Chest radiographs in the emergency department: is the radiologist really necessary?

BACKGROUND: The chest radiograph is considered one of the most complex imaging modalities to interpret. Several studies have evaluated radiograph interpretation in the emergency department, and considerable disagreement among clinical physicians and expert radiologists has been observed in the reading of chest films. The interpretation of chest radiographs by emergency department physicians was compared with senior radiologists in discharged patients, and misinterpretations assessed in relation to the physician's level of training. METHODS: Radiological descriptions of 509 chest radiographs of 507 patients, aged 16-98 years who were discharged from the emergency department, were prospectively reviewed. Missed findings were recorded with regard to the physician's level of training and experience. The effects of misinterpretations on discharge recommendations were also investigated. Statistical assessment was conducted using the chi(2) test. Interobserver agreement was also tested by the kappa coefficient. RESULTS: The sensitivity for detecting different abnormalities in the radiographs ranged from 20% to 64.9% and specificity from 94.9% to 98.7%. Despite the low sensitivities found, there were relatively few clinical implications of the "missed" findings since they were either of a minor nature or appropriate follow up was prescribed. The overall interobserver reliability, assessed by the kappa coefficient, was 0.40 (95% confidence interval 0.35 to 0.46). These findings did not change significantly by emergency department physician's level of training. CONCLUSIONS: Emergency department physicians frequently miss specific radiographic abnormalities and there is considerable discrepancy between their interpretations and those of trained radiologists. These findings highlight the importance of routine evaluation of chest radiographs by a well trained radiologist and emphasise the need for improving interpretive skills among emergency department physicians.

The yield of blood cultures in a department of emergency medicine.

This study sought to determine the yield of blood cultures drawn in the department of emergency medicine. The results of 730 blood cultures taken from 718 patients were retrospectively analysed. The total percentage of positive cultures was 9.7%. Only 3.4% of the blood cultures were classified as true bacteraemia and the rest as contaminants. The commonest type of isolate was coagulase-negative staphylococci (49%), which were considered contaminants in all cases. Other contaminants represented 13.2% of all the positive blood cultures. The following bacteria comprised the group of true bacteraemia: Escherichia coli (12.6%), Streptococcus pneumoniae (9.8%), viridans streptococci (7%), Staphylococcus aureus (2.8%), Bacteroides fragilis (2.8%), Moraxella species (1.4%) and Flavobacterium species (1.4%). Blood cultures were positive in 3.6% of patients with pneumonia and in 10% of patients with urinary tract infections. In patients with fever of unclear source blood cultures were positive in 3.1% of children between 0-36 months of age and in 1.1% of patients older than 16 years. As a whole, patients with positive blood cultures were clinically sicker, a higher percentage of them required admission to the hospital and had higher temperatures or rapidly fatal disease, compared with the group of patients with negative blood cultures. In order to improve the yield of blood cultures in febrile patients, first, better a priori identification of those subjects at high risk for bacteraemia will reduce the number of unnecessary blood cultures and second, sterile venipuncture techniques should be improved in order to reduce the number of contaminants.

Rectal ulcers: a rare gastrointestinal manifestation of systemic lupus erythematosus.

A patient with systemic lupus erythematosus (SLE) developed a rectal ulcer and sepsis from colonic bacteria. At that time she had no other clinical manifestations of SLE. Histopathologic examination of the biopsies taken from the ulcer found evidence of vasculitis. Treatment with high-dose systemic steroids healed the ulcer clinically and endoscopically, but symptoms recurred when steroids were tapered. The patient was referred for surgery. This is a rare but dangerous complication of SLE and can be the only clinical manifestation of the disease.

Effect of colchicine and bisacodyl on rat intestinal transit and nitric oxide synthase activity.

BACKGROUND: Bisacodyl and colchicine affect smooth-muscle contractility, intestinal water, and electrolyte transport. Nitric oxide (NO) stimulates intestinal electrolyte secretion and has an important role as a mediator of intestinal motility. We therefore studied, in rats, the effects of these agents on nitric oxide synthase (NOS) activity and gastrointestinal transit. METHODS: Rats were treated with bisacodyl (10 mg/kg intragastrically) or colchicine (5 mg/kg intraperitoneally) with or without pretreatment with ketotifen (1 mg/kg intragastrically). Rats were killed after 1, 2, and 4 h. The intestine was isolated and rinsed, the mucosa scraped, and NOS activity determined. In all rats small-intestinal transit was measured 15 min after intragastric administration of charcoal. RESULTS: Bisacodyl (10 mg/kg) and colchicine (5 mg/kg) induced a significant decrease in jejunal NOS activity. Pretreatment with the mast cell stabilizer ketotifen, which has been shown to attenuate the increased permeability induced by NO inhibition, prevented the decrease in colonic and jejunal NOS activity induced by bisacodyl and colchicine. Bisacodyl and colchicine significantly decreased intestinal transit time. Their effect on transit time was similar to that induced by intravenous administration of NG-nitro-L-arginine methyl ester (10 mg/kg). CONCLUSIONS: It is suggested that the effect of bisacodyl and colchicine on intestinal transport is, at least partly, mediated through NO inhibition.

Open-access endoscopy of the upper gastrointestinal tract: is it indicated and efficient? Retrospective and prospective studies in an Israeli population.

Open-access endoscopy has recently gained popularity in referring patients for endoscopic procedures. Retrospective (looking into patients' medical files) and prospective studies (using 2 different questionnaires, and evaluating a selection system) were conducted, comparing the efficacy of open-access endoscopy for patients referred by either family practitioners or gastroenterologists. In the retrospective study, 673 patients (mean age 48.8 years, male-58%) underwent upper gastrointestinal endoscopy. The main indications for upper endoscopy were epigastric pain (71%), heartburn (18%) and vomiting (13%). Severe endoscopic findings were not different between the study groups. Normal or mildly abnormal findings were diagnosed in 75% of patients in both groups. In the prospective study, 361 patients were referred for upper endoscopy (mean age 50.2 years, male-58%). Although there were significantly (p < 0.01) fewer normal and more mild endoscopic findings in the patients referred by gastroenterologists, as compared with family practitioners, there was no difference in the clinically significant (severe) endoscopic findings. Previous ulcer, smoking, gender, age and nocturnal pain were predictive for severe endoscopic findings. There was a linear correlation between the severity of the scoring system and the endoscopic findings. The results of the present study, which reveal nonsignificant differences in the indications for and the findings of endoscopies, indicate that selection of patients for endoscopy can be safely done by family practitioners. In order to reduce the number of referred patients with no gastrointestinal pathology, a better scoring system to detect at-risk patients should be developed.

Role of small bowel biopsy in the endoscopic evaluation of adults with iron deficiency anemia.

OBJECTIVES: The recommended evaluation of adult patients presenting with iron deficiency anemia (IDA) includes the performance of colonoscopy and esophagogastroduodenoscopy. IDA is a common feature in patients with celiac disease and, in several, may be the only presenting sign. The performance of small bowel biopsy (SBB) for the evaluation of celiac disease as the cause of IDA is not routinely recommended. The aim of the present study was to determine the yield of SBB performed during routine endoscopy of adults with IDA. METHODS: We prospectively studied 93 patients with IDA. Three control groups were included: 23 patients with steatorrhea, 37 patients with idiopathic diarrhea, and 9 patients in whom SBB was performed for miscellaneous indications. RESULTS: Eleven patients with IDA and two patients with steatorrhea had SBB findings compatible with celiac disease. None of the patients from the other two groups had similar findings. Two patients with IDA, who were later diagnosed to suffer from celiac disease, presented: one with occult blood in the stool and the other with rectal bleeding. Subgroup analysis of patients with IDA revealed that patients with celiac disease were younger, had significantly more episodes of diarrhea, lower mean hemoglobin level, and longer duration of anemia than those without celiac disease. Other mucosal abnormalities were found in a substantial number of patients with celiac disease: esophagitis, gastritis, duodenitis, hemorrhoids, and colitis. CONCLUSIONS: A substantial number of adult Israeli patients who present with IDA are found, on SBB, to have mucosal abnormalities compatible with the diagnosis of celiac disease. The presence of esophagitis, gastritis, or duodenitis on esophagogastroduodenoscopy, or other abnormalities on colonoscopy, do not exclude the coexistence of celiac disease. Celiac disease should be included and routinely looked for in the differential diagnosis of adult patients with IDA.

Limitations of paperless on-line reporting of diagnostic bacteriology culture results.

AIMS: To estimate the extent to which microbiology laboratory results made available on a computerised reporting system do not reach their intended destination. METHODS: Prospective observational study of 180 urine cultures submitted from patients seen at the accident and emergency department of a 250 bed university affiliated general hospital. Observations were made of: telephone requests for results; whether results were noted in patients' charts; and antibiotic administration to patients sent home. RESULTS: Results were requested/recorded for 73% of 37 patients admitted to hospital and for only 23% of 143 patients sent home (p < 1 x 10(-7)). Overall, results were more frequently recorded for patients with positive cultures (p = 0.04). When determined separately for admitted and discharged groups, this association was not shown. Three of 14 culture positive patients sent home and for whom results were not recorded received inappropriate therapy; 19 culture negative patients were given antibiotics. CONCLUSIONS: In view of the results, measures were instituted to ensure delivery of printed reports to the health care providers of patients not admitted from the accident and emergency department. Organisations operating computerised reporting systems in evolving health care settings must ensure that system design guarantees delivery of reports to all end-users. This will minimise therapeutic problems, reduce wastage of laboratory resources, and limit risks of litigation.

Paresthesia in envenomation by the scorpion Leiurus quinquestriatus.

We observed two patients with systemic paresthesia as the sole systemic manifestation of envenomation by L. quinquestriatus. A prospective study of the incidence of local and systemic paresthesia in 20 consecutive patients stung by this scorpion was done. Sixteen patients (80%) had only local complaints and 4/20 (20%) had mild systemic manifestations. Eleven patients (55%) had local paresthesia and in 2 patients (10%) systemic paresthesia was noted involving all four extremities in one patient and the perioral area in the other. The possible mechanism of paresthesia following a scorpion sting is discussed.

The effect of nizatidine on duodenal ulcer healing and on mucosal inflammatory mediators.

The aim of this double-blind, randomized, placebo-controlled trial was to evaluate the effect of nizatidine on duodenal ulcer healing and generation of mucosal prostaglandin estradiol and inflammatory mediators. Fifty-five patients with endoscopically proven active duodenal ulcer received either nizatidine 300 mg or placebo, once nightly, for 4 weeks, when a second endoscopy was performed. Healing was defined as complete epithelialization of the ulcer crater. At both endoscopies mucosal biopsies were obtained for determination of prostanoids and inflammatory mediators. Nizatidine and placebo induced ulcer healing in 76% and 60.9% of the patients, respectively, but the difference did not reach statistical significance. Nizatidine treatment did not significantly affect mucosal leukotriene B4, leukotriene C4 or platelet activating factor generation. It is concluded, therefore, that the antisecretory effect is probably the main mechanism responsible for nizatidine's therapeutic effects in peptic ulcer disease.

Enhanced gastric nitric oxide synthase activity in duodenal ulcer patients.

Nitric oxide, the product of nitric oxide synthase in inflammatory cells, may have a role in tissue injury through its oxidative metabolism. Nitric oxide may have a role in the pathogenesis of duodenal ulcer and may be one of the mechanisms responsible for the association between gastric infection with Helicobacter pylori and peptic disease. In this study, calcium independent nitric oxide synthase activity was detected in human gastric mucosa suggesting expression of the inducible isoform. In 17 duodenal ulcer patients gastric antral and fundic nitric oxide synthase activity was found to be two and 1.5-fold respectively higher than its activity in the antrum and fundus of 14 normal subjects (p < 0.05). H pylori was detected in the antrum of 15 of 17 duodenal ulcer patients and only in 7 of 14 of the control subjects. Antral nitric oxide synthase activity in H pylori positive duodenal ulcer patients was twofold higher than in H pylori positive normal subjects (p < 0.05). In duodenal ulcer patients antral and fundic nitric oxide synthase activity resumed normal values after induction of ulcer healing with ranitidine. Eradication of H pylori did not further affect gastric nitric oxide synthase activity. These findings suggest that in duodenal ulcer patients stimulated gastric mucosal nitric oxide synthase activity, though independent of the H pylori state, may contribute to the pathogenesis of the disease.

Acute bacterial diarrhoea in the emergency room: therapeutic implications of stool culture results.

Empiric treatment with ciprofloxacin and norfloxacin has been recommended recently for patients with acute diarrhoeal disease. In a retrospective 6-month study period the results of stool cultures from 209 patients with acute diarrhoea admitted to the emergency room were analysed. Seventy-eight cultures (37%) were positive for one or more bacteria. Shigella was the most commonly isolated pathogen (68%). Shigella sonnei comprised 72% and Shigella flexneri 19% of all the bacterial isolates. While no antimicrobial resistance to ciprofloxacin was found for both Shigella species, only 36 and 26% of the Shigella isolates were sensitive to ampicillin and trimethoprim-sulfamethoxazole (TMP-SMZ), respectively. These findings point out to the emergence of drug resistance to commonly used antimicrobial drugs. Shigella's high sensitivity to the newer quinolones should make this the treatment of choice for the very sick patient, although physicians should be cautioned to the fact that indiscriminate use of this drug could result in the emergence of resistance similar to that noted with ampicillin and TMP-SMZ.

NSAID-induced gastroduodenal damage: is prevention needed? A review and metaanalysis.

We have reviewed the effects of nonsteroidal antiinflammatory drugs (NSAIDs) on the gastroduodenal mucosa and then, by means of meta-analysis, have evaluated the results of therapeutical trials in the prevention of NSAID-induced gastroduodenal mucosal damage. We searched the literature through Medline (1980-1990) and through the references of relevant articles. Of 19 trials retrieved by these means, 11 proved eligible for meta-analysis on the basis of eight selection criteria defined a priori. The data included seven studies where the effect of preventive treatment during short-term use of NSAIDs was analyzed and four studies dealing with prevention of mucosal damage in subjects treated with NSAIDs for long periods. Results were expressed in terms of the percentage of patients developing severe mucosal damage or an ulcer during short- and long-term treatment with NSAIDs, respectively. The pooling of the results showed that, during short-term NSAID use, 37% of the subjects developed severe gastric mucosal damage as compared to 12% of subjects given some protective agent. The figures for the duodenum are 13% and 4%, respectively. Owing to the small number of studies on prevention of chronic NSAID-induced gastroduodenal damage, results were not pooled together; misoprostol was shown to be highly effective in reducing the prevalence of gastric ulcer, and ranitidine prevented the occurrence of duodenal but not gastric ulcer. Despite these positive results, there is no proof that protective agents should be recommended to the general population requiring NSAIDs therapy. Nor is there yet evidence that taking a protective agent will avoid the complications of NSAIDs, such as bleeding or perforation.

Risk of gastric cancer after gastric surgery for benign disorders.

The objective of this review was to evaluate published evidence for the association between gastric resection for benign disorders and subsequent cancer of the gastric remnant. We searched the literature through Medline (1970 to 1988) and through the references of relevant articles. Fifty-eight studies consisting of case series, uncontrolled surveys, and case control or cohort analyses were identified and critically assessed using defined methodological criteria. There were no consistent differences between the expected and observed number of cancers occurring within 15 years after gastric resection. However, all case control studies and seven of the eight cohort analyses, in which the prevalence of cancer was stratified by time since gastric resection, indicated a twofold to fourfold increase in the risk of gastric cancer in patients who survived 15 or more years after gastric surgery. We conclude that most studies of the association of gastric surgery with subsequent gastric cancer have relatively weak designs. Still, the repetitive demonstration of this association by different investigators using different research designs supports the hypothesis that gastric resection increases the risk of cancer in the gastric remnant.

Crohn's disease in the elderly.

We compared eleven patients in whom symptoms of Crohn's disease appeared at age greater than or equal to 65 with a younger group in whom symptoms had appeared earlier. Only 64% of the older patients were initially recognized as having Crohn's disease, as compared with 96% of the younger patients even though clinical characteristics and initial response to medical treatment were similar in both groups. A higher rate of complications occurred in the older group and follow-up data showed that they had higher mortality and a greater need for continuous treatment. We suggest that awareness of Crohn's disease in the elderly is less than in the young; the diagnosis is more often missed despite the similarity of the clinical features to those of younger patients.

Indomethacin-induced gastroduodenal damage is not affected by cotreatment with ranitidine.

A randomized, double-blind, placebo-controlled study was conducted to determine whether concomitant administration of ranitidine reduces gastroduodenal mucosal damage associated with 1 week of indomethacin treatment. One hundred ten subjects with acute musculoskeletal conditions and who received indomethacin 150 mg/day completed the trial: 55 were treated with ranitidine 150 mg b.i.d. and 51 subjects received placebo b.i.d. Endoscopic gastric and duodenal injury were assessed before and after one week of treatment. There was no statistically significant difference in the percentage of patients with gastroduodenal damage or in the severity of the lesions in both treatment groups. Ranitidine did not ameliorate indomethacin-induced gastrointestinal symptoms and there was no correlation between upper gastrointestinal symptoms and endoscopic findings.