Hepatic dysfunction and neurotoxicity in a patient receiving long-term low-dose amiodarone therapy.

BACKGROUND: Amiodarone is commonly used in the treatment of refractory paroxysmal atrial fibrillation. Much of the literature focuses on the toxic effects of this medication in the setting of rapid loading or long-term therapy with high maintenance doses. However, patients have been known to develop multi-organ toxicities with long-term low-dose therapy. CASE REPORT: We present a 90-year-old man with paroxysmal atrial fibrillation undergoing low-dose amiodarone therapy for a period of 18 months without medical follow-up who developed signs and symptoms consistent with neurotoxicity and hepatotoxicity in association with hyperammonemia. Upon discontinuation of the medication and treatment of the hyperammonemia, the patient had a rapid decline in symptoms and a return to his baseline status. CONCLUSION: Identifying toxicity early and correcting it rapidly may prevent life-threatening sequelae associated with amiodarone toxicity.

Authorship, collaboration, and predictors of extramural funding in the emergency medicine literature.

OBJECTIVES: The objectives of the study were to examine the last decade of general emergency medicine (EM) literature published in the United States for trends with regard to authorship and multidisciplinary collaboration and to estimate the effect on extramural funding. METHODS: Print articles published in the Academic Emergency Medicine, Annals of Emergency Medicine, Journal of Emergency Medicine, and American Journal of Emergency Medicine between 1994 and 2003 were reviewed. Original research, case reports/series, and others (consensus/educational) were considered; abstracts, book reviews, and editorials were not. The author byline was reviewed for number, specialty, nationality, collaboration, and presence of extramural funding. Multidisciplinary collaboration was defined as authors from 2 or more specialties, whereas multi-institutional collaboration was defined as EM authors from more than one institution. Logistic regression was used to identify predictors of extramural funding from the variables collected. RESULTS: Of 5728 articles identified, there were 3278 (57%) original research, 1437 (25%) case reports/series, and 975 (17%) classified as others. The percentage funded was 22% for all articles (32% for original research). The literature had at least one EM investigator as coauthor 84% of the time. Article location of origin was the United States (63%), foreign (15%), and combined (22%). Multidisciplinary collaboration increased overall from 33% in 1994 to a high of 43% in 2003. Multi-institutional collaboration also increased from 16% in 1994 to 26% in 2003. The percentage of articles having 6 or more authors increased from 12% to 18% over the decade. Of all variables studied, only article type (original research: odds ratio, 4.8; 95% confidence interval, 4.0-5.6) and foreign source (non-United States: odds ratio, 1.3; 95% confidence interval, 1.1-1.5) predicted extramural funding. CONCLUSIONS: The number of authors per article in the EM literature has steadily increased over the last decade, as has evidence of collaboration with other specialties. This increase in collaboration and author number has not been associated with increased extramural funding in the general EM literature published in the United States.

Classifying patients suspected of appendicitis with regard to likelihood.

BACKGROUND: We sought to develop a clinical predictive model for acute appendicitis and contrast it with current clinical practice. METHODS: A prospective observational study of patients presenting with signs or symptoms consistent with acute appendicitis. Random-partition modeling was used to develop an appendicitis likelihood model (ALM). RESULTS: Four hundred thirty-nine patients were enrolled, 101 with appendicitis, and 338 with other diagnoses. The ALM classified patients as "low likelihood" if they had a white blood cell count <9,500 and either no right lower-quadrant tenderness or a neutrophil count <54%. Patients were classified as "high likelihood" if they had a white blood cell count >13,000 with rebound tenderness or both voluntary guarding and neutrophil count >82%. The ALM outperformed actual clinical practice with regard to "missed" appendicitis, negative laparotomies, and total number of imaging studies. CONCLUSION: The ALM may permit more judicious use of advanced radiographic imaging with lower nontherapeutic laparotomy rates.

Funding and publishing trends of original research by emergency medicine investigators over the past decade.

OBJECTIVES: To update the profile of author-reported funding of reports of original research published since 1994 in the four U.S. peer-reviewed general emergency medicine (EM) journals. METHODS: For the primary analysis, articles published in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Medicine between 1994 and 2003 were reviewed by two emergency physicians trained in abstracting from the literature. Original research was identified; case reports, case series, abstracts, and meta-analysis were excluded. Articles were classified by author report of extramural funding as government (public), private nonprofit (foundation), for profit (industry), or multiple. Data are reported as percent per year per journal. A secondary analysis of MEDLINE was performed to identify publishing trends by EM investigators outside of these four journals over the same period. RESULTS: The primary analysis identified 5,728 articles; 3,278 (57%) were considered original research, with 32% of these reporting extramural funding. In 1994, there were 292 articles with 28% funded (28% public, 43% foundation, 17% industry, and 12% multiple). By 2003, there were 358 articles with 36% funded (42% public, 30% foundation, 18% industry, and 10% multiple). There was a trend toward increased extramural funding in all four journals (p = 0.007), with an estimated growth of 3.6% (95% confidence interval = 1.0% to 6.3%) per year over the past decade. The primary review identified 48% of all articles published by EM investigators. CONCLUSIONS: Author-reported extramural funding rates for original research have increased in the EM literature over the past decade. Foundations have funded the largest number of studies, with public (government) sources increasing in 2003.

Treatment of hyperkalemia in a patient with unrecognized digitalis toxicity.

Cardiac glycoside toxicity is frequently associated with hyperkalemia and dysrhythmias in patients with renal insufficiency. Two common therapeutic options for these complications (calcium and transvenous cardiac pacing) are considered contraindicated in the setting of cardiac glycoside toxicity. We present the case of a patient presenting with a pronounced bradydysrhythmia and hyperkalemia who was treated with intravenous calcium and transvenous cardiac pacing and later found to have digitalis toxicity and acute renal failure. There were no adverse events associated with the therapies. The patient received digoxin-specific Fab fragments and hemodialysis as definitive therapeutic modalities. The case and the relevant literature evaluating the interaction of calcium salts and cardiac pacing in the setting of cardiac glycoside toxicity are discussed.

The ability of traditional vital signs and shock index to identify ruptured ectopic pregnancy.

OBJECTIVE: This study evaluated the correlation between vital signs and hemoperitoneum and the association between abnormal vital signs and tubal rupture. STUDY DESIGN: With the use of a retrospective case-control design, the initial heart rate, systolic blood pressure, and heart rate/systolic blood pressure were correlated with respect to degree of hemoperitoneum; predictive values were calculated. RESULTS: Fifty-two patients were studied (25 ruptured pregnancies and 27 unruptured ectopic pregnancies). Correlation coefficients were heart rate (r=0.50; 95% CI, 0.26-0.68), systolic blood pressure (r=-0.34; 95% CI, -0.56 to -0.08), and heart rate/systolic blood pressure (r=0.69; 95% CI, 0.51-0.81). The sensitivity for heart rate, systolic blood pressure, and heart rate/systolic blood pressure was 28%, 36%, and 72% respectively; the specificity was 96%, 96%, and 67%, respectively. CONCLUSION: Normal vital signs alone are poor predictors of ruptured ectopic pregnancy; the heart rate/systolic blood pressure correlates best with the quantity of intraperitoneal hemorrhage.