Tap water scald burns in children.

Tap water scald burns account for 7% to 17% of all childhood scald burns that require hospitalization. Often the burns are severe and disabling. Toddlers and preschool children are the most frequent victims. In 45% of the injuries, the unsupervised victim or peer turned on the tap water; in 28% the cause was abuse. Eighty percent of the homes tested had unsafe bathtub water temperatures of 54 C (130 F) or greater, exposing the occupants to the risk of full-thickness scald with 30-second exposure to hot water. Such burns may be prevented passively by limiting household water temperatures to less than 52 C (125 F). New water heaters could be preset at this temperature and families could be taught to turn down the temperature on existing units.

Hallervorden-Spatz disease in a psychiatric setting.

Neurodegenerative disorders of sufficient severity to be lethal are also likely to generate psychiatric symptomatology. At times, behavioral changes may predate neurologic manifestations, whereas at other times disturbances in mental status and physical functioning may coexist. In either situation, accurate assessment and appropriate treatment may prove challenging. The case of Hallervorden-Spatz disease reported here illustrates this difficulty; the authors present it to highlight the general issues that often arise in this group of illnesses. In this patient, as well as in three of his relatives, initially subtle neurologic signs were preceded by and then intermingled with significant and sometimes severe symptoms of depression. The authors emphasize the importance of attending to the neurologic symptom picture and family history in order to more appropriately assess the psychiatric manifestations of the disorder. Knowledge of neurodegenerative illnesses, even those as admittedly rare as Hallervorden-Spatz disease, can facilitate accurate and prompt diagnostic assessment, guide treatment strategies (including avoidance of inappropriate interventions), and help to more realistically define outcome expectations.

Follow-up of patients after nephrectomy for renal cell carcinoma.

Follow-up of patients after nephrectomy for renal cell carcinoma is often inadequate. The sooner secondary lesions are identified and treated the better. Routine annual admission of these patients is urged for abdominal angiography, bone scan, chest roentgenograms, and specialized diagnostic procedures as indicated.

The impact of changes in HCFA documentation requirements on academic emergency medicine: results of a physician survey.

BACKGROUND: The Health Care Financing Administration (HCFA) has dramatically increased documentation and procedural supervision required by faculty in academic emergency departments (EDs). OBJECTIVES: To determine academic emergency medicine (EM) physicians' perceptions of the impact of HCFA documentation requirements (HDR) on teaching time, clinical efficiency, and job satisfaction. METHODS: An observational cross-sectional study was done using a survey of New England academic EM faculty from September to December 1999. E-mail surveys were followed by hard copy to nonresponders. Teaching time, clinical efficiency, and job satisfaction were rated on a five-point Likert scale. Yes/no questions about other possible benefits of HCFA regulations were asked. Frequency (95% CI) and chi-square analyses were performed. RESULTS: One hundred seventy-four of 233 (75%) responded. Eighty-nine percent (95% CI = 84% to 93%) of the respondents thought teaching time was somewhat or markedly decreased by changes in HDR (somewhat 46%, markedly 43%). Seventy-nine percent (95% CI = 73% to 85%) believed clinical efficiency was somewhat or markedly decreased by changes in HDR (somewhat 49%, markedly 30%). Eighty percent (95% CI = 73% to 86%) reported somewhat or markedly decreased job satisfaction due to changes in HDR (somewhat 56%, markedly 24%). Twenty-one percent (95% CI = 15% to 27%) believed changes in HDR had improved patient care by requiring increased patient supervision. Forty-eight percent (95% CI = 40% to 56%) thought that changes in documentation requirements had decreased medicolegal risk by improving patient documentation. CONCLUSIONS: Most academic EM physicians in New England perceive that HDR have decreased clinical efficiency, teaching time, and job satisfaction. These findings suggest that changes in HDR may have a substantial impact on many different aspects of emergency care provided in academic settings.

Cocaine-associated chest pain: one-year follow-up.

OBJECTIVE: To determine the one-year mortality and incidence of myocardial infarction (MI) post-hospital discharge or ED release for patients with cocaine-associated chest pain. METHODS: A prospective, observational study of an inception cohort of consecutive patients who presented to one of four municipal hospital EDs with cocaine-associated chest pain. Patients were followed for one year from the end of the enrollment period. Main outcome parameters were the one-year actuarial survival and the frequency of nonfatal MI. RESULTS: Mortality data were available for all 203 patients at a mean of 408 days. Additional clinical information was available for 185 patients (91%). There were six deaths (one-year actuarial survival 98%; 95% CI, 95-100%); none from MI. Nonfatal MI occurred in two patients (1%; 95% CI, 0-2%). Continued cocaine use was common (60%; 95% CI, 52-68%) and was associated with recurrent chest pain (75% vs 31%, p < 0.0001). No MI or death was reported for patients who claimed to have ceased cocaine use. CONCLUSIONS: Patients who presented with cocaine-associated chest pain commonly continued to use cocaine after discharge. Urgent evaluation of coronary anatomy or cardiac stress tests may not be necessary for patients for whom MI is ruled out and who do not have recurrent potentially ischemic pain. The subsequent risk for MI and death in this group appears to be low. Intervention strategies should emphasize cessation of cocaine use.

The evaluation of cocaine-induced chest pain with acute myocardial perfusion imaging.

OBJECTIVE: To use myocardial perfusion imaging to determine the etiology of cocaine-induced chest pain in patients without ECG evidence of acute cardiac ischemia. METHODS: The authors conducted a prospective study of consecutive consenting patients aged 18-70 years with cocaine-induced chest pain who reported cocaine use within three days and presented with a chief complaint of chest pain occurring within three hours and lasting longer than 15 minutes with a normal or nondiagnostic ECG. Patients were excluded if they had a clear-cut noncardiac cause of chest pain, ECG evidence of acute cardiac ischemia, history of myocardial infarction, pregnancy, or lactation, required immediate hospitalization, or were unable to consent. Patients were injected with Tc-99m tetrofosmin and imaged. Perfusion scans were independently read by two nuclear radiologists. Clinicians blinded to scan results determined patient disposition. Patients with abnormal scans were asked to return for follow-up resting scans. RESULTS: Fourteen patients were enrolled. Twelve of the 14 patients had chest pain at the time of Tc-99m tetrofosmin injection. Ten of the 14 [(71%) 95% CI = 48% to 95%] scans were normal or within normal limits. Four of the 14 [(29%) 95% CI = 5% to 52%] were abnormal. Of the four patients with abnormal scans, two had follow-up scans that demonstrated an irreversible perfusion abnormality, and two who did not return for follow-up reported no subsequent hospitalizations for acute cardiac ischemia. CONCLUSION: Perfusion imaging did not demonstrate reversible ischemia in most patients (12/14, 86%) with cocaine-induced chest pain without ECG evidence of ischemia. These results suggest that cocaine-induced chest pain in most patients without ECG evidence of ischemia is not due to acute ischemia.

Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group.

OBJECTIVE: To describe a large cohort of patients who had chest pain following cocaine use, and to determine the incidence of and clinical characteristics predictive for myocardial infarction in this group of patients. METHODS: A prospective observational cohort study of consecutive patients with cocaine-associated chest pain was conducted in six municipal hospital emergency departments (EDs). Demographic variables, drug abuse patterns, medical histories, chest pain characteristics, ECG results, and laboratory data were recorded. Myocardial infarction was the primary endpoint. RESULTS: Fourteen of 246 patients (5.7%; 95% confidence interval [CI], 2.7-8.7%) had myocardial infarction, as diagnosed by elevated CK-MB isoenzyme levels. There were two deaths (0.8%). The patients had a median age of 33 years. The majority were male (71.5%), non-white (83.3%), cigarette smokers (83.3%) who used cocaine regularly. Chest pain began a median of 60 minutes after cocaine use and persisted for a median of 120 minutes. Chest pain was most frequently described as substernal (71.3%) and pressure-like (46.7%). Shortness of breath (59.3%) and diaphoresis (38.6%) were common. There was no clinical difference between patients who had myocardial infarctions and those who did not. Twelve patients had arrhythmias and four had congestive heart failure. All cases requiring intervention were evident upon presentation. An ECG revealing ischemia or infarction had a sensitivity of 35.7% for predicting a myocardial infarction. The specificity, positive predictive value, and negative predictive value of the ECGs were 89.9%, 17.9%, and 95.8%, respectively. CONCLUSIONS: Myocardial infarction in patients who have cocaine-associated chest pain is not uncommon. No clinical parameter available to the physician can adequately identify patients at very low risk for myocardial infarction. Therefore, all patients with cocaine-associated chest pain should be evaluated for myocardial infarction.

Interference of herbal drinks with urinalysis for drugs of abuse.

Recently there have been claims among drug users that some herbal drinks interfere with urinalysis for drugs of abuse and yield false positive results. Proof of such claims has yet to be shown. Screening for drugs of abuse is usually carried out using fluorescence polarization immunoassay (FPIA) or thin-layer chromatography (TLC). Fifty herbal samples which are considered among the most purchased herbs in the consumer market were used to investigate such claims. The drug groups that were tested for included amphetamines, opiates, barbiturates, cocaine metabolite, methadone, and their analogs. The herbs were analyzed at different concentrations (0.1, 1, 3, and 5 g/100 mL of distilled water) using TLC and FPIA to determine if any interfere with urinalysis for drugs of abuse and yield false positive results. For the FPIA test, the sample infusions were analyzed directly using the automated ADX analyzer (Abbott Laboratory). For TLC, infusions of the herbs were added to a solid-phase extraction column (pH 9.25), then extracted with a methylene chloride-isopropanol solvent system. At this pH, neutral, basic, and acidic drugs of abuse are extractable. The developed chromatographic plates were sprayed sequentially with several reagents. None of the herbs in the concentration ranges screened showed any interference with TLC or FPIA, indicating the invalidity of such claims.

Resuscitation fluid for a patient with head injury and hypovolemic shock.

The resuscitation of a patient with severe closed head injury and hypovolemic shock is a commonly encountered clinical scenario. The optimal resuscitation formula remains controversial. Aggressive use of crystalloid solutions may worsen brain injury. Early use of mannitol or hypertonic agents may worsen hemorrhage and shock. The optimal approach to the resuscitation of a patient with head trauma and hypovolemic shock is reviewed and discussed. Recent experimental evidence suggests that the early inclusion of an agent such as mannitol in the resuscitation formula may be appropriate despite the evidence of shock. However, the controversy remains unresolved.

Dynamic connections in neural networks.

Massively parallel (neural-like) networks are receiving increasing attention as a mechanism for expressing information processing models. By exploiting powerful primitive units and stability-preserving construction rules, various workers have been able to construct and test quite complex models, particularly in vision research. But all of the detailed technical work was concerned with the structure and behavior of fixed networks. The purpose of this paper is to extend the methodology to cover several aspects of change and memory.

Thrombolytic therapy and cocaine-associated acute myocardial infarction.

The role of thrombolytic therapy in patients with cocaine-associated acute myocardial infarction (AMI) is controversial. Some have suggested that because the AMI mortality may be low in young patients with cocaine usage, the risks outweigh the benefits of thrombolytic therapy. Two cases of cocaine-associated AMI are presented. Each case illustrates different aspects of this controversy. In one case, ECG interpretation and concerns with thrombolytic therapy in this setting led to prolonged treatment delay. The second case illustrates unrecognized cocaine-associated AMI treated safely with thrombolytic therapy and beta-blockade. The arguments for and against thrombolytic therapy in this setting are discussed. The available literature suggesting increased risk associated with thrombolytic therapy in patients with cocaine-associated AMI is critically reviewed.

Medication noncompliance: an issue to consider in the drug selection process.

Patient medication noncompliance is a major public health problem that represents a significant cost to our health care system. Health care professionals--through counseling programs, and the pharmaceutical industry--through various improvements in drug products, have helped to improve medication noncompliance. Yet, additional research needs to be conducted on noncompliant behavior and into methods to improve it. All health care professionals, particularly those involved in selecting and guiding drug therapy decisions, need to be made aware of the costs to the health care system that result from noncompliance.

High-performance liquid chromatographic radioenzymatic assay for plasma catecholamines.

A new assay method for plasma CA's requiring only 50 microliter has been developed, which uses HPLC. The NE, D, and E compounds found in plasma are radioactively o-methylated with 3H-SAM by the reaction of COMT. The reaction is terminated and a standard mixture of nonradioactive o-methylated analogues of NE, D, and E is addded to act as a carrier. Following separation by HPLC, the NMN, 3-MOT, and MN radioactive peaks are collected which represent NE, D, and E, respectively. Then MNM and MN are oxidized to vanillin, and 3-MOT is acetylated. The products are subsequently separated by solvent extraction. This is necessary in order to avoid high radioactive blanks and to allow quantitation of the radioactivity by liquid scintillation spectrometry. The mean supine levels of NE, D, and E in normal subjects were respectively 182, 33, and 87 pg/ml of plasma. Similar assays on patients with pheochromocytoma revealed 797, 80, and 470 pg/ml.

Acute cardiac ischemia in patients with cocaine-associated complaints: results of a multicenter trial.

STUDY OBJECTIVE: To describe the characteristics of a large group of patients who presented to emergency departments with cocaine-associated symptoms consistent with acute cardiac ischemia (ACI) and to determine the incidence of confirmed ACI including acute myocardial infarction (AMI) in this population. METHODS: We performed a substudy on all patients in a multicenter prospective clinical trial (the Acute Cardiac Ischemia-Time Insensitive Predictive Instrument [ACI-TIPI] Clinical Trial) that enrolled ED patients with chest pain or other symptoms consistent with ACI including subjects with identified cocaine use. Demographic and clinical features, including initial and follow-up clinical data, ECGs, and tests to determine serum creatine kinase isoenzyme MB subunit concentrations, were analyzed. Diagnoses of AMI followed the World Health Organization criteria for AMI and of angina pectoris, the Canadian Cardiovascular Society Classification. RESULTS: Of the 10,689 patients enrolled in the trial, 293 (2.7%) had cocaine-associated complaints. Among the 10 participating hospitals, the incidence of patients with cocaine-associated symptoms varied from 0.3% to 8.4%. Only 6 patients (2.0%, 95% confidence interval [CI] 0.76% to 4.4%) had a diagnosis of ACI; 4 (1.4%, 95% CI 0.37% to 3.5%) had unstable angina, and 2 (0.7%, 95% CI 0.08% to 2.4%) had AMI. Although patients with cocaine-induced complaints were as likely to be admitted to the coronary care unit compared with all study patients without cocaine use (14% versus 18%, P =.14, difference not significant), these patients were much less likely to have confirmed unstable angina (1.4% versus 9.3%, P <.001) or AMI (0. 7% versus 8.6%, P <.001). Compared with patients younger than 45 years, patients with cocaine usage were more likely to be admitted to the ICU (14% versus 8.0%, P =.0018) but less likely to have confirmed AMI (0.7% versus 2.8%, P =.033). CONCLUSION: Patients presenting to EDs with cocaine-associated chest pain or related symptoms infrequently had ACI, and even less so, AMI. This suggests the need for selectivity in the hospitalization of patients with such cocaine-associated symptoms.