The UHP ultrasound protocol: a novel ultrasound approach to the empiric evaluation of the undifferentiated hypotensive patient.

This report describes a novel sonographic protocol for the evaluation of the undifferentiated hypotensive patient. This protocol combines components of 3 sonographic applications: free fluid, cardiac, and abdominal aorta into a single protocol. We believe this protocol and its underlying principles should be a routine part of the empiric evaluation of the patient with undifferentiated hypotension or pulseless electrical activity.

Minor head trauma: Is computed tomography always necessary?

STUDY OBJECTIVE: To determine the clinical value of routine computed tomography (CT) of the head in patients with normal mental status after minor head trauma. METHODS: We carried out a prospective study of a consecutive series of patients of all ages who presented to our urban university Level I trauma center emergency department with a Glasgow Coma Scale score of 15 and underwent CT of the head after loss of consciousness (LOC) or amnesia to event. A data form was filled out for each patient before CT. Patients with abnormal CT results were followed to discharge. We analyzed data with the chi 2 and student t tests. RESULTS: Of 1,382 patients, traumatic intracranial abnormality was identified on CT of the head in 84 (6.1%). Three patients in this group (.2%) required surgery. The subgroup of patients with history of LOC/amnesia but no symptoms or signs of a depressed skull fracture had a rate of abnormal CT findings of only 3% (24 of 789), and no patient in this group required medical or surgical intervention. Nausea and vomiting and signs of head trauma were significantly more common in the group with abnormal CT findings. CONCLUSION: Routine CT of the head in patients with history of LOC/amnesia but no symptoms or signs of depressed skull fracture has minimal clinical value and is not warranted. Patients with symptoms of head injury or apparent depressed skull fracture should undergo head CT because a small number will require surgery.

Prospective identification and triage of nonemergency patients out of an emergency department: a 5-year study.

STUDY OBJECTIVE: To determine whether nonemergency patients can be prospectively identified by triage nurses and safely triaged out of the emergency department without treatment. METHODS: All adult patients (16 years or older) who presented to a university ED were provided an evaluation by a triage nurse. For a patient's case to be defined as nonemergency, four criteria were required: vital signs within a specific range, presence of 1 of 50 potentially nonemergent chief complaints, absence of key indicators found on screening examination, and absence of chest pain, abdominal pain, any severe pain, and inability to walk. Between July 1988 and July 1993, patients who satisfied these criteria were defined as nonemergency, refused care in the ED, and triaged out of the ED. Patients were referred to off-site clinics. The clinics had agreed to see patients in advance of the study, and the referral lists were frequently updated. Outcome data were obtained by telephone surveys to both triaged individuals and other health care providers. RESULTS: In this 5-year study, 176,074 adults presented to the ambulatory triage area in the ED, and 31,165 (18%) were defined as nonemergency, were not treated, and were referred elsewhere. Letters and telephone calls to all referral clinics, eight local EDs, and the coroner's office identified no instances of gross mistriage and only a small number of insignificant adverse outcomes. Telephone follow-up to individuals triaged away was successful in 34% of calls and showed that 39% of persons received care elsewhere on the same day, 35% received care within 3 days, and 26% decided not to seek medical care. A group of 1.0% sought care at other hospital EDs for minor complaints. CONCLUSION: A subset of patients with nonemergency problems can be prospectively identified and triaged out of the ED without significant adverse outcomes provided there is community support for follow-up care.

Orthodontic risk factors for temporomandibular disorders (TMD). I: Premolar extractions.

Concern about claims that premolar extractions may put patients at risk for temporomandibular disorders (TMD) led to this study. We report first findings from a longitudinal study of orthodontic patients begun in 1983. By using the methods of Helkimo, we collected TMD data before initiation of orthodontic treatment, between 0 and 12 months after debanding, and 12 to 24 months after debanding. Analyses related Helkimo scores with premolar extractions in 65 patients for whom orthodontic treatment had been completed. Twenty-six patients were treated without premolar extractions, 25 had four premolars extracted, and 14 had two upper premolars extracted. Tests for significance of differences between mean Helkimo scores were conducted for the nonextraction group compared with the extraction groups, and between pretreatment and posttreatment Helkimo scores for each group. Results included: (1) no significant intergroup differences between mean pretreatment or posttreatment scores, and (2) small but statistically significant (p less than 0.05) differences (in the direction of improvement) between mean pretreatment and posttreatment scores for both the nonextraction group and for the four premolar extraction group.

Orthodontics as a risk factor for temporomandibular disorders (TMD). II.

Debate about orthodontic treatment as a risk factor for temporomandibular disorders (TMD) led to this study. This report, the second in a series, concerns findings from a longitudinal study in which 30 new orthodontic patients have been enrolled annually since 1983. The method of Helkimo was used to collect TMD data before initiation of orthodontic treatment, and at annual intervals after debanding. Treatment was by fixed edgewise appliances. Data from a pretreatment and at least one posttreatment Helkimo examination were available for 109 patients. Follow-up data were available for 92 patients in the first year after debanding, with the corresponding sample sizes declining to 56, 33, 19, 11, and 7 for the second through the sixth posttreatment years, respectively. Primary analyses involved comparison of mean scores from the Helkimo 25-point dysfunction index scale. There were no significant differences between mean pretreatment and posttreatment Helkimo scores for any of the various groupings except for small, clinically unimportant improvements seen in the 12 to 24 month subgroup of 55 patients and in the 48 to 60 month subgroup of 11 patients. With average follow-up time of about 2 years for the 109 patients, 90% had Helkimo scores that stayed the same or improved, and 10% had scores that increased or worsened from 2 to 5 Helkimo points. We conclude that the orthodontic treatment experienced by our sample was not an important etiologic factor for TMD.

A quantitative and subjective characterization of tarnishing in low-gold alloys.

1. The quantitative objective characterization of tarnish gave results which are identical with those obtained from a blind subjective analysis. 2. The low-gold alloys fall into three classes. The alloy Ney Cast III is superior in performance to the other low golds and approximately equivalent to the high-gold alloy Firmilay. The intermediate alloys, including Midacast, Stabilor G, Mowrey No. 46, Tiffany, and Midas are similar in performance to the high-gold alloy Rx O.R.Y. The low-gold alloys Dent Cast 44, Minigold, and Progold tarnish in a manner which, in our opinion, makes them unacceptable.