Longitudinal profiling of plasma cytokines in melioidosis and their association with mortality: a prospective cohort study.

OBJECTIVES: To characterize plasma cytokine responses in melioidosis and analyse their association with mortality. METHODS: A prospective longitudinal study was conducted in two hospitals in Northeast Thailand to enrol 161 individuals with melioidosis, plus 13 uninfected healthy individuals and 11 uninfected individuals with diabetes to act as controls. Blood was obtained from all individuals at enrolment (day 0), and at days 5, 12 and 28 from surviving melioidosis patients. Interferon-γ (IFN-γ), interleukin-1ß (IL-1ß), IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IL-23, and tumour necrosis factor-α (TNF-α) were assayed in plasma. The association of each cytokine and its dynamics with 28-day mortality was determined. RESULTS: Of the individuals with melioidosis, 131/161 (81%) were bacteraemic, and 68/161 (42%) died. On enrolment, median levels of IFN-γ, IL-6, IL-8, IL-10, IL-23 and TNF-α were higher in individuals with melioidosis compared with uninfected healthy individuals and all but IFN-γ were positively associated with 28-day mortality. Interleukin-8 provided the best discrimination of mortality (area under the receiver operating characteristic curve 0.78, 95% CI 0.71-0.85). Over time, non-survivors had increasing IL-6, IL-8 and IL-17A levels, in contrast to survivors. In joint modelling, temporal trajectories of IFN-γ, IL-6, IL-8, IL-10 and TNF-α predicted survival. CONCLUSIONS: In a severely ill cohort of individuals with melioidosis, specific pro- and anti-inflammatory and T helper type 17 cytokines were associated with survival from melioidosis, at enrolment and over time. Persistent inflammation preceded death. These findings support further evaluation of these mediators as prognostic biomarkers and to guide targeted immunotherapeutic development for severe melioidosis.

Acoustic power delivery to pipeline monitoring wireless sensors.

The use of energy harvesting for powering wireless sensors is made more challenging in most applications by the requirement for customization to each specific application environment because of specificities of the available energy form, such as precise location, direction and motion frequency, as well as the temporal variation and unpredictability of the energy source. Wireless power transfer from dedicated sources can overcome these difficulties, and in this work, the use of targeted ultrasonic power transfer as a possible method for remote powering of sensor nodes is investigated. A powering system for pipeline monitoring sensors is described and studied experimentally, with a pair of identical, non-inertial piezoelectric transducers used at the transmitter and receiver. Power transmission of 18mW (Root-Mean-Square) through 1m of a118mm diameter cast iron pipe, with 8mm wall thickness is demonstrated. By analysis of the delay between transmission and reception, including reflections from the pipeline edges, a transmission speed of 1000m/s is observed, corresponding to the phase velocity of the L(0,1) axial and F(1,1) radial modes of the pipe structure. A reduction of power delivery with water-filling is observed, yet over 4mW of delivered power through a fully-filled pipe is demonstrated. The transmitted power and voltage levels exceed the requirements for efficient power management, including rectification at cold-starting conditions, and for the operation of low-power sensor nodes. The proposed powering technique may allow the implementation of energy autonomous wireless sensor systems for monitoring industrial and network pipeline infrastructure.

Subclavian vein thrombosis following clavicular fracture.

A very rare case is presented of a woman with subclavian vein thrombosis that resulted from a fragment of her fractured clavicle impinging on the subclavian vein.

Allosteric inhibition of fructose-1,6-bisphosphatase by anilinoquinazolines.

Anilinoquinazolines currently of interest as inhibitors of tyrosine kinases have been found to be allosteric inhibitors of the enzyme fructose 1,6-bisphosphatase. These represent a new approach to inhibition of F16BPase and serve as leads for further drug design. Enzyme inhibition is achieved by binding at an unidentified allosteric site.

Emergency medicine in Ukraine: challenges in the post-Soviet era.

The practice of emergency medicine in Ukraine is markedly different from the practice in North America. The emergency physician counterpart in Ukraine attends 6 years of medical school then 18 months of prehospital physician training at an EMS base station. Once trained, prehospital physicians work 160 hours/month in 24-hour shifts at the base station as part of a physician-nurse team which answers ambulance requests. Most patients are seen and treated on site of the ambulance call. Patients are transported to the hospital only 20% of the time. Prehospital physicians can expect to earn $35 to $65 per month. Nearly all prehospital physicians are government employees. Since becoming an independent democratic republic, Ukraine's turbulent economy has negatively affected health care. Deaths from infectious diseases, including vaccine-preventable illnesses are 10-fold to that of Western countries. A 90% income tax discourages the private practice of medicine. Medical care is provided free of charge, however, if a patient wants a higher standard of care, they may have to pay an attending physician up to $200. Most medications used to treat emergencies are free, but if thrombolytics are required, the patient will have to pay for them before they are administered. Budgetary constraints limit equipment and technology. The disparity between urban and rural resources is striking as even the most basic equipment is antiquated and in need of repair. Despite the economic challenges facing Ukranian physicians, they are enthusiastic about the care and services they provide. EMS is well organized and offers services not seen in the United States. Prehospital physicians in Ukraine are viewed as an integral part of the health care system by their hospital-based colleagues.

Metal detectors in the pediatric emergency department: patron attitudes and national prevalence.

OBJECTIVES: The purpose of this study was to investigate patron attitudes toward a walk through a metal detector that was used for universal weapon screening in a pediatric emergency department. Additionally, we conducted a telephone survey to determine the nationwide prevalence of metal detectors in pediatric emergency departments. METHODS: A convenience sample of family and acquaintances of patients seen in the pediatric emergency department was selected, and members were interviewed using scripted questions. Members of the National Association of Children's Hospitals and Related Institutions were interviewed for the nationwide survey. RESULTS: The vast majority of patrons responded favorably to the presence of the arch-style walk through a metal detector. The metal detector was felt to be appropriate in a pediatric emergency department by a large majority of patrons and was protective for both patrons and employees. Handbag searches were felt to be an invasion of privacy by 14%. Nationwide, the prevalence of arch-style metal detectors for security purposes in pediatric emergency departments was only 6%. CONCLUSIONS: The public has a strong perception that a metal detector protects both patrons and employees in a pediatric emergency department. Fear that patrons will be disturbed or that the presence of a metal detector will reflect negatively upon the institution appear to be unfounded. Nationwide use of metal detectors in pediatric emergency departments remains uncommon but is apparently increasing.

Prevalence and risk factors for multidrug resistant uropathogens in ED patients.

The purpose of this study was to describe resistance patterns of infecting organisms and determine risk factors for multidrug resistance in patients with urinary tract infections. Retrospective case series of 435 patients age > or =16 with urinary tract infection. Multidrug resistance was defined as resistance to > or = two classes of antibiotics. Demographic, historical, and microbiological data were collected. Univariate analysis and multivariate logistic regression were used to determine risk factors for multidrug resistance. Multidrug resistance was seen in 37% of isolates. Univariate analysis revealed numerous associations with resistance. Multivariate analysis found three independent factors associated with multidrug resistance: urinary catheter use (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.4 to 4.8), age > or = 65 years (OR 3.0, 95% CI 1.7 to 5.4) and antibiotic use (OR 4.6, 95% CI 2.8 to 7.5). Diabetes was also a risk factor when patients with urinary catheters were excluded (OR 2.4, 95% CI 1.1 to 5.3). Resistance was seen in all groups of patients, but was particularly common in older patients and those who used a urinary catheter. Antibiotic use was highly associated with multidrug resistance.

Trimethoprim-sulfamethoxazole resistance among urinary coliform isolates.

OBJECTIVE: A large majority of urinary tract infections are caused by coliform organisms. Trimethoprim-sulfamethoxazole (TMP-SMX) resistance among uropathogens is increasing in many areas. The objective of this study was to determine risk factors for TMP-SMX-resistant coliforms in patients with urinary tract infections. DESIGN: Retrospective case-control study. SETTING: Emergency department of a tertiary care university hospital. PATIENTS: We studied 448 emergency department patients aged 14 years or older with a urinary tract infection caused by a coliform organism. Cases consisted of all patients with a culture-documented urinary tract infection caused by a TMP-SMX-resistant coliform, while control patients were those with a TMP-SMX-sensitive organism. MEASUREMENTS AND MAIN RESULTS: A univariate analysis of clinical variables associated with TMP-SMX resistance was performed. Multiple logistic regression was performed to determine independent predictors of TMP-SMX resistance. Resistance to TMP-SMX was seen in 15% of isolates. Numerous variables were associated with TMP-SMX resistance on the univariate screen. Independent predictors of resistance were diabetes (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.2, 8.4), recent hospitalization (OR 2.5; 95% CI 1.1, 5.7), current use of antibiotics (OR 4.5; 95% CI 2.0, 10.2), and recent use of TMP-SMX (OR 5.1; 95% CI 2.2, 11.5). When those with recent hospitalization were excluded from analysis, independent predictors were current use of any antibiotic (OR 3.5; 95% CI 1.4, 8. 4) and recent use of TMP-SMX (OR 5.9; 95% CI 2.4, 14.3). CONCLUSIONS: Coliforms resistant to TMP-SMX are common in our emergency department. Diabetes, recent hospitalization, and the use of antibiotics, particularly the use of TMP-SMX, are independent risk factors for TMP-SMX resistance. Clinicians should consider these findings when deciding on antimicrobial therapy for patients with urinary tract infections.

Anxiety levels in EMS providers: effects of violence and shifts schedules.

We tried to measure anxiety levels in emergency medical service (EMS) providers to determine the effects of (1) having had a violent encounter during a shift and (2) different shift schedules, conducting a prospective observational study over 3 months in an urban EMS system setting. A convenience sample of 23 EMTs and 40 EMT-Ps was observed. Anxiety levels were measured using the Spielberger State-Trait Anxiety Inventory. A total of 99 inventories were completed by 63 EMS providers. The mean state (32.6+/-8) and trait (31.7+/-7.1) scores were less than normative scores (35.7+/-10.4 and 34.9+/-9.2 respectively) for working adult males (P = .004 and .007, respectively). Paramedics had lower anxiety scores than basic EMTs (P = .015 and .039) and years of experience also decreased anxiety scores (P < .0001). There was no significant difference in state scores between those EMS providers who had encountered violence during the preceding 12 hours and those providers who had not. Comparisons of state scores of providers assessed at hour 12 of a 12 hour shift, hour 12 of a 24 hour shift, and hour 24 of a 24 hour shift failed to show any significant differences. Although the working environment of the EMS provider contains numerous stressors and uncertainties, this population of providers were no more anxious than the general working public. Advanced training and years of experience decreased anxiety. Violent encounters during a shift did not appear to affect anxiety levels. There was no difference in anxiety levels in providers who worked 12 and 24 hour shifts.

Incidence of pertussis infection in healthcare workers.

OBJECTIVE: To determine the incidence of pertussis infection in two groups of healthcare workers. DESIGN: Retrospective cohort study. SETTING: 660-bed, urban, tertiary-care university hospital. PARTICIPANTS: 106 resident physicians and 39 emergency department employees. INTERVENTIONS: Antibodies to pertussis toxin and filamentous hemagglutinin were determined in fresh serum specimens and in stored sera collected 1 to 3 years previously. A 50% rise in both the pertussis toxin and filamentous hemagglutinin from the initial to the follow-up specimen was considered diagnostic of a pertussis infection. RESULTS: Two of 106 residents had serological evidence of a pertussis infection during 151.3 subject-observation years, for an annual incidence rate of 1.3% (95% confidence interval [CI95], 0%-3.5%). Three of 39 emergency department employees had serological evidence of a pertussis infection during 81.2 subject-observation years, for an annual incidence of 3.6% (CI95, 0%-9.6%). Of these 5 subjects, 2 had symptomatic disease. CONCLUSION: We found both symptomatic and asymptomatic pertussis infections in two cohorts of healthcare workers. Although the incidence rates were somewhat lower than found in other studies, they nonetheless were higher than for almost all other diseases for which we vaccinate healthcare workers. Our results would support the use of acellular pertussis vaccine in healthcare workers.

Appropriateness of vancomycin use in the emergency department.

STUDY OBJECTIVE: The emergence of vancomycin-resistant organisms is a major problem at many hospitals. Vancomycin use is associated with development of resistance. The objective of this study was to determine the appropriateness of vancomycin use in the emergency department. In addition, we sought to determine whether appropriateness of vancomycin use increased after the publication of the Centers for Disease Control and Prevention guidelines for prudent vancomycin use. METHODS: This retrospective study was conducted at a tertiary care university hospital, and all patients who received vancomycin while in the ED during the first 6 months of each year from 1995-1997 were eligible for study. We developed appropriateness criteria based on national and local guidelines. Vancomycin use was determined to be appropriate or inappropriate according to these guidelines. RESULTS: Vancomycin use increased each year of the 3-year study period; 40% of use was considered inappropriate. However, appropriateness increased in a linear fashion (P <.001). A resistant organism was cultured from 17% of those with appropriate use and none of those with inappropriate use. Most patients, regardless of the appropriateness of drug use, continued to receive vancomycin after admission. CONCLUSION: Overall vancomycin use rose each year despite an increase in the proportion with appropriate use. However, inappropriate use remained common. Emergency physicians and consultants should become familiar with national and local guidelines for prudent vancomycin use.

Alcohol on campus: alcohol-related emergencies in undergraduate college students.

OBJECTIVES: We reviewed demographic factors associated with alcohol-related disorders in undergraduates seen in the emergency department (ED) and determined the incidence of alcohol-related ED visits among undergraduates. METHODS: This prospective, observational study was done in a university-affiliated emergency department. Demographic variables and incidence of students with alcohol-related disorders were analyzed. RESULTS: Of the 616 students seen in the ED during 1 academic year, 101 (16%) had an alcohol-related disorder. White students and freshmen were overrepresented. There were equal numbers of male and female students. The overall annual incidence for an alcohol-related visit among undergraduates was 1.7% per academic year. The incidence for freshmen was 2.9%. Four students were admitted; one died of a severe head injury. CONCLUSIONS: We estimate that 1 of every 15 undergraduates at our college comes to our ED with an alcohol-related problem during their 4-year college career. Younger and nonminority students were more commonly seen; there was no difference by sex. Serious outcomes included one death. This study probably underestimates the true incidence of alcohol-related disorders among students on campus.

Randomized clinical trial of melatonin after night-shift work: efficacy and neuropsychologic effects.

OBJECTIVE: Melatonin has received considerable publicity for its sleep-promoting properties; however, there is little scientific evidence of its efficacy. The objective of this study is to determine whether there are measurable beneficial effects from exogenous melatonin in emergency physicians after intermittent night-shift duty. METHODS: This randomized, placebo-controlled, double-blind, crossover trial was conducted in the emergency department of an urban tertiary care hospital. Fifteen emergency physicians were given melatonin 5 mg or placebo for 3 consecutive nights after night-shift duty with crossover to the opposite agent after a subsequent block of night shifts. The primary outcome measure was the global assessment of recovery measured by a visual analog scale. Secondary outcome measures included sleep quality, duration, and tiredness. In addition, the Profile of Mood States questionnaire and neuropsychologic testing were performed. RESULTS: There was no difference between melatonin and placebo in the global assessment of recovery (60.4+/-16.9 and 58.9+/-14.5, respectively; P=.29). There were no differences in sleep quality, duration or tiredness scores, sleep latency, hours of sleep obtained per night, and night or early awakening at any measurement point. Profile of Mood States and neuropsychologic test performances were similar. CONCLUSION: We found no beneficial effect of melatonin on sleep quality, tiredness, or cognitive function in emergency physicians after night-shift duty. Our results suggest that exogenous melatonin is of limited value in recovery from night-shift work in emergency physicians.

Pertussis infection in adults.

BACKGROUND: Pertussis is a potentially serious vaccine-preventable disease. Many clinicians are unaware that pertussis is common in adults, and that adults are a major reservoir of the disease in the United States. METHODS: A MEDLINE search was conducted of all English-language articles pertinent to pertussis infections in adults. Results of relevant articles were compiled into a narrative review. RESULTS: Studies have shown that sporadic cases of pertussis in adults are common in a variety of clinical settings. Patients typically present with a prolonged cough illness preceded by upper respiratory symptoms. Widespread outbreaks of pertussis occasionally occur in high schools, college campuses, and healthcare settings. The diagnosis and treatment of adults with pertussis are reviewed. CONCLUSIONS: Pertussis infection, because of waning immunity, is common in adults. Routine booster immunization of adults with the newer acellular vaccine may lead to the elimination of the disease in both children and adults.

Prospective field study of violence in emergency medical services calls.

STUDY OBJECTIVE: To investigate the nature and frequency of violence encountered by EMS personnel. DESIGN: We conducted a prospective, observational case-series study of a city-county EMS system serving a population of 500,000. RESULTS: We analyzed 297 EMS runs over 737 hours of observation. The Overt Aggression Scale (OAS) was used to assess each violent episode. There were 239 (81%) nonviolent runs, 16 (5%) violent runs, and 42 (14%) violent runs that occurred after a violent episode had taken place (postviolent runs). This was a frequency of one violent episode for every four 12-hour shifts, or for every 19 runs. The violent behaviors included verbal aggression solely in 50% (n = 8), physical aggression solely in 13% (n = 2), and both verbal and physical aggression in 38% (n = 6). One episode involved an unsecured weapon. CONCLUSION: These data indicate that violent situations occur in 5% of calls in this EMS system. The fact that an additional 14% of calls are precipitated by the results of violence may influence perceptions by EMS personnel of danger and frequency of exposure to unstable situations. Exposure to violence is underreported in our EMS documentation.

Sedation of pediatric patients for minor laceration repair: effect on length of emergency department stay and patient charges.

INTRODUCTION: Sedating children can facilitate minor laceration repair by minimizing physical and psychic discomfort. However, some clinicians are reluctant to use sedation, in part because of concern about increased patient charges and fear that the emergency department (ED) stay will be prolonged. The purpose of this study was to determine the extent to which sedative use during the repair of simple facial lacerations in children increased the length of ED stay and patient charges. METHODS: This was a retrospective cohort study of 152 children with small, simple, facial lacerations. Patients with complex lacerations and those requiring specialty consultation were excluded. Patients, at the discretion of the treating physician, received either intramuscular ketamine (n = 14), intranasal or rectal midazolam (n = 38), or no sedation (n = 100). Length of ED stay and the total patient charges were analyzed. RESULTS: Groups were equal with respect to age, sex, and length of the wound. The mean patient time in the ED, from placement in examination room to discharge, was significantly longer for those given ketamine (149+/-37 minutes) and midazolam (98+/-31 minutes) compared with those given no sedation (82+/-28 minutes). Patient charges were also higher in those given ketamine ($695+/-172) or midazolam ($498+/-153) compared with those receiving no sedation ($390+/-86). CONCLUSIONS: The results of this study demonstrate that sedation with ketamine or midazolam increases the length of ED stay compared with using no sedation. However, the increased lengths of stay were modest, particularly for midazolam. Fear of prolonged recovery time should not dissuade clinicians from using either sedative for minor procedures. The patient charges are considerably higher with both midazolam and ketamine, but they may not reflect the actual cost of patient care.

Tenure track in emergency medicine.

STUDY OBJECTIVE: Tenure was designed to guarantee academic freedom through lifelong job security. Productive research, especially in the basic sciences, is the main criterion for tenure at most institutions; therefore faculty in more clinically focused specialties may experience more difficulty obtaining tenure. We examined the relationship between academic emergency medicine and tenure. METHODS: We used a questionnaire to survey the directors of all 108 approved US emergency medicine residency programs. The surveyed population was asked whether the program was affiliated with a medical school, the number of full-time faculty, and how many faculty members were tenured or on the tenure track. Follow-up mailings were sent to nonresponders. We also conducted a search of the Association of American Medical Colleges (AAMC) database to compare the number of emergency medicine faculty involved in the tenure process in other specialties. RESULTS: One hundred surveys (93%) were returned. At programs in which faculty were eligible for tenure, 9% (95% confidence interval [CI], 4% to 16%) were tenured and 27% (95% CI, 19% to 37%) were on the tenure track. Therefore only 36% of all EM faculty (95% CI, 27% to 46%) were tenured or on the tenure track. Among the 53 residency programs that offered tenure, 45% (95% CI, 32% to 60%) had no tenured faculty. At programs with academic department status, 74% of chairs were tenured, in contrast to only 32% of chiefs at institutions without academic department status (95% CI for difference of 42%, 14% to 71%). The AAMC survey revealed that about one-third as many emergency medicine faculty members were tenured compared with the other specialties. The proportion of faculty on the tenure track, however, was similar between the specialties. CONCLUSION: Most eligible emergency medicine faculty members are not tenured or on track to become tenured, and fewer emergency medicine faculty are tenured compared with the more traditional specialties. Emergency medicine may be vulnerable to being considered less academic unless its faculty members gain access to the tenure process.

Necrobiosis lipoidica in a diabetic intravenous drug user.

Necrobiosis lipoidica occurs most commonly on the lower extremities in patients with diabetes; lesions typically occur in the pretibial region. Although the pathogenesis of necrobiosis lipoidica remains unclear, both external trauma and vascular damage have been proposed as contributing to the development of this disorder. We report polarizable foreign material in small blood vessels and multinucleated histiocytes in lesions of necrobiosis lipoidica. This phenomenon occurred in a patient who was both diabetic and an intravenous drug user.

Pediatric cervical spine injury sustained in falls from low heights.

STUDY OBJECTIVE: To determine whether history and clinical examination findings can identify young children who have sustained cervical injury after falling short distances. METHODS: We conducted a retrospective review of the medical records of children younger than 6 years old with the diagnosis of cervical vertebral fracture or cervical spinal cord injury after a fall of less than 5 feet. Data from medical records over an average time span of 11 years at four large children's hospitals were compiled. RESULTS: We identified eight children who sustained cervical spine injury after a fall of less than 5 feet. These children ranged in age from 9 to 68 months. Three had rotary subluxation of C1, and three had subluxation of C1-C2. One of the children in the latter group also had an odontoid fracture. Two children had a fracture of C2. All the children had limited range of motion of the neck or neck pain. CONCLUSION: All children in this study with the diagnosis of cervical spine injury had clinical evidence of that injury on history or physical examination. Clinicians treating asymptomatic young children who sustain short falls may not need to perform radiographic evaluation of the cervical spine.