Do elder emergency department patients and their informants agree about the elder's functioning?

OBJECTIVE: To compare elder patients' and their informants' ratings of the elder's physical and mental function measured by a standard instrument, the Medical Outcomes Study Short Form 12 (SF-12). METHODS: This was a randomized, cross-sectional study conducted at a university-affiliated community teaching hospital emergency department (census 65,000/year). Patients >69 years old, arriving on weekdays between 10 AM and 7 PM, able to engage in English conversation, and consenting to participate were eligible. Patients too ill to participate were excluded. Informants were people who accompanied and knew the patient. Elder patients were randomized 1:1 to receive an interview or questionnaire version of the SF-12. The questionnaire was read to people unable to read. Two trained medical students administered the instrument. The SF-12 algorithm was used to calculate physical (PCS) and mental (MCS) component scores. Oral and written versions were compared using analysis of variance. The PCS and MCS scores between patient-informant pairs were compared with a matched t-test. Alpha was 0.05. RESULTS: One hundred six patients and 55 informants were enrolled. The patients' average (+/-SD) age was 77 +/- 5 years; 59 (56%; 95% CI = 46% to 65%) were women. There was no significant difference for mode of administration in PCS (p = 0.53) or MCS (p = 0.14) scores. Patients rated themselves higher on physical function than did their proxies. There was a 4.1 (95% CI = 99 to 7.2) point difference between patients' and their proxies' physical component scores (p = 0.01). Scores on the mental component were quite similar. The mean difference between patients and proxies was 0.49 (95% CI = 3.17 to 4.16). The half point higher rating by patients was not statistically significant (p = 0.79). CONCLUSIONS: Elders' self-ratings of physical function were higher than those of proxies who knew them. There was no difference in mental function ratings between patients and their proxies. Switching from informants' to patients' reports in evaluating elders' physical function in longitudinal studies may introduce error.

Intranasal lidocaine for the treatment of migraine headache: a randomized, controlled trial.

OBJECTIVE: To evaluate the effect of intranasal lidocaine for immediate relief (5 minutes) of migraine headache pain. METHODS: A randomized, double-blind, placebo-controlled clinical trial at two university-affiliated community teaching hospitals enrolled patients 18-50 years old with migraine headache as defined by the International Headache Society. Patients who were pregnant, lactating, known to abuse alcohol or drugs, or allergic to one of the study drugs, those who used analgesics within two hours, or those with a first headache were excluded. Statistical significance was assessed by using chi-square or Fisher's exact test for categorical variables and Student's t-test for continuous variables. Patients rated their pain on a 10-centimeter visual analog scale (VAS) prior to drug administration and at 5, 10, 15, 20, and 30 minutes after the initial dose. Medication was either 1 mL of 4% lidocaine or normal saline (placebo) intranasally in split doses 2 minutes apart and intravenous prochlorperazine. Medications were packaged so physicians and patients were unaware of the contents. Successful pain relief was achieved if there was a 50% reduction in pain score or a score below 2.5 cm on the VAS. RESULTS: Twenty-seven patients received lidocaine and 22 placebo. No significant difference was observed between groups in initial pain scores, 8.4 (95% CI = 7.8 to 9.0) lidocaine and 8.6 (95% CI = 8.0 to 9.2) placebo (p = 0.75). Two of 27 patients (7.4%, 95% CI = 0.8, 24.3) in the lidocaine group and three of 22 patients (13.6%, 95% CI = 2.8 to 34.9) in the placebo group had immediate successful pain relief (p = 0.47), with average pain scores of 6.9 (95% CI = 5.9 to 7.8) and 7.0 (95% CI = 5.8 to 8.2), respectively. No difference in pain relief was detected at subsequent measurements. CONCLUSION: There was no evidence that intranasal lidocaine provided rapid relief for migraine headache pain in the emergency department setting.

Screening metal binding selectivities of macrocycle mixtures by HPLC--ESI-MS and postcolumn reactions.

A rapid method for the screening of metal binding selectivities of host compounds in mixtures is presented. This method involves the separation of mixtures of hosts by HPLC, followed by postcolumn complexation with one or more metals, then analysis by mass spectrometry. The intensities of the host-guest complexes in the mass spectra correlate with the binding selectivities of the hosts. The method was applied to a series of lariat ethers that were synthesized as ion-selective reagents for ion-selective electrodes. The compounds most selective for Na+ vs Li+ and K+ were identified. Additionally, a mixture of substituted calixarenes was screened for alkali-metal-binding selectivity. These compounds were determined to be selective for Cs+ over Rb+, K+, and Na+.

The bronchodilator effect of intravenous glucagon in asthma exacerbation: a randomized, controlled trial.

STUDY OBJECTIVE: Glucagon is a rapid-acting smooth muscle relaxant with a short half-life. Previous studies suggested glucagon may have bronchodilator effects. We sought to determine whether intravenous glucagon produces clinically important immediate bronchodilation in emergency department patients with asthma exacerbation. METHODS: We conducted a randomized, double-blind, placebo-controlled study at 2 university-affiliated community teaching hospital EDs (annual census 90,000). ED patients 18 to 50 years old with asthma exacerbation and peak expiratory flow rate (PEFR) less than 350 L/min were eligible. Exclusion criteria were need for intubation, chronic obstructive pulmonary disease, diabetes mellitus, insulinoma, pheochromocytoma, pregnancy, lactation, or current oral steroid treatment. Patients were randomly assigned to receive glucagon 0.03 mg/kg or an equivalent volume of saline solution intravenously. At 10 minutes, PEFR was measured and all patients began standardized albuterol therapy. Successful bronchodilation was a PEFR increase of 60 L/min at 10 minutes. RESULTS: Success occurred in 2 (9.5%) of 21 glucagon-treated patients and 3 (12%) of 25 placebo-treated patients (95% confidence interval [CI] for difference of -2.5% [-20.4% to 15. 4%]). Mean PEFR improvement for glucagon was 2 L/min versus 9 L/min for placebo (95% CI for difference of -7 L/min [-36 L/min to 23 L/min]). CONCLUSION: Glucagon alone provided no clinically important immediate bronchodilation in ED patients with asthma exacerbation.

EMTs' knowledge regarding transmission of infectious disease.

OBJECTIVE: To describe EMTs' knowledge of CDC universal precaution guidelines and transmission routes for human immunodeficiency virus (HIV), hepatitis, meningitis, and tuberculosis (TB) and their perceived exposures to and concerns about these diseases. METHODS: A convenience sample of EMTs were surveyed at mandatory continuing education meetings in a midwest community (pop. 523,191) between October 1 and November 30, 1996. The survey contained 101 questions about knowledge of universal precautions, transmission routes, postexposure actions, personal and family concerns, and demographics. Correct responses were based on CDC guidelines, and incorrect answers were added. RESULTS: Four hundred of 425 surveys (94%) were returned. Eighty-one percent of the EMTs were full-time paramedics with 9.4 (95% CI 8.7-10.0%) years of experience. Seventy-five percent reported HIV, hepatitis, and TB education, while 57% reported meningitis education within the preceding year. Ninety-one percent knew universal precautions should be used with every patient. Needlestick was correctly reported as a transmission route for HIV (98%) and hepatitis (92%), but incorrectly reported for TB (37%) and meningitis (60%). Tuberculosis (94%) and meningitis (64%) were correctly identified as airborne. Thirty-four percent of the EMTs reported inadequate knowledge of infectious diseases (IDs) to protect themselves. Their perceived exposure for all four diseases ranged from 65% to 73%, but only 10-40% reported follow-up testing. Families' concern about EMTs' exposure was reported as moderate to high by 63% of the respondents. CONCLUSIONS: There appears to be a need for continuing education for EMTs focusing on the routes of transmission of IDs, their chance of exposure, appropriate use of protective equipment, and the need for follow-up testing. This may allow more effective use of protective equipment and allay fears of EMTs and their families.

Assessment of the "scholarly project" requirement for emergency medicine residents: report of the SAEM Research Directors' workshop. SAEM Research Directors' Interest Group.

OBJECTIVES: Differences in interpretation of the residency review committee (RRC) directive concerning resident scholarly activity have resulted in inconsistencies in the practical fulfillment of this responsibility among the various training programs in emergency medicine. During a workshop organized by the SAEM Research Directors' Interest Group (RDIG), a consensus statement was developed regarding the scope, definition, and purpose of the scholarly project requirement. METHODS: During the workshop, the NIH model of consensus building was used to develop statements pertaining to specific questions of the goals, definition, and endpoints of the scholarly project. The program consisted of an overview of the history and issues related to the scholarly project and presentations of varying viewpoints from interested parties. A final consensus of answers to the defined questions was then developed by the workshop participants during roundtable discussions and further refined through interactive debate using the RDIG e-mail list server. RESULTS: By consensus it was agreed that the primary role of the scholarly project is to instruct residents in the process of scientific inquiry, to teach problem-solving skills, and to expose the resident to the mechanics of research. To realize these goals, the project should include the general elements of hypothesis formulation, data collection, analytic thinking, and interpretation of results. It was also thought that these elements should be documented in some written form with a literature review. CONCLUSIONS: While each residency program must implement the RRC residency requirements in a manner that best suits the needs and culture of its individual environment, a concurrence of definition and approach to satisfying the scholarly project requirement would provide better consistency in resident training. Guidelines developed by consensus during the SAEM RDIG workshop may serve as a general recipe that can be used to fulfill the goals of the scholarly project and the spirit of the RRC directive.

Acute fatty liver of pregnancy.

We report the case of a previously healthy 32-year-old woman nearing the third trimester of pregnancy who presented to the emergency department (ED) with acute jaundice, nausea, and vomiting. An evaluation revealed intrauterine fetal demise, liver failure, renal failure and disseminated intravascular coagulation. The patient required aggressive supportive care, dialysis, transfusion of multiple blood products, and hysterotomy. The patient was diagnosed with acute fatty liver of pregnancy, an uncommon disorder associated with devastating complications for the mother and infant. A review of this disorder and other medical emergencies causing jaundice in pregnancy is presented.

Emergency medicine resident research requirements and director characteristics.

OBJECTIVES: To describe emergency medicine (EM) residency program research requirements, characterize research directors (RDs), and describe their research activities and productivity. METHODS: A survey with questions addressing program research requirements, RDs' background, type of research productivity, time spent, and compensation was mailed to RDs at all Accreditation Council for Graduate Medical Education (ACGME)-approved programs. RESULTS: One hundred of 111 (90%) RDs responded; 54 of the 100 respondents were from university programs. Research is a formal requirement in 80% of EM programs. Writing a manuscript (35%) and major involvement in a project (31%) are the most common minimum requirements. University and community programs had similar research requirements and were equally likely to have delayed/withheld certificates. Eighty-six percent of the RDs were male; 70% held this position for <5 years and 70% plan on being in the position for <5 additional years. More than half were junior faculty and 21 had completed a fellowship. Most (88%) did not serve in an associate RD position, and currently only 20 programs reported having this position. Fifty-four percent had protected time. Median hour/week time allocations are: clinical-22, own research--10, other people's research--6, administration--5, and department administration--5. Factors associated with research productivity were senior rank (OR 6.87), having a research assistant (OR 4.78), protected time for their own research (OR 3.06), and reporting that extramural funding was considered in the RD's performance evaluation (OR 2.69). CONCLUSIONS: Most programs have established research requirements. Most RDs are junior faculty, have limited research training, expect a short tenure in the position, and have variable access to research resources. EM needs to foster an environment that will enable us to thrive in the academic community and create opportunity for residents to participate in meaningful research. This requires that all RDs have protected time, and that a greater proportion be at the associate or full professor level, have qualified research assistants, and receive periodic evaluation reviewing their ability to generate external funds. Appointment of associate RDs may improve research training and help ensure qualified RDs.

Behavioral risk factors in emergency department patients: a multisite survey.

BACKGROUND: Many people rely on EDs for routine health care. Often, however, screening and counseling for health risks are not provided. OBJECTIVE: To determine prevalence rates of chronic disease and injury risk factors and access to routine health care in a random sample of ED patients in 3 cities. METHODS: A prospective survey was conducted at 3 hospital EDs in Akron, OH, Boston, MA, and Denver, CO. A modified version of the national Behavioral Risk Factor Surveillance Survey was administered by trained researchers to a convenience sample of non-critically ill patients during randomly selected shifts. RESULTS: Of 1,143 eligible patients, 923 (81%) agreed to participate. Their mean age was 39 (range = 17-96) years. Most were female (58%), white (60%), and unmarried (68%). Thirty-eight percent had no access to primary care. Injury-prone behaviors were prevalent: 53% of the respondents did not wear seat belts regularly; 15% had no working smoke detector; 3% kept loaded, unlocked handguns in their homes; 11% had attempted suicide; 23% had a positive CAGE screen for alcoholism; 3% had operated a motor vehicle in the preceding month while alcohol-intoxicated; and 11% had ridden in an automobile with an intoxicated driver. Cancer and chronic disease risks were also common: 48% smoked; 16% had not received a blood pressure check in the preceding year; and 4% reported unsafe sexual practices. Among women aged > 50 years, 42% had not received a Pap test in the prior 2 years and 14% had never had mammography. Many prevalence rates and access to care varied among the 3 sites. However, for most risk factors, prevalence rates did not differ in patients with and without access to primary health care. CONCLUSIONS: ED patients have high rates of injury and chronic disease risks, and many have no other source of routine health care. Research is needed to determine whether ED-based programs, designed to reduce injury and chronic disease risks, are feasible and cost-effective.

Ultrasound-assisted internal jugular vein catheterization in the ED.

A prospective, descriptive study is reported on the use and success of ultrasound-assisted internal jugular central vein catheterization (CVC) in the emergency department (ED). In patients not in cardiac arrest who had an indication for internal jugular CVC, lines were placed by trained ED staff using ultrasound. Data were collected prospectively on age, sex, body habitus, indication, vein visibility, number of punctures and needle passes, and success. There were 40 attempts at internal jugular CVC in 34 patients and ultrasound was used in 32 of the 40 (80%) attempts. Incidences of successful puncture and cannulation using ultrasound were 93.8% (30 of 32) and 81.3% (26 of 32), respectively, compared with 62.5% (5 of 8) and 62.5% (5 of 8) in the landmark group. In 8 patients with no visual or palpable landmarks, cannulation was successful in 100% (7 of 7) using ultrasound and in 0% (0 of 1) using landmark technique. Ultrasound-assisted internal jugular CVC is an easily learned technique that is useful in the ED. It may be especially helpful in patients in whom landmarks are not visible and not palpable.

Comparison of intramuscular triamcinolone and oral prednisone in the outpatient treatment of acute asthma: a randomized controlled trial.

STUDY OBJECTIVE: To determine whether a one-time dose of triamcinolone diacetate, 40 mg intramuscular (i.m.), given to adult patients treated in the emergency department for mild to moderate exacerbation of asthma would decrease the rate of relapse during the following week, compared with a nontapering course of oral prednisone, 40 mg/day over 5 days. METHODS: A randomized, double-blind, controlled clinical trial was conducted at two university-affiliated community teaching hospitals with a combined annual census of 97,000. Patients were eligible if they were between the ages of 18 and 50 years, had an initial peak expiratory flow rate of less than 350 L/minute, and were to be discharged from the ED taking steroids. Patients were randomly assigned to receive either triamcinolone (40 mg i.m.) and placebo tablets or a placebo injection and prednisone (40 mg/day orally for 5 days). Patients were instructed to use a beta-agonist metered-dose inhaler, to continue other routine medications, to complete symptom diary cards, and to return in 7 to 10 days for follow-up. The main outcome measure was relapse, which was defined as an unscheduled visit to a physician's office or ED for worsening or persistent symptoms within 7 days of the initial ED visit. RESULTS: A total of 168 patients were initially enrolled; 6 patients were withdrawn for protocol violations and 8 because they could not be contacted for follow-up. A total of 154 patients were available for outcome analysis, 78 in the triamcinolone group and 76 in the prednisone group. There were no differences between the two patient groups with regard to demographics, smoking history, weight, or symptom severity. Mean initial peak flows were 244+/-64 L/minute for the triamcinolone group and 245+/-83 L/minute for the prednisone group. Fifty percent of the study patients were current smokers. The relapse rates were 9.0% (7/78) in the triamcinolone group and 14.5% (11/76) in the prednisone group (P=.29). The absolute difference in relapse rates was 5.5% (95% confidence interval [CI], 4.6% to 15.6%). There was no difference in symptom frequency or severity between the two groups during the first 5 days of outpatient treatment. Analysis between the groups stratified for smoking showed no difference in relapse rate between smokers and nonsmokers. CONCLUSION: A single dose of triamcinolone diacetate, 40 mg i.m., produced a relapse rate similar to that of prednisone, 40 mg/day orally for 5 days, after ED treatment of mild to moderate exacerbations of asthma. Intramuscular triamcinolone would appear to be an attractive alternative when compliance with a daily oral regimen is of concern.

Posterior epistaxis: clinical features and acute complications.

STUDY OBJECTIVE: To describe the clinical features, evaluate the incidence of serious complications, and identify factors associated with rebleeding in adults with acute posterior epistaxis. DESIGN: Retrospective chart review. SETTING: University-affiliated community teaching hospital. PARTICIPANTS: We studied 88 episodes of posterior epistaxis in 81 patients (mean age, 64.3 years; range, 27 to 96 years) who were treated in the emergency department and hospitalized during a 6-year period. Inclusion criterion was active hemorrhage into the posterior pharynx without identifiable anterior bleeding or severe nasal hemorrhage refractory to anterior packing. Patients with anterior epistaxis were excluded. RESULTS: Posterior epistaxis accounted for 5% of all cases of epistaxis. The most common factors associated with posterior epistaxis were a history of hypertension in 39 patients (48%) and previous epistaxis in 30 (37%). Of 57 patients who reported duration of epistaxis, 39 (68.4%) had nasal hemorrhage for less than 12 hours before ED presentation, and 13 patients (22.8%) had nasal bleeding that lasted more than 24 hours. Bleeding was recorded as moderate or severe for 88% of patients. All patients were treated with posterior nasal packing in the ED (73% with traditional gauze packing, 15% with balloon, and 12% with tampon). After admission, 16 patients (19.8%) required surgical intervention, 17 (21%) experienced acute sinusitis, 10 (12.3%) received blood transfusions, and 3 (3.7%) were intubated. Rebleeding occurred in 24 patients (29.6%), with 13 episodes (44.1%) occurring less than 24 hours after admission. Factors associated with rebleeding were posterior epistaxis described as "severe" (OR, 2.53; 95% CI, .88 to 7.39; chi 2 = 2.84, 1 df, P = .92) and pack removal within 48 hours after admission (OR, 3.07; 95% CI, .98 to 9.88; chi 2 = 3.66, 1 df, P = .056). Factors that failed to predict rebleeding included age, prior hypertension, anticoagulant use, vital signs, and type of posterior pack used (gauze or balloon). CONCLUSION: Although posterior epistaxis is an uncommon otolaryngologic emergency, many patients experience clinically significant complications. Rebleeding was associated with severe posterior epistaxis and pack removal within 48 hours after admission.