Decision rule and utility of routine urine toxicology screening of trauma patients.

The objective of this study was to determine the impact of urine drug screening of major trauma victims on patient care and derive a decision rule for selective screening. Retrospective chart review of 170 trauma patients at a Level I Trauma Center, certified by the American College of Surgeons, was undertaken. The decision rule was developed by Classification and Regression Tree (CART) analysis to maximize sensitivity, with secondary attention to specificity. Eighty-nine percent of trauma patients were screened, while 26.0% had positive tests for illicit drugs. Serum ethanol was positive in 31.2%, over the legal limit of 0.08 g/dl. Both a legally intoxicated ethanol level and positive illicit drug screen were found in 11.0%. Additionally, 42.5% of patients with a positive illicit drug screen were also intoxicated (blood alcohol level above legal limit). Conversely, 35.4% of legally intoxicated patients also had positive illicit screens. Drug treatment referral occurred in 17.5% of positive drug screens. For urgent surgery, median time to drug screen result was 117 min, while median time to operation was 110 min. Of operative patients, 57% had the drug screen result recorded on the chart at any time, but only 14.3% of illicit screens were noted in the anaesthesia record. For all patients with and without operations, 71.1% had the result noted on the chart. We derived a 'low risk rule' to identify most patients with positive illicit drug screens (95% sensitivity, 55% specificity, 66% positive and 93% negative predictive values; accuracy 74%), while limiting the number of unnecessary tests. The rule avoids screening 48% of patients, missing only 5% of true positives. It is concluded that urine screening for illicit drugs in trauma patients can be performed selectively according to a decision rule based on demographics, mechanism of injury and time of presentation. This rule, which captures most positive screens while eliminating screening in low risk patients, could result in significant cost savings. Only prospective validation of these rules in patient populations of other trauma centres will offer confidence that the decision points are valid. Urine drug screening infrequently affected patient management or resulted in drug treatment referral in our sample. We call for increased vigilance in recording results and referring patients for treatment.

Emergency medicine residency applicant educational debt: relationship with attitude toward training and moonlighting.

OBJECTIVES: Heated debate persists regarding the role of resident moonlighting in emergency medicine (EM). The attitudes of EM residency applicants have not been assessed. The objectives of this study were to assess: 1) the level of educational debt among EM residency applicants, 2) their perception of increased risk potential to patients from unsupervised EM resident practice, and 3) their opposition to laws restricting moonlighting. The authors then report the relationship between the degree of indebtedness and these stated positions. METHODS: Fifty-four EM residency programs returned 393 responses to a 1996 anonymous survey. Applicants recorded: 1) their indebtedness, 2) whether they believed that EDs should hire only physicians who have completed full training in an EM residency, and 3) whether they believed that unsupervised EM practice prior to completing EM training carries a higher risk of adverse patient outcomes. The authors used a t-test and logistic regression to determine whether there was any significant difference in debt between responders who answered yes and those who answered no to the various questions. A p-value < 0.05 was considered significant. RESULTS: The mean +/- SD debt was $72,290 +/- 48,683 (median $70,000). Most EM applicants (84.8%) agreed that unsupervised medical care by EM residents carries a higher risk of adverse patient outcomes. Paradoxically, only half the applicants opposed a moonlighting ban. Responses did not statistically correlate with educational debt. CONCLUSIONS: Emergency medicine residency applicant debt is large. The EM applicants' opposition to laws that would restrict moonlighting was mixed. This was inconsistent with the majority acknowledging an increased risk potential to patients. Nearly all EM applicants would still select EM as a career, even if moonlighting were to be banned.

Excitotoxins can produce protein degradation in the spinal cord.

Overdistraction and derotation of the scoliotic spine during surgery represent potential complications that could lead to spinal cord dysfunction and paralysis. Neuronal loss and, consequently, the inability to regain function may be attributable to primary damage (eg, mechanical), secondary cell death (eg, such as that produced by ischemia) or a combination of both. Beyond intraoperative recognition and removal of the rods, effective strategies to prevent this neuronal loss have yet to be developed. This emphasizes the need for a clearer understanding of the molecular events that contribute to neuronal injury in the central nervous system. Considerable evidence has indicated that the excitatory transmitter L-glutamate and the N-methyl-D-aspartate (NMDA) excitatory amino acid receptor may contribute to the secondary neuronal death observed in a wide variety of neurological insults, including ischemia. The current investigation was undertaken to elucidate the potential role of the NMDA receptor in spinal cord pathology. Isolated rat spinal cords were exposed to anoxic physiologic solutions in the presence and absence of Ca++, NMDA receptor agonists, and a noncompetitive NMDA receptor antagonist. The extent of neuronal damage was assessed by quantitating the degradation of the cytoskeletal neurofilament protein. A substantial increase in the loss of neurofilament protein was observed in spinal cords exposed to anoxic conditions in the presence of Ca++ as compared with the absence of Ca++. Exposure to excitatory amino acid agonists (L-glutamate or NMDA) further potentiated the degradation of the neurofilament protein; an effect that was reversed by a noncompetitive NMDA receptor antagonist.(ABSTRACT TRUNCATED AT 250 WORDS)