Risk of Radiation Exposure to Emergency Department Personnel From Portable Radiographs.

BACKGROUND: There are concerns that emergency health care workers are exposed to ionizing radiation as the result of frequent portable radiographs obtained in the emergency department (ED) during active patient care. OBJECTIVE: Our aim was to investigate whether ED staff are exposed to significant radiation due to scatter from portable radiography at a busy trauma center and whether exposure was related to factors such as location or distance. METHODS: This was a prospective cohort study performed during 3 consecutive months in the ED at a large, academic trauma center. Volunteer attendings, nurses, and resident physicians were asked to wear dosimeter badges during their shifts throughout the study period. Twelve stationary dosimeters were placed in selected locations in the ED, particularly in the resuscitation rooms, where most of the portable radiographs were obtained. RESULTS: During the 3-month study period, 1464 portable radiographs were obtained in the resuscitation rooms in the ED, mostly chest and pelvic radiographs. Analysis from stationary dosimeters placed in the ED showed a median of 0.18 mSv (95% CI 0.16-0.22 mSv) for the main resuscitation room and 0 mSv for other critical care patient rooms. Analysis of dosimeters worn by staff showed no measurable radiation exposure (0.00 mSv). CONCLUSIONS: The level of radiation exposure to ED staff found in this study was well below the recommended allowable occupational exposure of 50 mSv/y. Radiation exposure is not a significant occupational hazard in a busy ED level I trauma center. Existing precautions should adequately protect staff from occupational exposure, and use of further protective gear, or the need for individual monitoring using dosimeters, appears unwarranted.

Overutilization of Helicopter Emergency Medical Services in Central Gulf Coast Region Results in Unnecessary Expenditure.

INTRODUCTION: When appropriately used, helicopter emergency medical services (HEMSs) allow for timely delivery of severely injured patients to definitive care. Inappropriate utilization of HEMSs results in increased cost to the patient and trauma system. The purpose of this study was to review current HEMS criteria in the central Gulf Coast region and evaluate for potential areas of triage refinement and cost savings. We hypothesized that a significant number of patients received potentially unwarranted HEMS transport. METHODS: A retrospective cohort study of all patients with trauma arriving to a level I trauma center by helicopter over 28 mo was performed; 381 patients with trauma and with HEMS transport from the scene were included. Data were collected from prehospital sources, as well as hospital chart review for each patient. The primary outcome was the rate of unwarranted HEMS transport. RESULTS: A total of 381 adult patients with trauma transported by the HEMS were analyzed, of which 34% were deemed potentially nonwarranted transports. The significant factors correlating with warranted HEMS transport included age, multiple long bone fractures, penetrating mechanism, and vehicle ejection. Insurance demographics did not correlate to transport modality. Many of these patients were transported from a location within the same county or the county adjacent to the trauma center. When comparing patients transported by ground and HEMSs from the same scene, no time savings were identified. Unwarranted transports at the trauma center represented an estimated health care expenditure of over $3 million. CONCLUSIONS: HEMSs may be overused in the central Gulf Coast region, creating the risk for a substantial resource and financial burden to the trauma system. Further collaboration is needed to establish HEMS triage criteria, that is, more appropriate use of resources.

Care Transitions After Acute Myocardial Infarction for Transferred-In Versus Direct-Arrival Patients.

BACKGROUND: Many patients in the United States require transfer from one hospital to another for acute myocardial infarction (MI) care. How well these transferred-in patients are transitioned back to their local community is unknown. METHODS AND RESULTS: We used linked Medicare claims data to examine postdischarge outcomes of 39 136 patients with acute MI aged ≥65 years discharged alive from 451 US hospitals in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines. Multivariable Cox modeling was used to compare the likelihood of outpatient clinic follow-up and risks of all-cause mortality and all-cause or cardiovascular readmission at 30 days post MI between transferred-in and direct-arrival patients. From 2007 to 2010, 14 060 of 39 136 patients (36%) required interhospital transfer for acute MI care, traveling a median of 43 miles (interquartile range, 27-68 miles; 77.6 km [interquartile range, 48.2-122.6 km]). Compared with those arriving directly, transferred-in patients with MI were slightly younger (median age, 73 versus 74; P<0.01) but less likely to have previous MI, heart failure, and previous revascularization than direct-arrival patients. Relative to direct-arrival patients, those transferred-in had a lower likelihood of outpatient follow-up within 30 days post discharge (risk-adjusted incidence, 69.9% versus 78.2%; hazard ratio [HR], 0.90; 95% confidence interval, 0.87-0.92) and higher adjusted 30-day all-cause and cardiovascular readmission risks (14.5% versus 14.0%; HRall-cause, 1.08; 95% confidence interval, 1.01-1.15 and 9.5% versus 9.1%; HRcardiovascular, 1.13; 95% confidence interval, 1.04-1.22). In contrast, risk-adjusted 30-day mortality was similar between transferred-in and direct arrivals (1.6% versus 1.6%; HR, 1.05; 95% confidence interval, 0.86-1.27). CONCLUSIONS: Transferred-in patients with acute MI are less likely to have outpatient clinic follow-up within 30 days and more likely to be readmitted within the first 30 days post discharge compared with direct-arrival patients. These results indicate room for improvement in the safe and seamless transition of care for transferred patients with MI traveling back to their home environments.

Performance of the 4-way range of motion test for radiographic injuries after blunt elbow trauma.

OBJECTIVES: Acute elbow injuries are common in the acute care setting. A previous study observed that limited active range of motion (ROM) was highly sensitive for radiographic injuries after blunt trauma. Our aim was to validate these findings in patients ≥5 years old with an acute (<24 hours) nonpenetrating elbow injury. METHODS: This prospective study included a convenience sample of patients undergoing plain radiographs of an injured elbow in 3 emergency departments. Before imaging, treating clinicians completed a standardized data collection sheet including mechanism of injury and 4-way ROM findings (full extension, flexion to 90°, full pronation and supination). Radiographic interpretation by a staff radiologist was used to ascertain the presence of fracture or joint effusion. RESULTS: The median age of the 251 patients was 24 years. Ninety-two patients (36.7%) had active 4-way ROM, and 159 patients (63.3%) demonstrated limited ROM. Negative radiographs were present in 152 patients (60.6%), whereas 99 patients (39.4%) had abnormal radiographs: 75 with explicit fractures and 24 with only joint effusions. The 4-way ROM elbow test had a sensitivity of 0.99 (95% confidence interval [CI], 0.94-1.00), specificity of 0.60 (95% CI, 0.52-0.68), positive predictive value of 0.62 (95% CI, 0.54-0.69), and negative predictive value of 0.99 (95% CI, 0.94-1.00). CONCLUSIONS: Active 4-way ROM test is 99% sensitive for all radiographic injures following blunt elbow trauma and 100% sensitive for injuries requiring surgical intervention. Caution should be used in relying on this test in the pediatric population until it is validated in a larger cohort.

Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era.

IMPORTANCE: Clostridium difficile is a major cause of health care-associated infection, but disagreement between diagnostic tests is an ongoing barrier to clinical decision making and public health reporting. Molecular tests are increasingly used to diagnose C difficile infection (CDI), but many molecular test-positive patients lack toxins that historically defined disease, making it unclear if they need treatment. OBJECTIVE: To determine the natural history and need for treatment of patients who are toxin immunoassay negative and polymerase chain reaction (PCR) positive (Tox-/PCR+) for CDI. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational cohort study at a single academic medical center among 1416 hospitalized adults tested for C difficile toxins 72 hours or longer after admission between December 1, 2010, and October 20, 2012. The analysis was conducted in stages with revisions from April 27, 2013, to January 13, 2015. MAIN OUTCOMES AND MEASURES: Patients undergoing C difficile testing were grouped by US Food and Drug Administration-approved toxin and PCR tests as Tox+/PCR+, Tox-/PCR+, or Tox-/PCR-. Toxin results were reported clinically. Polymerase chain reaction results were not reported. The main study outcomes were duration of diarrhea during up to 14 days of treatment, rate of CDI-related complications (ie, colectomy, megacolon, or intensive care unit care) and CDI-related death within 30 days. RESULTS: Twenty-one percent (293 of 1416) of hospitalized adults tested for C difficile were positive by PCR, but 44.7% (131 of 293) had toxins detected by the clinical toxin test. At baseline, Tox-/PCR+ patients had lower C difficile bacterial load and less antibiotic exposure, fecal inflammation, and diarrhea than Tox+/PCR+ patients (P < .001 for all). The median duration of diarrhea was shorter in Tox-/PCR+ patients (2 days; interquartile range, 1-4 days) than in Tox+/PCR+ patients (3 days; interquartile range, 1-6 days) (P = .003) and was similar to that in Tox-/PCR- patients (2 days; interquartile range, 1-3 days), despite minimal empirical treatment of Tox-/PCR+ patients. No CDI-related complications occurred in Tox-/PCR+ patients vs 10 complications in Tox+/PCR+ patients (0% vs 7.6%, P < .001). One Tox-/PCR+ patient had recurrent CDI as a contributing factor to death within 30 days vs 11 CDI-related deaths in Tox+/PCR+ patients (0.6% vs 8.4%, P = .001). CONCLUSIONS AND RELEVANCE: Among hospitalized adults with suspected CDI, virtually all CDI-related complications and deaths occurred in patients with positive toxin immunoassay test results. Patients with a positive molecular test result and a negative toxin immunoassay test result had outcomes that were comparable to patients without C difficile by either method. Exclusive reliance on molecular tests for CDI diagnosis without tests for toxins or host response is likely to result in overdiagnosis, overtreatment, and increased health care costs.

Recovery of salivary DNA from the skin after showering.

PURPOSE: After sexual assault there is a limited amount of time before the DNA evidence on the surface of the victim's body is not recoverable. During an assault, the offender may leave saliva on the victim's skin. Traditional examination methods use a swabbing technique to collect saliva for DNA testing. Victim activity, especially hygiene activity such as showering, may negatively affect DNA recovery. METHODS: In this experiment, we compared two techniques for recovery of salivary DNA from the skin's surface after a victim showers. We compared the traditional swabbing method to a "wet-vacuum" method using the M-Vac© to collect saliva from four body regions (neck, arm, stomach, and leg). In our research, we tested whether either collection technique obtained enough salivary DNA for autosomal and Y-STR analysis. In addition, we tested whether the M-Vac© is more effective at collecting DNA from large surface areas than traditional methods, by determining the amount of DNA collected. RESULTS: With both collection techniques, we were able to obtain male salivary DNA from at least one body region of the female after she had showered. There was no statistical difference in the amount of DNA collected between the swabbing technique and the M-Vac©. Autosomal STR analysis failed to detect the male contributor's DNA; therefore, we used Y-STRs. With Y-STR analysis, 47 samples returned a full male profile, and 26 samples returned a partial male profile after sample concentration. CONCLUSIONS: This research shows that salivary DNA can be collected from skin after showering and successfully analyzed using Y-STRs.

Epidemiology of the Systemic Inflammatory Response Syndrome (SIRS) in the emergency department.

INTRODUCTION: Consensus guidelines recommend sepsis screening for adults with systemic inflammatory response syndrome (SIRS), but the epidemiology of SIRS among adult emergency department (ED) patients is poorly understood. Recent emphasis on cost-effective, outcomes-based healthcare prompts the evaluation of the performance of large-scale efforts such as sepsis screening. We studied a nationally representative sample to clarify the epidemiology of SIRS in the ED and subsequent category of illness. METHODS: This was a retrospective analysis of ED visits by adults from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey (NHAMCS). We estimated the incidence of SIRS using initial ED vital signs and a Bayesian construct to estimate white blood cell count based on test ordering. We report estimates with Bayesian modified credible intervals (mCIs). RESULTS: We used 103,701 raw patient encounters in NHAMCS to estimate 372,844,465 ED visits over the 4-year period. The moderate estimate of SIRS in the ED was 17.8% (95% mCI: 9.7 to 26%). This yields a national moderate estimate of approximately 16.6 million adult ED visits with SIRS per year. Adults with and without SIRS had similar demographic characteristics, but those with SIRS were more likely to be categorized as emergent in triage (17.7% versus 9.9%, p<0.001), stay longer in the ED (210 minutes versus 153 minutes, p<0.0001), and were more likely to be admitted (31.5% versus 12.5%, p<0.0001). Infection accounted for only 26% of SIRS patients. Traumatic causes of SIRS comprised 10% of presentations; other traditional categories of SIRS were rare. CONCLUSION: SIRS is very common in the ED. Infectious etiologies make up only a quarter of adult SIRS cases. SIRS may be more useful if modified by clinician judgment when used as a screening test in the rapid identification and assessment of patients with the potential for sepsis. [West J Emerg Med. 2014;15(3):329-336.].

Shock index and early recognition of sepsis in the emergency department: pilot study.

INTRODUCTION: Screening for severe sepsis in adult emergency department (ED) patients may involve potential delays while waiting for laboratory testing, leading to postponed identification or over-utilization of resources. The systemic inflammatory response syndrome (SIRS) criteria are inaccurate at predicting clinical outcomes in sepsis. Shock index (SI), defined as heart rate / systolic blood pressure, has previously been shown to identify high risk septic patients. Our objective was to compare the ability of SI, individual vital signs, and the systemic inflammatory response syndrome (SIRS) criteria to predict the primary outcome of hyperlactatemia (serum lactate ≥ 4.0 mmol/L) as a surrogate for disease severity, and the secondary outcome of 28-day mortality. METHODS: We performed a retrospective analysis of a cohort of adult ED patients at an academic community trauma center with 95,000 annual visits, from February 1st, 2007 to May 28th, 2008. Adult patients presenting to the ED with a suspected infection were screened for severe sepsis using a standardized institutional electronic order set, which included triage vital signs, basic laboratory tests and an initial serum lactate level. Test characteristics were calculated for two outcomes: hyperlactatemia (marker for morbidity) and 28-day mortality. We considered the following covariates in our analysis: heart rate >90 beats/min; mean arterial pressure < 65 mmHg; respiratory rate > 20 breaths/min; ≥ 2 SIRS with vital signs only; ≥2 SIRS including white blood cell count; SI ≥ 0.7; and SI ≥ 1.0. We report sensitivities, specificities, and positive and negative predictive values for the primary and secondary outcomes. RESULTS: 2524 patients (89.4%) had complete records and were included in the analysis. 290 (11.5%) patients presented with hyperlactatemia and 361 (14%) patients died within 28 days. Subjects with an abnormal SI of 0.7 or greater (15.8%) were three times more likely to present with hyperlactatemia than those with a normal SI (4.9%). The negative predictive value (NPV) of a SI ≥ 0.7 was 95%, identical to the NPV of SIRS. CONCLUSION: In this cohort, SI ≥ 0.7 performed as well as SIRS in NPV and was the most sensitive screening test for hyperlactatemia and 28-day mortality. SI ≥ 1.0 was the most specific predictor of both outcomes. Future research should focus on multi-site validation, with implications for early identification of at-risk patients and resource utilization.

Examination of histological samples from submerged carrion to aid in the determination of postmortem submersion interval.

The use of histology in the as a tool for estimating postmortem intervals has rarely been explored but it has the potential for offering medical examiners an additional means for estimating the postmortem submersion interval (PMSI) during a death investigation. This study used perinatal piglets as human analogs which were submerged in freshwater for various time intervals. Each piglet was extracted from the water and underwent a necropsy examination during which histological samples were collected. The samples revealed that the necrotic tissue decomposed relatively predictably over time and that this decompositional progression may have the potential to be used via a scoring system to determine or aid in determining the PMSI. This method for calculating PMSI allows for normalization between piglets of various mass and body types. It also prevents any contamination of the remains via algae growth and animal activity that may exacerbate and possibly exaggerate PMSI calculation.

Comparison of protocols for measuring and calculating postmortem submersion intervals for human analogs in fresh water.

Protocols for determining postmortem submersion interval (PMSI) have long been problematic for forensic investigators due to the wide variety of factors affecting the rate of decomposition of submerged carrion. Likewise, it has been equally problematic for researchers to develop standardized experimental protocols to monitor underwater decomposition without artificially affecting the decomposition rate. This study compares two experimental protocols: (i) underwater in situ evaluation with photographic documentation utilizing the Heaton et al. total aquatic decomposition (TAD) score and (ii) weighing the carrion before and after submersion. Complete forensic necropsies were performed as a control. Perinatal piglets were used as human analogs. The results of this study indicate that in order to objectively measure decomposition over time, the human analog should be examined at depth using the TAD scoring system rather than utilizing a carrion weight evaluation. The acquired TAD score can be used to calculate an approximate PMSI.

Hyperlactatemia affects the association of hyperglycemia with mortality in nondiabetic adults with sepsis.

BACKGROUND: Admission hyperglycemia has been reported as a mortality risk factor for septic nondiabetic patients; however, hyperglycemia's known association with hyperlactatemia was not addressed in these analyses. OBJECTIVES: The objective was to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia. METHODS: This was a post hoc, nested analysis of a retrospective cohort study performed at a single center. Providers had identified study subjects during their emergency department (ED) encounters; all data were collected from the electronic medical record (EMR). Nondiabetic adult ED patients hospitalized for suspected infection, two or more systemic inflammatory response syndrome (SIRS) criteria, and simultaneous lactate and glucose testing in the ED were enrolled. The setting was the ED of an urban teaching hospital from 2007 to 2009. To evaluate the association of hyperglycemia (glucose > 200 mg/dL) with hyperlactatemia (lactate ≥ 4.0 mmol/L), a logistic regression model was created. The outcome was a diagnosis of hyperlactatemia, and the primary variable of interest was hyperglycemia. A second model was created to determine if coexisting hyperlactatemia affects hyperglycemia's association with mortality; the main outcome was 28-day mortality, and the primary risk variable was hyperglycemia with an interaction term for simultaneous hyperlactatemia. Both models were adjusted for demographics; comorbidities; presenting infectious source; and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction. RESULTS: A total of 1,236 ED patients were included, and the median age was 77 years (interquartile range [IQR] = 60 to 87 years). A total of 115 (9.3%) subjects were hyperglycemic, 162 (13%) were hyperlactatemic, and 214 (17%) died within 28 days of their initial ED visits. After adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (odds ratio [OR] = 4.14, 95% confidence interval [CI] = 2.65 to 6.45). Hyperglycemia and concurrent hyperlactatemia were associated with increased mortality risk (OR = 3.96, 95% CI = 2.01 to 7.79), but hyperglycemia in the absence of simultaneous hyperlactatemia was not (OR = 0.78, 95% CI = 0.39 to 1.57). CONCLUSIONS: In this cohort of septic adult nondiabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. The previously reported association of hyperglycemia with mortality in nondiabetic sepsis may be due to the association of hyperglycemia with hyperlactatemia.

Impact of metformin use on the prognostic value of lactate in sepsis.

OBJECTIVE: The objective of this study is to determine if metformin use affects the prevalence and prognostic value of hyperlactatemia to predict mortality in septic adult emergency department (ED) patients. METHODS: This is a single-center retrospective cohort study. Emergency department providers identified study subjects; data were collected from the medical record. PATIENTS: Adult ED patients with suspected infection and 2 or more systemic inflammatory response syndrome criteria were included. The outcome was 28-day mortality. The primary risk variable was serum lactate (<2.0, 2.0-3.9, ≥ 4.0 mmol/L) categorized by metformin use; covariates: demographics, Predisposition, Infection, Response, Organ Dysfunction score and metformin use contraindications. SETTING: The study was conducted at an urban teaching hospital; February 1, 2007 to October 31, 2008. RESULTS: A total of 1947 ED patients were enrolled; 192 (10%) were taking metformin; 305 (16%) died within 28 days. Metformin users had higher median lactate levels than nonusers (2.2 mmol/L [interquartile range, 1.6-3.2] vs 1.9 mmol/L [interquartile range, 1.3-2.8]) and a higher, although nonsignificant, prevalence of hyperlactatemia (lactate ≥ 4.0 mmol/L) (17% vs 13%) (P = .17). In multivariate analysis (reference group nonmetformin users, lactate <2.0 mmol/L), hyperlactatemia was associated with an increased adjusted 28-day mortality risk among nonmetformin users (odds ratio [OR], 3.18; P < .01) but not among metformin users (OR, 0.54; P = .33). In addition, nonmetformin users had a higher adjusted mortality risk than metformin users (OR, 2.49; P < .01). These differences remained significant when only diabetic patients were analyzed. CONCLUSIONS: In this study of adult ED patients with suspected sepsis, metformin users had slightly higher median lactate levels and prevalence of hyperlactatemia. However, hyperlactatemia did not predict an increased mortality risk in patients taking metformin.

Evaluation of the Stratus CS Acute Care D-dimer assay (DDMR) using the Stratus CS STAT Fluorometric Analyzer: a prospective multisite study for exclusion of pulmonary embolism and deep vein thrombosis.

BACKGROUND: D-dimer testing is an integral part of the diagnostic algorithm in excluding patients with venous thromboembolism. In this study, we prospectively evaluated the Stratus DDMR D-dimer test in patients suspected of pulmonary embolism (PE) and deep vein thrombosis (DVT). METHODS: Patients suspected of venous thromboembolism were prospectively enrolled at four different clinical sites, with sodium citrate and lithium heparin plasma was tested using the DDMR D-dimer test on the Stratus CS analyzer. RESULTS: 1,012 patients were enrolled for analysis, with 85/603 (14.1%) patients with PE and 80/443 (18.1%) with DVT, and four of the patients (0.4%) with PE and DVT. For the samples collected in 3.2% sodium citrate, the DDMR method had a sensitivity, specificity, and negative predictive value for VTE of 98.0%, 38.1%, and 99.1%, respectively. For the samples collected in lithium heparin, the DDMR method had a sensitivity, specificity, and negative predictive value (NPV) for VTE of 98.9%, 28.8%, and 99.4%, respectively. In PE, DDMR testing on citrate plasma had a sensitivity, specificity, and NPV of 98.8%, 39.5%, and 99.6%, respectively, while heparin samples had a sensitivity, specificity, and NPV for PE of 98.0%, 28.4%, and 99.1%, respectively. In DVT, citrate plasma had a sensitivity, specificity, and NPV for DVT of 97.5%, 32.0%, and 98.3%, respectively, while heparin samples had a sensitivity, specificity, and NPV for DVT of 100%, 27.8%, and 100%, respectively. CONCLUSION: The Stratus CS DDMR D-dimer can be used in those patients with non-high clinical pre-test probability for the exclusion of PE.

Fracture of a GlideScope® Cobalt GVL® Stat disposable blade during an emergency intubation.

BACKGROUND: Emergency airway management is a diverse discipline, often utilizing advanced equipment with video technology to enable the intubator to visualize a patient's vocal cords that would be difficult or impossible to see with routine direct laryngoscopy. The GlideScope® Cobalt (Saturn Biomedical Systems, Inc., Burnaby, BC, Canada) is one type of video laryngoscope with disposable plastic GVL® Stat blades (Saturn Biomedical Systems) that can improve glottic view over direct laryngoscopy. It also benefits from rapid turnaround time and few infection control issues due to its disposable blade. OBJECTIVE: To report what we believe to be the first GlideScope® blade failure to be reported in the medical literature. The circumstances surrounding the blade failure may raise awareness of GVL® Stat usage in obese patients with limited mouth opening. CASE REPORT: During a standard emergency intubation, insertion of the GVL® Stat into the patient's mouth resulted in breakage of the distal segment of the blade. The patient was severely obese and had limited mouth opening, which required the blade to be inserted obliquely, rather than in the midline, into the patient's mouth. As the handle was repositioned back to midline, the distal segment of the blade broke off. No excessive force was used during blade repositioning when breakage occurred. CONCLUSION: Twisting forces on the distal flat segment of the GVL® Stat may have caused its failure. Because this was only a single occurrence of breakage, it is not clear if design issues or atypical insertion of the blade was responsible for breakage. Care must be exercised when midline insertion is not possible, which can occur in obese patients with limited mouth opening.

S-adenosyl-L-methionine treatment for alcoholic liver disease: a double-blinded, randomized, placebo-controlled trial.

BACKGROUND: S-adenosyl-L-methionine (SAM) is the methyl donor for all methylation reactions and regulates the synthesis of glutathione, the main cellular antioxidant. Previous experimental studies suggested that SAM may benefit patients with established alcoholic liver diseases (ALDs). The aim of this study was to determine the efficacy of SAM in treatment for ALD in a 24-week trial. The primary endpoints were changes in serum aminotransferase levels and liver histopathology scores, and the secondary endpoints were changes in serum levels of methionine metabolites. METHODS: We randomized 37 patients with ALD to receive 1.2 g of SAM by mouth or placebo daily. Subjects were required to remain abstinent from alcohol drinking. A baseline liver biopsy was performed in 24 subjects, and a posttreatment liver biopsy was performed in 14 subjects. RESULTS: Fasting serum SAM levels were increased over timed intervals in the SAM treatment group. The entire cohort showed an overall improvement of AST, ALT, and bilirubin levels after 24 weeks of treatment, but there were no differences between the treatment groups in any clinical or biochemical parameters nor any intra- or intergroup differences or changes in liver histopathology scores for steatosis, inflammation, fibrosis, and Mallory-Denk hyaline bodies. CONCLUSIONS: Whereas abstinence improved liver function, 24 weeks of therapy with SAM was no more effective than placebo in the treatment for ALD.

Patients prefer boarding in inpatient hallways: correlation with the national emergency department overcrowding score.

Objective. The boarding of patients in Emergency Department (ED) hallways when no inpatient beds are available is a major cause of ED crowding. One solution is to board admitted patients in an inpatient rather than ED hallway. We surveyed patients to determine their preference and correlated their responses to real-time National Emergency Department Overcrowding Score (NEDOCS). Methods. This was a survey of admitted patients in the ED of an urban university level I trauma center serving a community of 5 million about their personal preferences regarding boarding. Real-time NEDOCS was calculated at the time each survey was conducted. Results. 99 total surveys were completed during October 2010, 42 (42%) patients preferred to be boarded in an inpatient hallway, 33 (33%) preferred the ED hallway, and 24 (24%) had no preference. Mean (±SD) NEDOCS (range 0-200) was 136 ± 46 for patients preferring inpatient boarding, 112 ± 39 for ED boarding, and 119 ± 43 without preference. Male patients preferred inpatient hallway boarding significantly more than females. Preference for inpatient boarding was associated with a significantly higher NEDOCS. Conclusions. In this survey study, patients prefer inpatient hallway boarding when the hospital is at or above capacity. Males prefer inpatient hallway boarding more than females. The preference for inpatient hallway boarding increases as the ED becomes more crowded.

Using forms to develop research projects.

This article is the 16(th) in a multipart series designed to assist readers, particularly novices, in the area of clinical research. This article is focused on the process of developing a new research project. It provides tools to help those involved in beginning their own research projects.

Impaired homocysteine transsulfuration is an indicator of alcoholic liver disease.

BACKGROUND & AIMS: Although abnormal hepatic methionine metabolism plays a central role in the pathogenesis of experimental alcoholic liver disease (ALD), its relationship to the risk and severity of clinical ALD is not known. The aim of this clinical study was to determine the relationship between serum levels of methionine metabolites in chronic alcoholics and the risk and pathological severity of ALD. METHODS: Serum levels of liver function biochemical markers, vitamin B6, vitamin B12, folate, homocysteine, methionine, S-adenosylmethionine, S-adenosylhomocysteine, cystathionine, cysteine, alpha-aminobutyrate, glycine, serine, and dimethylglycine were measured in 40 ALD patients, of whom 24 had liver biopsies, 26 were active drinkers without liver disease, and 28 were healthy subjects. RESULTS: Serum homocysteine was elevated in all alcoholics, whereas ALD patients had low vitamin B6 with elevated cystathionine and decreased alpha-aminobutyrate/cystathionine ratios, consistent with decreased activity of vitamin B6 dependent cystathionase. The alpha-aminobutyrate/cystathionine ratio predicted the presence of ALD, while cystathionine correlated with the stage of fibrosis in all ALD patients. CONCLUSIONS: The predictive role of the alpha-aminobutyrate/cystathionine ratio for the presence of ALD and the correlation between cystathionine serum levels with the severity of fibrosis point to the importance of the homocysteine transsulfuration pathway in ALD and may have important diagnostic and therapeutic implications.

Evaluation of the chest pain patient: survey of current practice patterns.

The objective of this study was to measure the prevalence of chest pain centers, and describe the associated protocols most commonly used to rapidly risk-stratify patients in these units. This study is a survey conducted from May to July 2003 via direct mail. A questionnaire was mailed to 4653 hospitals in the United States. A total of 462 questionnaires were returned, representing a return rate of approximately 10%. This survey revealed that approximately 64% of all hospitals have a protocol for the evaluations of patients who present with chest pain, and 38% of all hospitals reported a designated area for the evaluation of these patients. The majority of hospitals responding to this survey have a protocol for the evaluation of patients presenting with chest pain, however, the presence of a chest pain unit exists in only 38% of all responding institutions.