people.

BACKGROUND: Older adults in the United States receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization have not been adequately studied in this population. OBJECTIVES: The goals of this study were to examine the relationships between health care use before and after an ED visit among older adults. METHODS: This retrospective cohort study examined health care use among 308 patients 65 years or older discharged from a university-affiliated ED. Proportional-hazards models were used to assess the relationship between pre-ED health care use (primary care physician [PCP], specialist, ED, and hospital) and risk of return ED visits. RESULTS: Older ED patients in this study had visited other types of providers frequently in the previous year (median number of PCP and specialist visits, 4). Patients who used the ED on 2 or more occasions in the previous year were found to have visited their PCP more often than those without frequent ED use (median number of visits, 7.0 vs 4.0; P < .001). Despite more PCP use in this population, frequent ED use was associated with increased risk of a repeat ED visit (hazard ratio, 2.20; 95% confidence interval, 1.15-4.21), in models adjusted for demographics and health status. CONCLUSION: Older adults who use the ED are also receiving significant amounts of care from other sources; simply providing additional access to care may not improve outcomes for these vulnerable individuals.

Comprehensive analysis of kinase inhibitor selectivity.

We tested the interaction of 72 kinase inhibitors with 442 kinases covering >80% of the human catalytic protein kinome. Our data show that, as a class, type II inhibitors are more selective than type I inhibitors, but that there are important exceptions to this trend. The data further illustrate that selective inhibitors have been developed against the majority of kinases targeted by the compounds tested. Analysis of the interaction patterns reveals a class of 'group-selective' inhibitors broadly active against a single subfamily of kinases, but selective outside that subfamily. The data set suggests compounds to use as tools to study kinases for which no dedicated inhibitors exist. It also provides a foundation for further exploring kinase inhibitor biology and toxicity, as well as for studying the structural basis of the observed interaction patterns. Our findings will help to realize the direct enabling potential of genomics for drug development and basic research about cellular signaling.

An observation unit may help improve an institution's Press Ganey satisfaction score.

BACKGROUND: : Hospitals measure patient satisfaction through Press Ganey (PG) surveys. The impact of an emergency department observation unit (EDOU) on patient satisfaction has not been reported to date. We hypothesize that an EDOU has a positive impact on patient satisfaction results as measured by PG surveys. METHODS: : This is a retrospective observational analysis of PG scores collected for 8 quarters before the opening of a 13-bed EDOU in January 2002 and compared with 6 quarters post-EDOU opening, starting April 1, 2003, at a tertiary care, academic, urban hospital. The facility, physician staffing, nursing, and wait times all remained the same during this period. Mean values and a 95% confidence interval (CI) are reported and statistical significance is calculated using a t test. Significance is defined as a P < 0.05. RESULTS: : The mean overall PG scores pre-EDOU was 75.2 (95% CI: 74.2-76.2) and post-EDOU was 80.2 (95% CI: 78.9-82.6), which is statistically significant (P = 0.00005). Of 9 scoring categories, 9 increased post-EDOU. Other than the category for physician scores, all other mean values were higher for the EDOU in the subcategories. CONCLUSION: : The introduction of an observation unit appears to be associated with a statistical improvement in patient satisfaction scores as reported by PG, in the setting of same facility, physician staffing, and nursing staffing.

Evaluation of a novel wound closure device: a multicenter randomized controlled trial.

OBJECTIVES: A novel wound closure device combining a mesh tape and octylcyanoacrylate (OCA) topical skin adhesive (TSA) was developed to facilitate wound closure and enhance the adhesive's strength. The objective of this study was to determine whether the incidence of wound dehiscence after laceration repair with the new device was equivalent to that after use of a high-viscosity OCA. We hypothesized that the rate of complete wound edge apposition would be equivalent for the two closure devices. METHODS: This was a multicenter, randomized clinical trial in nine academic and community emergency departments (EDs) and urgent care centers. Patients with simple traumatic lacerations were included. Lacerations were randomly closed with a high-viscosity OCA or mesh tape-OCA combination. The rate of complete wound edge apposition at 14 days, rates of wound infection at 14 and 30 days, and the percentage of optimally appearing scars at 30 days after closure were assessed. Assuming a maximal clinically acceptable difference for equivalence of 8% in the rate of completely apposed wound edges, a sample of at least 138 patients in the tape-OCA group and at least 69 in the OCA-only group would give 80% power and a one-sided significance level of 5%. RESULTS: During the study period the investigators enrolled 216 subjects, of whom 143 were randomized to the tape-OCA combination and 73 to the OCA-only group. Most wounds were located on the face and the upper extremities. Mean laceration length was similar in patients in both groups (tape-OCA 2.1 cm vs. OCA-only 2.0 cm; difference 0.1 cm, 95% confidence interval [CI] = -0.45 to 0.58 cm). The rate of complete wound edge apposition at 14 days was higher in wounds treated with the tape-OCA combination than in wounds treated with OCA alone (86.0% vs. 78.1%). The upper bound of the one-sided CI was 1.0% for the intention-to-treat population, which was less than the predetermined acceptable difference of less than 8%. There were no between-group differences in rates of infection and optimally appearing scars. CONCLUSIONS: When compared with OCA alone, the novel tape-OCA combination is equivalent with regard to complete wound edge apposition and cosmetic appearance.

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes.

OBJECTIVES: To describe older patients' understanding of emergency department (ED) discharge information and to explore the relationship between understanding of ED discharge information and adverse outcomes. METHODS: Telephone interviews were conducted with patients 65 years or older (or their proxies) within 72 hours of discharge from an academic medical center ED. We assessed 4 areas of discharge information: ED diagnosis, expected course of illness, self-care instructions, and return precautions. Adverse events were defined as repeat ED visits and hospitalizations or deaths within 90 days of ED discharge. Reverse Kaplan-Meier curves were constructed to illustrate cumulative event probabilities according to patient understanding of discharge information (differences examined with log-rank tests). RESULTS: Of 92 respondents (mean patient age, 75.1; SD, 7.4; 59.8% female subjects), patients or proxies reported not understanding discharge information about diagnosis (20.7%), self-care instructions (16.3%), expected course of illness (63%), and return precautions (55.7%). Within 90 days of ED discharge, 42.3% of patients had returned to the ED, 30.4% were hospitalized, and 4.3% had died. There was little difference in cumulative event probabilities according to whether patients understood self-care instructions or return precautions. Adverse event probabilities were higher among patients who did not understand their ED diagnosis (P = 0.33) and those who did not understand expected course of illness (P = 0.12), although these did not achieve statistical significance. CONCLUSIONS: A substantial number of older patients, or proxies, may not understand ED discharge information, and this could have an effect on patient outcomes. Strategies are needed to improve communication of ED discharge information to older patients and their families.