Indications for computed tomography in patients with minor head injury.

BACKGROUND: Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury who do not need to undergo CT. METHODS: In the first phase of the study, we recorded clinical findings in 520 consecutive patients with minor head injury who had a normal score on the Glasgow Coma Scale and normal findings on a brief neurologic examination; the patients then underwent CT. Using recursive partitioning, we derived a set of criteria to identify all patients who had abnormalities on CT scanning. In the second phase, the sensitivity and specificity of the criteria for predicting a positive scan were evaluated in a group of 909 patients. RESULTS: Of the 520 patients in the first phase, 36 (6.9 percent) had positive scans. All patients with positive CT scans had one or more of seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3 percent) had positive scans. In this group of patients, the sensitivity of the seven findings combined was 100 percent (95 percent confidence interval, 95 to 100 percent). All patients with positive CT scans had at least one of the findings. CONCLUSIONS: For the evaluation of patients with minor head injury, the use of CT can be safely limited to those who have certain clinical findings.

Acute respiratory failure in pregnancy.

Pregnancy increases the risk for respiratory failure from to numerous pulmonary diseases. Adult respiratory distress syndrome, aspiration, venous air embolism, asthma, thromboembolism, and heart disease are etiologies shared by non-pregnant women. However, their management is complicated by complex physiologic changes during pregnancy. Amniotic fluid embolism and tocolytic-induced pulmonary edema are unique to pregnancy and must be added to the list of causes of respiratory failure. Diagnostics and supportive care is difficult and must be directed with the mother and the fetus in mind. This dictates a thorough understanding of maternal physiology, and the safety of drug use during pregnancy.

Exercise training improves cardiac performance in diabetic rats.

Diabetes mellitus is often associated with a cardiomyopathy characterized by alterations in cardiac metabolism and declines in cardiac performance. We sought to determine whether exercise training would attenuate the depressed cardiac performance seen in diabetic animals. Female rats were divided into four groups: sedentary control, trained control, sedentary diabetics, and trained diabetics. After 1 week of training, we induced diabetes by intravenous injection of streptozotocin (65 mg/kg). We trained animals on a treadmill using a progressive protocol that plateaued at 27 m/min for 1 hr/day, 5 days/week for a total of 8 weeks. We measured cardiac output at a variety of left atrial filling pressures with an isolated working heart apparatus; glucose was the sole metabolic substrate for the heart. Training increased succinate dehydrogenase activity in the soleus muscle of exercised rats, but did not change heart and body weights or plasma glucose and thyroid hormone levels. The diabetic groups exhibited depressed cardiac outputs at high workloads compared to nondiabetics. Training increased the cardiac output of both sedentary and diabetic animals at high, but not low, preloads. We suggest that exercise can attenuate the severity of diabetic cardiomyopathy.

Exercise training attenuates the myocardial dysfunction induced by endotoxin.

The purpose of this study was to determine whether exercise training protected against endotoxin-induced myocardial dysfunction. After a 12-wk treadmill training period, carotid catheters were implanted 24 h before saline or endotoxin administration into four groups of animals: trained saline-injected (TS), trained endotoxin-injected (TE), sedentary saline-injected (SS), and sedentary endotoxin-injected (SE). Heart rate and mean arterial pressure were monitored 4 h after in vivo endotoxin or saline injection. Mean arterial pressure decreased an average of 32 +/- 3 mmHg 1 h after endotoxin administration but was normal (109 +/- 6 mmHg) 2 h later. Plasma catecholamines, in vitro myocardial performance, and isolated myocyte adenosine 3',5'-cyclic monophosphate (cAMP) production in response to isoproterenol were assessed 4 h after endotoxin injection. Plasma catecholamine levels were 5- to 15-fold higher in SE compared with the other groups. These data suggest that myocardial protection may be related to the lowered catecholamine levels elicited in TE compared with SE in response to endotoxin administration. The product of cardiac output and peak systolic pressure, an index of cardiac work, was 24-32% greater in TS compared with SS. Cardiac work was decreased 32% in TE compared with a 45% decrease in SE. cAMP was reduced in myocytes from SE in response to isoproterenol (-28%) and to forskolin (-44%) but not in myocytes from TE, compared with TS and SS. The difference in cAMP accumulation suggests that training maintains the integrity of the beta-adrenergic receptor adenylate cyclase system, which can be depressed by in vivo endotoxin administration.