Recreational injuries among older Americans, 2001.

OBJECTIVE: To describe the epidemiology of non-fatal recreational injuries among older adults treated in United States emergency departments including national estimates of the number of injuries, types of recreational activities, and diagnoses. METHODS: Injury data were provided by the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), a nationally representative subsample of 66 out of 100 NEISS hospitals. Potential cases were identified using the NEISS-AIP definition of a sport and recreation injury. The authors then reviewed the two line narrative to identify injuries related to participation in a sport or recreational activity among men and women more than 64 years old. RESULTS: In 2001, an estimated 62 164 (95% confidence interval 35 570 to 88 758) persons >/=65 years old were treated in emergency departments for injuries sustained while participating in sport or recreational activities. The overall injury rate was 177.3/100 000 population with higher rates for men (242.5/100 000) than for women (151.3/100 000). Exercising caused 30% of injuries among women and bicycling caused 17% of injuries among men. Twenty seven percent of all treated injuries were fractures and women (34%) were more likely than men (21%) to suffer fractures. CONCLUSIONS: Recreational activities were a frequent cause of injuries among older adults. Fractures were common. Many of these injuries are potentially preventable. As more persons engage in recreational activities, applying known injury prevention strategies will help to reduce the incidence of these injuries.

Preventive care in the emergency department: should emergency departments institute a falls prevention program for elder patients? A systematic review.

OBJECTIVE: To perform a systematic review of the emergency medicine literature to assess the appropriateness of an intervention to identify, counsel, and refer emergency department (ED) patients >64 years old who are at high risk for falls. METHODS: The systematic review was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. A reference librarian did two PubMed searches using the following: ED visits, patients >64 years old, falls, high risk, and effectiveness of intervention. Emergency Medical Abstracts, Science Citation Index, and the Cochrane Collaboration database were searched. Two team members reviewed the abstracts and selected pertinent articles. References were screened for additional pertinent articles. RESULTS: Twenty-six articles were reviewed. None were ED-based primary or secondary falls prevention in older patients. One randomized controlled trial of an intervention to decrease subsequent falls in elder community-dwelling patients who presented with a fall showed a structured interdisciplinary approach significantly reducing the number of falls. Two ED-based studies showed it was possible to identify ED patients at risk for falls. CONCLUSIONS: Based on one randomized controlled trial demonstrating a significant reduction in the risk of further falls, the burden of suffering caused by falls, and other studies demonstrating the value of interventions to reduce the risk of falling, the authors recommend that EDs conduct research to evaluate the effectiveness of clinical interventions to identify, counsel, and refer ED patients >64 years old who are at high risk for an unintentional fall.

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.

Medical care use by treated and untreated substance abusing medicaid patients.

Medicaid reimbursement costs for county residents at least 18 years old who used a treatment service (n = 1043) and residents who were Medicaid enrollees with a substance abuse diagnosis but who did not receive treatment (n = 2125) were compared. Untreated patients were more likely to be male (47% vs. 39%), white (56% vs. 45%), and older (39.7 yrs. +/- 13 SD vs. 35.5 yrs +/- 10 SD). The average monthly Medicaid costs ($257) for the untreated were higher in the year prior to identification than were costs ($207) for the treated. The monthly costs in the six months following identification were $761 for the untreated and $373 for the treated. The costs in the next six months returned to near the original for the treated ($224), while those for the untreated remained higher at $340. Medicaid enrollees with untreated substance abuse pose a significant cost to the Medicaid system.

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.

Curling iron-related injuries presenting to U.S. emergency departments.

OBJECTIVE: To describe curling iron-related injuries reported to the National Electronic Injury Surveillance System (NEISS) between January 1, 1992, and December 31, 1996. METHODS: The authors retrospectively reviewed data from NEISS, a weighted probability sample of emergency departments (EDs) developed to monitor consumer product-related injuries. The information reported includes patient demographics, injury diagnosis, body part injured, incident locale, patient disposition, and a brief narrative description. The authors reviewed the narrative in the hair care products category and abstracted records indicating the injury was caused by contact with a curling iron. Also analyzed were the design features of commonly available curling irons purchased from national discount department stores. RESULTS: There were an estimated 105,081 hair care product-related injuries in the five-year period, of which 82,151 (78%) involved a curling iron. Seventy percent of injuries were to females. The patient's median age was 8 years (range 1 month to 96 years). The most commonly occurring injury was thermal burns (97%; 79,912/82,151). Ninety-eight percent of the injuries occurred in the home and 99% of the patients were discharged home from the ED. In patients <4 years old, 56% of burns occurred by grabbing or touching, while in those > or =10 years the burns occurred by contact while in use. In the older group 69% of burns were of the cornea. Most curling irons use small amounts of power, yet there are no standards for temperature settings or control. The cylinder containing the heating element is mostly exposed, and many irons do not have a power switch. CONCLUSIONS: The most common injury resulting from curling irons is thermal burns. The mechanisms and patterns of injury in developmentally distinct age groups suggest that many of these injuries could be prevented by public education and the re-engineering of curling irons.

Preventive care in the emergency department, Part II: Clinical preventive services--an emergency medicine evidence-based review. Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group.

INTRODUCTION: Emergency departments (EDs) provide an opportunity to initiate preventive services for millions of Americans who have no other source for these services. OBJECTIVES: To identify primary and secondary preventive interventions appropriate for inclusion in routine emergency care and, secondarily, to recommend areas in which research into the efficacy and cost-effectiveness of interventions is needed. METHODS: Systematic reviews were performed on 17 candidate preventive interventions with potential applicability in the ED. All but one was selected from those reviewed by the U.S. Preventive Services Task Force (USPSTF). Each two-person review team followed a template that provided a uniform approach to search strategy, selection criteria, methodology appraisal, and analysis of the results of primary studies bearing on ED cost-effectiveness. Assigned proctors provided methodological guidance to the review teams throughout the review process. A grading scheme was developed that took into account the evidence and recommendations of the USPSTF supporting primary efficacy of the intervention and the level of evidence supporting ED application identified by the Society for Academic Emergency Medicine Public Health and Education Task Force (PHTF) review teams. RESULTS: Seventeen reviews were completed. The following interventions received an alpha rating, indicating that evidence is sufficient to support offering these services in the ED setting, assuming sufficient resources are available: alcohol screening and intervention, HIV screening and referral (in high-risk, high-prevalence populations), hypertension screening and referral, adult pneumococcal immunizations (age >/=65 years), referral of children without primary care physicians to a continuing source of care, and smoking cessation counseling. Interventions receiving a beta or gamma rating, indicating that existing research is not sufficient to recommend for or against instituting them routinely in the ED, include: identification and counseling of geriatric patients at risk of falls, Pap tests in women having a pelvic exam in the ED, counseling for smoke detector use, routine social service screening, depression screening, domestic violence screening, safe firearm storage counseling, motorcycle helmet use counseling, and youth violence counseling programs in the ED. Interventions not recommended for ED implementation (omega rating) include Pap test screening for women not having a routine pelvic exam, diabetes screening, and pediatric immunizations. CONCLUSIONS: A set of recommendations for prevention, screening, and counseling activities in the ED based on systematic reviews of selected interventions is presented. The applicability of these primary and secondary preventive services will vary with the different clinical environments and resources available in EDs. The PHTF recommendations should not be used as the basis of curtailing currently available services. This review makes clear the need for further research in this important area.

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.

Sexual Assault Nurse Examiner programs in the United States.

STUDY OBJECTIVE: We sought to provide a descriptive study of the Sexual Assault Nurse Examiner (SANE) programs and their characteristics in the United States. METHODS: A confidential survey addressing patient and staff demographics, administration attributes, examination procedures, and medical and legal issues was mailed to SANE programs in the United States. RESULTS: Sixty-one (66%) of 92 programs responded. More than half of the programs (32/58 [55%]) had been in operation for less than 5 years. Thirty (52%) of the 58 programs performed the initial sexual assault examination in hospital emergency departments. Written consent (57/59 [97%]) was obtained for the initial examination, and most (51/59 [86%]) programs used preprepared commercial sexual assault kits. Program directors were predominately registered nurses. All but one program mandated specific training requirements for their staff, with a median requirement of 80 hours. Procedures used for initial examinations varied; most offered pregnancy testing (56/58 [97%]), pregnancy prophylaxis (57/59 [97%]), and sexually transmitted disease (STD) prophylaxis (53/59 [90%]). HIV testing was not offered in 32 (54%) of 59 programs. Almost all programs used Wood's lamp (51/59 [86%]), colposcopes (42/59 [71%]), and photographs (46/59 [78%]) for documentation. Median time required per patient for initial examination and evidence collection was 3 hours (range, 1 to 8 hours). Follow-up is consistently offered to the survivor. Most programs (45/61 [74%]) could report the number of survivors treated, but few could provide information on survivor medical follow-up or the number of prosecutions by survivors and their outcomes. CONCLUSION: This survey provided an overview of SANE programs. SANE programs are similar across the country with regard to staffing, training, STD and pregnancy prophylaxis, and documentation techniques. They are inconsistent in the use of STD cultures, HIV testing, and alcohol and drug screening. SANE programs were unable to provide data regarding survivor follow-up and legal outcomes. This information is essential to evaluate the programs' effectiveness and to improve performance. The need for better outcome data should be addressed to define success or failure of SANE programs.

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.

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.

Paramedic judgment of the need for trauma team activation for pediatric patients.

OBJECTIVE: To determine the value of paramedic judgment in determining the need for trauma team activation (TA) for pediatric blunt trauma patients. METHODS: A prospective, observational study was conducted at the ED of Children's Hospital Medical Center of Akron between July 12, 1996, and February 28, 1997, in cooperation with Akron Fire Department emergency medical technician-paramedics (EMT-Ps). The ED provides on-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released at the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgment, a patient needed TTA. Patients 0-14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of >10 feet were included in the study. TTA was defined as necessary if the patient was admitted to the intensive care unit (ICU) or operating room (OR) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hospital records were reviewed. Coroners' records as well as medical records of all trauma admissions during the study period were reviewed to ensure that the patients released at the scene were not mistriaged. RESULTS: One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to need TTA were admitted to the ICU/OR, and neither of the patients identified by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have TTA deteriorated after arrival to the ED. Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for TTA for pediatric blunt trauma patients were 50% (95% CI 9.2-90.8) and 87.7% (95% CI 78.0-93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5). None of the patients released at the scene was mistriaged based on the review of the coroners' and trauma admission records. CONCLUSION: Results of this investigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for pediatric blunt trauma patients is not sufficiently sensitive to be of clinical use. The low sensitivity is explained by the deterioration in the clinical condition of 2 initially stable patients. The paramedic disposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjured pediatric trauma patients. Injured pediatric trauma patients who appear to be stable may deteriorate shortly after injury. However, if a pediatric patient appears injured, transport from the scene and examination by a trauma specialist are needed. Finally, the role of paramedic judgment must be further defined by larger studies with urban, rural, and suburban EMS systems before it can be used as a sole predictor of TTA.

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.

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.

Effect of menthol cigarettes on biochemical markers of smoke exposure among black and white smokers.

STUDY OBJECTIVES: Black smokers have been reported to have higher serum cotinine levels than do white smokers, and have higher rates of most smoking-related diseases, despite smoking fewer cigarettes per day. Another striking racial difference is the preference for mentholated cigarettes among black smokers. The contribution of menthol to variability in biochemical markers of cigarette smoke exposure (end-expiratory carbon monoxide and serum cotinine) was evaluated in a biracial sample. DESIGN: Descriptive cross-sectional. SETTING: A university smoking research laboratory. PARTICIPANTS: Sixty-five black and 96 white adult established smokers who were paid for their participation. MEASUREMENTS: Information was obtained through direct observation, self-report (interview and self-administered questionnaires), measurement of butts collected for a week, and laboratory analyses of the biochemical markers of exposure. RESULTS: Compared with the white smokers, the black smokers had significantly higher cotinine and carbon monoxide levels per cigarette smoked and per millimeter of smoked tobacco rod (both p < 0.001). After adjusting for race, cigarettes per day, and mean amount of each cigarette smoked, menthol was associated with higher cotinine levels (p = 0.03) and carbon monoxide concentrations (p = 0.02). CONCLUSIONS: The use of menthol may be associated with increased health risks of smoking. Menthol use should be considered when biochemical markers of smoke exposure are used as quantitative measures of smoking intensity or as indicators of compliance with smoking reduction programs. In addition, the effect of menthol on total "dose" should be considered in any efforts to regulate the amount of nicotine in cigarettes.

Response error in self-reported current smoking frequency by black and white established smokers.

As compared with white smokers, black smokers, although they report using fewer cigarettes per day, are at higher risk for most smoking-related diseases. Among black smokers serum cotinine levels are also higher in proportion to cigarettes per day; this observation has led to suggestions of bias in self-reporting. The purpose of this study was to evaluate and compare the extent of errors in self-reported smoking patterns among black and white established smokers. Ninety-seven white and 66 black smokers participated in structured telephone interviews, filled out two self-administered questionnaires one week apart, and collected all of their cigarette butts for a week. Group differences in the validity of self-reported smoking patterns were assessed by comparison with cigarette butt counts and the measured butt lengths. Both black and white smokers significantly overestimated smoking on our measure of smoking frequency (both P < 0.001); the group difference in bias was not significant (P = 0.13). There was no evidence that underreporting was more common among blacks than among whites (P = 0.67). Test-retest reliability was not significantly different in the two groups (P = 0.09). Both groups performed poorly when asked to categorize their smoking frequency according to the cutpoints of the Fagerström Test for Nicotine Dependence. Black smokers smoked more of each cigarette and smoked longer cigarettes, but they smoked fewer total millimeters of cigarettes per day (all P < 0.001). Contrary to an earlier report, the disproportionately high cotinine levels could not be attributed to reporting error.

Predictive factors for early mortality after percutaneous endoscopic gastrostomy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a safe access procedure for enteral nutrition. The purpose of this investigation is to identify predictive factors for early mortality after PEG. METHODS: A retrospective review of the hospital records of 416 patients undergoing PEG from June 1, 1989, through December 31, 1991, was conducted. Patient demographics, admitting diagnosis, indication for PEG, risk factors for early mortality, and cause and date of death were reviewed. Logistic regression analysis was used to develop a model to predict early mortality after PEG. The follow-up period ranged from 1 to 30 months. RESULTS: The overall mortality rate in this review was 227 of 416 patients (54.6%). The 7- and 30-day case fatality rates were 39 of 416 (9.4%) and 97 of 416 (23.3%), respectively. Logistic regression analysis showed that urinary tract infection (odds ratio (OR) = 3.05; 95% confidence interval (CI) = 1.45-6.43) and previous aspiration (OR = 6.86; 95% CI = 3.27-14.4) were predictive factors for death at 1 week after PEG. Patients who had both risk factors had a 48.4% probability of dying within 7 days after PEG insertion, whereas those who had no risk factors had a 4.3% probability of death. Urinary tract infection (OR = 2.00; 95% CI = 1.17-3.41), previous aspiration (OR = 3.62; 95% CI = 2.00-6.55), and age greater than 75 years (OR = 2.49; 95% CI = 1.47-4.21) were predictive factors for death at 1 month after PEG. Patients who had all three risk factors had a 67.1% probability of death at 1 month while those who had no risk factors had a 10% probability of death. CONCLUSIONS: A subgroup of patients exists that has a very high mortality rate after PEG. Less invasive ways of nutritionally supporting these high-risk patients should be evaluated.

Directing an emergency medicine residency: the problems and their potential solutions.

OBJECTIVE: To characterize the problems facing emergency medicine residency directors (EMRDs), to describe potential solutions, and to associate perceptions with anticipated duration in the position of EMRD. METHODS: A confidential questionnaire was mailed to the EMRDs at all Accreditation Council for Graduate Medical Education-approved programs. The survey included a problem and solution list constructed by a panel of EMRDs. The respondents were asked to rate problems using a Likert-like scale and were asked to indicate which of the listed solutions they had used and had found useful, or thought would be useful. Associations of these features and demographic variables with the intention to leave the position of EMRD within 5 years were sought. RESULTS: Eighty-seven of 93 EMRDs (93.5%) completed the survey. Their mean age was 40 years; 50% had been EMRDs for < 3 years. Most of the EMRDs (62%) had an associate EMRD, and 77% had at least one secretary. The EMRDs worked a median of 220 hours per month. Major problems included: insufficient time for the job (57%), career interfering with family needs (44%), and lack of adequate faculty help (38%). The most frequently cited and useful solutions included: attending education courses, self-reading on education and management techniques, and discussing problems with and seeking advice from others. Most (68%) of the EMRDs anticipated continuing as program director for < or = 5 years. Neither age, gender, previous amount of time in the position, number of hours worked, nor nature of the problems faced on the job was a significant predictor of which of the EMRDs anticipated leaving. CONCLUSIONS: Half the responding EMRDs were < 40 years of age, half had been EMRDs for < or = 3 years, and 68% anticipated continuing in their position for < or = 5 years. Major frustrations included lack of knowledge and time. Family and career conflicts were frequent. These problems are similar to those of program directors in other specialties. Some recommendations are made to assist EMRDs.