Incomplete discoid glenoid labrum combined with a ganglion cyst of the spinoglenoid notch.

In a 41-year-old man, right-sided infraspinatus muscle weakness was associated with compression of the suprascapular nerve caused by a spinoglenoid ganglion cyst. The lesion was confirmed using electromyography and MRI. In addition, arthroscopy showed an incomplete discoid labrum. The free inner edge of the labrum was removed as in a meniscectomy of a discoid meniscus in the knee joint. Arthroscopic decompression of the cyst was performed through a juxtaglenoid capsulotomy which was left open. Neurological function recovered completely.

Lactoferrin causes IgA and IgG2b isotype switching through betaglycan binding and activation of canonical TGF-ß signaling.

Lactoferrin (LF), a pleiotropic iron-binding glycoprotein, is known to modulate the humoral immune response. However, its exact role in Ig synthesis has yet to be elucidated. In this study, we investigated the effect of LF on Ig production by mouse B cells and its underlying mechanisms. LF, like transforming growth factor (TGF)-ß1, stimulated B cells to produce IgA and IgG2b, while downregulating other isotypes. Using limiting dilution analysis, LF was shown to increase the frequency of IgA-secreting B-cell clones. This was paralleled by an increase in Ig germ-line α (GLα) transcripts, indicating that LF plays a role as an IgA switch factor. Interestingly, LF directly interacted with betaglycan (TGF-ß receptor III, TßRIII) and in turn induced phosphorylation of TßRI and Smad3 through formation of the TßRIII/TßRII/TßRI complex, leading to IgA isotype switching. Peroral administration of LF increased intestinal/serum IgA production as well as number of IgA plasma cells in lamina propria. Finally, we found that LF has an adjuvant activity when nontoxigenic Salmonella typhimurium was inoculated perorally, conferring protection against intragastrical infection of toxigenic S. typhimurium. These results suggest that LF has an important effect on the mucosal/systemic IgA response and can contribute to protection against intestinal pathogens.

Fragment E derived from both fibrin and fibrinogen stimulates interleukin-6 production in rat peritoneal macrophages.

Fibrin derived from fibrinogen after thrombin cleavage plays an essential role in forming blood clots. Fibrin as well as fibrinogen is also involved in the induction of platelet aggregation, leukocyte cell adhesion and phagocytosis. An additional biological role of fibrin and fibrinogen is presented in this study. One of the proteolytic peptides of fibrin/fibrinogen, fragment E, and not fragment D, was able to stimulate rat peritoneal macrophages to express interleukin-6 (IL-6). The stimulation of fibrin/fibrinogen fragment E on macrophages appeared to work in a dose- and time-dependent manner. Adherent fibrin fragment E was able to stimulate IL-6 expression as well as IL-6 protein production. The effect of fibrin fragment E was inhibited by the addition of an excess amount of GPRP tetrapeptide, but not by GHRP, which are the amino acids derived from the amino terminus of fibrin alpha and beta chains, respectively. These results suggest that fibrin as well as fibrinogen function as a stimulator to macrophages, and leukocyte integrin p150,95 (CD11c/ CD18), not Mac-I (CD11b/CD18), is involved in mediating fibrin stimulatory activity in macrophages.

Response to dopamine vs norepinephrine in tricyclic antidepressant-induced hypotension.

OBJECTIVE: To compare the efficacy of dopamine (DA) with that of norepinephrine (NE) in the treatment of refractory hypotension caused by tricyclic antidepressants (TCAs). METHODS: A retrospective analysis was used to compare blood pressure responses in concurrent case series of patients treated with vasopressors for TCA-associated hypotension. The patients were adults (aged > or = 16 years) treated at 2 urban teaching hospitals from 1983 to 1994. All patients were diagnosed as having TCA ingestion (positive serum toxicologic assay), were hypotensive [systolic blood pressures (SBPs) < or = 90 mm Hg], and required vasopressor therapy. The patients were grouped by initial vasopressor treatment (i.e., NE vs DA). RESULTS: There were 26 hypotensive adult patients who met study criteria. All 26 patients remained hypotensive after initial treatment of their TCA-associated hypotension with crystalloid infusion and alkalinization. The NE and DA groups were similar in age, sex, and proportion of patients with single and co-drug ingestion. The NE group, however, had a significantly lower average SBP at study entry (56 vs 74 mm Hg, p = 0.04). Nine of 15 (60%) patients responded to DA (5-10 micrograms/kg/min) and 11/11 (100%) patients responded to NE (5-53 micrograms/min). The difference in response rates was statistically significant (p = 0.02). Six patients in whom DA (max rate 10-50 micrograms/min/kg) failed to raise the SBP subsequently responded to NE (max rate 5-74 micrograms/ min) when this drug was later used. One patient receiving NE (12 micrograms/min) developed ventricular ectopy, successfully treated with lidocaine. There were no ischemic complications from either NE or DA. Patients who failed DA therapy tended to be older (39 vs 30 years, p = 0.08), to be more hypotensive at study entry (64 vs 81 mm Hg, p = 0.008), and to remain hypotensive even at higher doses of DA (24 vs 7 micrograms/min/kg, p = 0.002). CONCLUSION: While this was not a prospective randomized study, NE appears advantageous over DA as the first-line vasopressor agent for those patients who require vasopressor support in the setting of TCA-induced hypotension that is refractory to IV fluid and serum alkalinization.

Gas exchange and lung mechanics during percutaneous transtracheal ventilation in an unparalyzed canine model.

OBJECTIVE: To compare the efficacy of percutaneous transtracheal ventilation (PTV) in the unparalyzed state with that in the paralyzed state using a sedated nonobstructed canine model. METHODS: Eight mongrel dogs (16.8-32 kg) were anesthetized, instrumented, and placed in a volume plethysmograph. Anesthesia was achieved with pentobarbital sodium (up to 30 mg/kg). The spontaneous respiratory drive was kept intact. PTV was performed using a 13-ga transtracheal catheter and compressed air at 45 psi at an I:E ratio of 1:3 (15 breaths/min). Each dog was sequentially ventilated in both the paralyzed and unparalyzed states. The paralyzed/unparalyzed sequence was alternated among the animals to avoid sequence bias. Paralysis was achieved with succinylcholine (0.1 mg/kg bolus and 0.01 mg/kg/min drip). Reversal of paralysis was achieved by discontinuing the succinylcholine infusion. Key variables, including arterial blood gas, tidal volume, and pulmonary mechanics, were measured and compared for the paralyzed and unparalyzed states. RESULTS: Gas exchanges and lung mechanics were similar between the unparalyzed and paralyzed states. There was no significant difference in mean pH, pCO2, pO2, tidal volume, or peak inspiratory transpulmonary pressure. There was also no significant difference in pulmonary resistance or pulmonary compliance. CONCLUSION: In a sedated nonobstructed canine model, PTV is as efficacious in the unparalyzed state as it is in the paralyzed state. The lung mechanics are also similar in the 2 states. These data suggest that it may be unnecessary to induce paralysis when using PTV for emergency ventilation in the heavily sedated state.

Perceptions and satisfaction with emergency department care.

A telephone questionnaire examining perceived quality of and satisfaction with Emergency Department (ED) care was administered to randomly selected patients within 60 days of their visit to a university hospital ED over a 13-month period. Patients, or the persons who accompanied them to the ED, rated overall service, nursing technical performance, physician technical performance, nursing bedside manner, physician bedside manner, and registration clerk service on a 5-point rating scale (5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor). Patients were also asked if they felt the care was delivered in a timely manner. A total of 618 interviews were conducted (1333 attempts to contact, 12 people declined to be interviewed). The results suggest that patient perceptions of the technical quality of care are more important than perceived timeliness of care or bedside manner in determining patient satisfaction with ED care.

Evaluating anatomical factors affecting endotracheal intubation.

Critically ill patients often require endotracheal intubation in the emergency department. Sometimes immediate attempts at endotracheal intubation are indicated. In other situations, a momentary delay to assess the anatomic factors that might make intubation difficult is advantageous. This examination should include assessment of nose and oral cavity patency, mobility and posterior depth of the mandible, and mobility and length of the neck.

Does the substitution of a resident for a flight nurse alter scene time?

The purpose of this study was to compare the performance of a nurse resident crew (N/R) to that of the usual nurse/nurse (N/N) crew in a helicopter transport service using scene time as a measure of overall teamwork. It was designed as a retrospective case control study carried out by a university-based helicopter emergency transport service. Emergency Medicine second-year residents who volunteered to be assigned to the helicopter transport service for 1 month rotations flew with an experienced flight nurse. This nurse/resident (N/R) team was compared to the usual nurse/nurse (N/N) team in scene trauma flights. The average ground time for the N/N crew (10.5 minutes, n = 43) was not significantly different from that of the N/R crew (10.3 minutes, n = 43). This study suggests that an emergency medicine resident can be incorporated into a flight crew without adversely affecting scene time.

Evaluation of hospital-based aeromedical transport programs using therapeutic intervention scoring.

The number of patients transported by hospital-based aeromedical transport programs is increasing rapidly across the country. How many of these patients really need this kind of transport and how to compare the performance of different services in this regard remain controversial issues. We examined these questions in a prospective analysis of 1,081 flights in 5 aeromedical transport programs using the Therapeutic Intervention Scoring System (TISS) as the basis for an index of appropriateness. An average of 41.5% of flights in all programs were clearly appropriate according to the index, i.e., had scores associated with a 99% probability of validation by direct review. Another 34.9% of flights had a greater than 50% probability of being appropriate. From 18 to 28% of flights had scores associated with only a 20% probability of justification. Although TISS scoring, which is carried out after transfer, cannot provide a means of selecting individual patients for aeromedical transfer, a TISS-based index appears to be a simple and useful method for examining overall appropriateness of program activity, and could be used to set objective standards of appropriateness for evaluation and comparison of aeromedical programs.

A comparison of emergency medical helicopter accident rates in the United States and the Federal Republic of Germany.

The purpose of this study was to compare accident rates of helicopter emergency medical services (USA-HEMS) to domestic air taxi service (USA-Taxi) and helicopter emergency medical services in the Federal Republic of Germany (FRG-HEMS). Contingency tables compared the total hours flown to the number of fatal and non-fatal accidents for USA-HEMS (1982-7) vs. USA-Taxi (1980-5) and USA-HEMS (1982-7) vs. FRG-HEMS (1982-7). The overall accident rate for USA-HEMS was 11.7/100,000 h, with the fatal accident rate being 4.7/100,000 h. This was significantly different from the USA-Taxi overall accident rate of 6.7/100,000 h and the fatal accident rate of 1.6/100,000 h (chi 2 = 20.441, p = 0.0001). The USA-HEMS overall and fatal accident rates were not significantly different than the FRG-HEMS overall (10.9/100,000 h) and fatal (4.1/100,000 h) accident rate (chi 2 = 0.061, p = 0.97). These data suggest that emergency air transport is inherently more risky than routine air taxi services.

Arthroscopic capsular suture for anterior instability of the shoulder.

We assessed the results of arthroscopic transglenoid capsular suture in eight recurrent traumatic unidirectional anterior dislocations. At an average follow up of 11 months, ranging from eight to 18 months, assessment by Rowe's scoring system were excellent or good in all shoulders. There were no redislocations and all patients achieved near full, painless range of motion. There were no complications. We propose a new classification of anterior capsular lesions (Bankart lesion) and we describe the details of the arthroscopic suture technique. We conclude that arthroscopic suture is an effective method with low surgical morbidity and low cost in the treatment of recurrent anterior dislocation of the shoulder.

Massive verapamil ingestion: a report of two cases and a review of the literature.

This report describes two patients who were victims of massive verapamil ingestion and then reviews the available literature. Because verapamil blocks the slow calcium channels of the heart and blood vessels, the use of calcium as a treatment would be logical. In the two cases reported here, calcium was only transiently effective in maintaining cardiac output and blood pressure. Several other agents were then used and most were ineffective. This is similar to experience reported in the literature that suggests that no single agent is capable of reversing verapamil's negative inotropic, dromotropic, chronotropic, and vascular smooth muscle effects.

Patient satisfaction with a nurse practitioner in a university emergency service.

STUDY OBJECTIVE: To compare the overall satisfaction with emergency department care of patients seen by a nurse practitioner (NP) with that of patients seen in the usual fashion. DESIGN: A case-control study comparing responses by means of a five-point scale from a prospectively designed telephone survey. SETTING: Midwestern urban university hospital ED in which most patients are seen mainly by fourth-year medical students or house staff and all patients are seen and evaluated by the attending staff. PARTICIPANTS: Patients or, for children and incompetent adults, the person who accompanied the patient to the ED. RESULTS: Overall satisfaction was good for both groups of patients and was not significantly different: 3.9 (SD, 1.1) for the NP group versus 4.0 (SD, 1.3) for the control group (P = .66 [NS]). CONCLUSIONS: This study supports data from earlier studies suggesting that patients are satisfied with ambulatory care delivered by NPs.

The incidence of battery in an urban emergency department.

STUDY OBJECTIVE: To determine the incidence of battery against emergency department medical staff by patients or visitors. DESIGN: Prospective descriptive study over a nine-month period. SETTING: A university-affiliated ED Level I trauma center with an annual census of approximately 64,000 located in a major metropolitan area. PARTICIPANTS: All staff members who had been punched, kicked, grabbed, pushed, or spat on by a patient or visitor while on duty in the ED. INTERVENTIONS: Questionnaire that was completed after the incident. RESULTS: During the study period, there were 19 instances of violence against staff by patients. Staff members were punched six times, kicked seven times, grabbed three times, pushed once, and spat on twice. Blows usually were sustained on the face or head (seven) or on the extremities (seven). In only four cases were hospital incident reports filled out, and in no case was there an injury serious enough to require ED treatment or disability leave. The assailant was usually male (15 of 19, 79%) and usually on a psychiatric or substance abuse detainment (15 of 19, 79%). CONCLUSION: This study suggests that instances of battery in an urban university hospital ED usually are not serious and are committed by patients on a psychiatric or substance abuse detainment.

Choreoathetoid disorder associated with amphetamine-like drugs.

Three cases of an acute choreoathetoid disorder that developed after the use of an amphetamine-like drug are reported. Because of the dramatic improvement in symptoms over a few hours in these cases, we recommend observation, supportive care, and the careful oral administration of activated charcoal.

The effect of an airway algorithm on flight nurse behavior.

This study examined the effects of a clinical algorithm (based on Glasgow Coma Scale) on the airway management of patients transported from the scene of accident or illness by a helicopter emergency medical service staffed with two flight nurses. The year before institution of the algorithm was compared to the subsequent year. Patients from the two years were similar with regard to diagnoses and physiologic status. Patients transported after the introduction of the algorithm were over twice as likely to have had an airway maneuver attempted. An algorithm defining when airway maneuvers ought to be attempted in the field may assist flight nurses in more aggressively managing airways.

Neuromuscular blockade-assisted oral intubation versus nasotracheal intubation in the prehospital care of injured patients.

STUDY OBJECTIVE: To compare nasotracheal intubation (NTI) to neuromuscular blockade-assisted oral intubation (NMB-assisted oral intubation) in the prehospital care of injured patients. DESIGN: Prospective, randomized study conducted over 21 months. SETTING: A university hospital-sponsored helicopter service. PARTICIPANTS: Consecutive adult (more than 12 years old) injured patients at the accident scene with an initial Glasgow Coma Scale of 8 or less in whom the airway was not managed immediately by unrelaxed oral intubation or cricothyrotomy. Subjects were randomized by 24-hour time blocks into NTI or NMB-assisted oral intubation treatment groups. Forty-four were entered into the NTI group (39 randomized, two crossed over to NMB-assisted oral intubation), and 33 were entered into the NMB-assisted oral intubation group (38 randomized, seven crossed over to NTI). INTERVENTIONS: NMB-assisted oral intubation (succinylcholine 1.5 mg/kg IV) or NTI was carried out according to standard protocols. RESULTS: The success rate for NTI was 79.5% (35 of 44) and was similar to that of NMB-assisted oral intubation, 75.8% (25 of 33; chi 2 = .16; P = .69). There were no significant differences between the NTI and the NMB-assisted oral intubation groups with regard to sex, age, outcome, and Glasgow Coma Scale. For those patients in whom the initial technique was successful, NTI was significantly quicker than NMB-assisted oral intubation (mean time of NTI, 2.9 minutes; mean time of NMB-assisted oral intubation, 5.9 minutes; Mann-Whitney U, 168.0; P < .01). CONCLUSION: In the prehospital management of severely injured patients, there is no significant difference between NMB-assisted oral intubation and NTI in the rate at which endotracheal intubation is achieved. However, practitioners may prefer NTI because it requires significantly less time to perform than NMB-assisted oral intubation.

The Rapid Acute Physiology Score.

The Rapid Acute Physiology Score (RAPS) was developed and tested for use as a severity scale in critical care transports. RAPS is an abbreviated version of the Acute Physiology and Chronic Health Evaluation (APACHE-II) using only parameters routinely available on all transported patients (i.e. pulse, blood pressure, respiratory rate, and Glasgow Coma Scale). RAPS has a range from 0 (normal) to 16. Two hundred eighty-three patients were transported by helicopter; 62 died. Pretransport RAPS was available on 282 of 283 patients (mean, 3.85; median, 3). Because of death, discharge, or transfer, 227 complete APACHE-II scores using least physiologic values for the first 24 hours after transfer were collected (mean, 14.98; median, 13). Stepwise logistic regression showed that when all APACHE-II and RAPS values were available, the best single predictor of mortality was worst value APACHE-II (X2(1) = 57.09, P less than .01). When pretransport RAPS was considered as a single explanatory variable, it too had significant predictive power for mortality (X2(1) = 92.53, P less than .01). Correlation analysis comparing RAPS with APACHE-II values at similar points in time revealed a significant relationship in all cases, with the highest correlation between RAPS worst values and APACHE-II worst values (r = .8472, P less than .01). It was concluded that RAPS can be applied usefully in complement with APACHE-II and may have limited utility when used alone.

Assessing the quality of care in a hospital emergency unit: a framework and its application.

This article presents a specific application of a general approach to quality assessment by describing in detail both the theoretical and the practical aspects of quality assessment in a hospital emergency unit. The theoretical framework is established by specifying the level and scope of assessment, adopting a definition of quality, modeling emergency care as a succession of phases, specifying evaluative attributes, choosing a method for case selection, and selecting one or more methods of assessment. The practical application of this framework is illustrated using two methods, "tracer" and "trajectory," and selecting specific conditions amenable to assessment with each method.