Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial.

OBJECTIVE: To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment. METHODS: Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double-blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment). RESULTS: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At follow-up, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69; p = 0 .005). CONCLUSIONS: Migraine recurrence is common after "successful" ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.

Low-molecular-weight heparin in the emergency department treatment of venous thromboembolism.

Accepted initial therapy for deep vein thrombosis (DVT) is intravenous heparin infusion, which requires hospitalization, inhibits patient ambulation, consumes nursing time, and generates laboratory cost. The effects of heparin are unpredictable, and maintaining optimal anti-coagulation requires careful laboratory monitoring. Many patients are underdosed and 5-20% of heparin-treated patients suffer hemorrhagic complications. Low-molecular-weight (LMW) heparins have a predictable anticoagulant response, require no laboratory monitoring, and can be administered once or twice daily by subcutaneous injection, thus facilitating outpatient treatment. LMW heparins are at least as safe and effective as standard intravenous heparin for the treatment of uncomplicated DVT. LMW heparin use is associated with decreased admission rates, shorter lengths of stay, decreased nursing time, better patient quality of life, and lower laboratory costs. In our emergency department, we have adopted a LMW heparin protocol for the outpatient treatment of suspected or proven DVT.

Effectiveness of verapamil-quinidine versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation.

STUDY OBJECTIVE: To determine the relative effectiveness of a verapamil-quinidine sequential combination versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation (PAF). METHOD: This prospective, double-blind, randomized, controlled trial involved patients, aged 18 to 75 years, with new-onset (< 48 hours) atrial fibrillation who presented to a community-based urban hospital with an annual ED census of 65,000. Exclusion criteria included ventricular response rate lower than 100 or higher than 200 beats/minute, allergy to study drugs, hypotension with evidence of end-organ hypoperfusion, and conduction abnormalities. Consenting patients were randomly assigned to receive rapid digitalization (1.0 mg over 2 hours) or i.v. verapamil (sequential 5-mg boluses up to 20 mg). After ventricular rate was controlled (< 100 beats/minute), oral quinidine (200 mg) was initiated and repeated every 2 hours until conversion to normal sinus rhythm (NSR) occurred, until 1 g of quinidine was administered, or until adverse effects supervened. Heart rate, blood pressure, cardiac rhythm, time to conversion, and adverse effects were documented. RESULTS: Forty-four patients received the study drugs. Three were withdrawn, leaving 19 in the verapamil-quinidine (VER-Q) group and 22 in the digoxin-quinidine (DIG-Q) group. Sixteen patients (84%) in the VER-Q group and 10 (45%) in the DIG-Q group converted to NSR within 6 hours (P < .02). Mean time to conversion (+/-SD) was 185 +/- 146 minutes for VER-Q and 368 +/- 386 minutes for DIG-Q patients (P = NS). Twelve VER-Q patients (63%) and 6 DIG-Q patients (27%) were discharged from the ED (P < .05). Minor adverse effects were more common in the VER-Q group. No mortality or significant morbidity occurred. CONCLUSION: The sequential combination of verapamil and quinidine, in the doses studied, is an effective treatment for PAF and is superior to digoxin-quinidine. Digoxin should no longer be considered the treatment of choice for uncomplicated PAF.

Diagnostic management by gatekeepers is not cost effective for neuro-ophthalmology.

PURPOSE: To determine whether the "gatekeeper physician system" for evaluating neuro-ophthalmologic problems is cost effective. METHODS: The authors retrospectively reviewed the records of 588 patients referred for neuro-ophthalmologic evaluation between July and December 1989 to determine the frequency and cost of unnecessary diagnostic testing ordered by "gatekeeper physicians." Pre-referral diagnostic testing costs were compared with the cost of neurophthalmologic consultation for four common problems: (1) optic neuropathy; (2) diplopia; (3) ptosis; and (4) proptosis. RESULTS: Between 16% and 26% of patients in the first three diagnostic categories were subjected to overtesting, resulting in $57,900 of excessive costs, a 724% overcharge. Although the evaluation of proptosis was performed correctly, the quality of 10 of the 18 neuro-imaging procedures was substandard. CONCLUSIONS: The gatekeeper system managed by primary care physicians for these four neuro-ophthalmologic problems not only did not conserve healthcare dollars but also had a negative impact on cost control. For neuro-ophthalmologic disorders, prompt subspecialty evaluation and examination appear to be a cost-effective strategy.

Compensatory epithelial hyperplasia in human corneal disease.

Compensatory hyperplasia of the corneal epithelium (CEH) has been observed histopathologically in animal and human eyes after excimer laser photoablative keratectomy, and has been implicated as a cause of variable refractive results and refractive regression after this procedure. Retrospective histopathologic analysis of routine keratoplasty specimens revealed CEH in 85 of 130 (65%) corneas with keratoconus, 18 of 36 (50%) corneas with chronic herpes simplex virus (HSV) keratitis, and 14 of 25 (56%) corneas coded as nonspecific scars. Mild CEH occurred apically and/or peripherally in keratoconus. Massive CEH (up to 200 microns thick) occurred in chronic HSV keratitis with irregular stromal loss. Our data indicate that CEH occurs frequently in several corneal diseases marked by stromal ectasia or loss. We postulate that stromal loss may contribute to CEH by providing relative protection against exfoliative shearing forces of superior eyelid closure. Our study complements previous reports that imply that CEH is a contributory factor in refractive regression after excimer laser photoablation.

Large surface area activated charcoal and the inhibition of aspirin absorption.

Activated charcoal's adsorptive capacity, and therefore potential efficacy, is generally related to its surface area. In our study, the efficacy of two activated charcoal preparations, Actidose-Aqua 1,500 m2/g and Super Char, 3,000 m2/g, were compared on the basis of their ability to inhibit aspirin absorption. Twelve healthy male subjects fasted for eight hours before and four hours after a 20 mg/kg oral dose of aspirin. One hour after aspirin dosing, each subject received either no charcoal, 25 g Actidose-Aqua, or 25 g Super Char in a randomized crossover design. Each aspirin dose was separated from the previous dose by at least seven days. Total urine volumes were collected over 12-hour intervals, beginning 12 hours before the aspirin dose and continuing for 72 hours after dosing. Urine salicylate concentration was measured with a colorimetric assay. The fraction of aspirin dose recovered in the urine was 0.96 +/- 0.13, 0.78 +/- 0.18, and 0.50 +/- 0.20 for the control, Actidose-Aqua, and Super Char treatment phases, respectively. In vitro, Super Char was found to bind more salicylic acid than Actidose-Aqua at pH 8.1. We conclude that both activated charcoal preparations significantly reduced the gastrointestinal absorption of aspirin (P less than .05) and that Super Char was significantly more effective than Actidose-Aqua in reducing the gastrointestinal absorption of aspirin (P less than .01).

Early esophageal cancer.

Early esophageal cancer (EEC) accounted for only seven (4.7%) of 148 cases of esophageal cancer diagnosed at the authors' hospital between 1977 and 1984. Two patients with EEC had squamous cell carcinoma and five had adenocarcinoma arising in Barrett's mucosa. All seven patients had associated clinical findings, including low-grade gastrointestinal bleeding (three cases), odynophagia (one case), and chronic reflux symptoms due to underlying reflux esophagitis and Barrett esophagus (three cases). Since Barrett esophagus is a premalignant condition, the high proportion of adenocarcinomas in this series presumably reflects the more frequent radiologic evaluation of symptomatic patients with Barrett esophagus. On esophagography, four patients had 3-4.5-cm polypoid intraluminal masses that could not be distinguished radiographically from advanced esophageal carcinoma. In the other three patients, esophagrams revealed secondary achalasia, irregular flattening of the esophageal wall, and diffuse nodularity of the mucosa. The authors conclude that "early" esophageal cancers are not necessarily small cancers, since they may undergo considerable intraluminal or intramural growth and still be classified histologically as EEC. Radiologists should be aware of these findings, since EEC has an excellent prognosis with a 5-year survival approaching 90%.