Use of on-line medical command to randomize patients in a prehospital research study.

OBJECTIVE: To describe the efficiency of using on-line medical command (OLMC) to conduct a prospective, randomized clinical trial addressing safety and patient enrollment. DESIGN, SETTING, AND PARTICIPANTS: Prospective design using OLMC to randomize adult asthmatics into one of three treatment groups. After verifying inclusion and exclusion criteria, OLMC physicians removed a covering label on study sheets and ordered the treatment specified underneath the label that had been assigned in a random sequence. RESULTS: A total of 204 patients were seen with dyspnea and wheezing during the three-month study. Of these, 68 (33%) were excluded from the study. Of the 136 (67%) patients who were eligible for study, 87 were enrolled (enrollment efficiency 64%), with 79 fully evaluable (evaluable efficiency 91%). The study safety was 100% because no enrolled patients met any exclusion criteria. CONCLUSIONS: The design was random and prospective, with patient entry blinded, using paramedics to enroll patients and OLMC physicians as gatekeepers, thus ensuring appropriate patient eligibility and study-arm assignment. Use of OLMC physicians to perform prospective randomized studies is safe and efficient, and results in a high yield of evaluable patients.

Prospective, randomized trial of epinephrine, metaproterenol, and both in the prehospital treatment of asthma in the adult patient.

STUDY OBJECTIVE: To compare the effectiveness and incidence of adverse reactions with three treatment regimens for asthma in adults in the prehospital setting. DESIGN: Prospective, randomized clinical study. SETTING: Inner-city emergency medical service system providing basic and advanced life support and transport to 14 urban area hospital emergency departments. PARTICIPANTS: One hundred fifty-four adult asthmatic patients, 18 to 50 years old, who presented to paramedics with shortness of breath and wheezing. RESULTS: Eligible patients were randomly assigned by the base station physician to one of three treatment groups: subcutaneous epinephrine, nebulized metaproterenol, or subcutaneous epinephrine and nebulized metaproterenol. Peak expiratory flow rate (PEFR), blood pressure, heart rate, and respiratory rate were measured before and after treatment in each patient. During a 9-month period (October 1992 through June 1993), 154 patients were enrolled in the study; 53 (34%) received epinephrine, 49 (32%) received metaproterenol, and 52 (34%) received both. There were no significant differences in patient demographics, initial vital signs, or pretreatment PEFR among the three groups. The mean difference between pretreatment and posttreatment PEFR was 73 L/min and did not significantly differ among the treatment groups. Significant changes in vital signs were seen in no treatment group. CONCLUSION: Nebulized metaproterenol is as effective as subcutaneous epinephrine in the prehospital treatment of adult patients with acute asthma. The combination of these two treatments offered no additional clinical benefit in the patients we studied.

Adolescent (in)vulnerability.

Three groups of subjects were asked to judge the probability that they and several target others (a friend, an acquaintance, a parent, a child) would experience various risks. Subjects were middle-class adults, their teenage children, and high-risk adolescents from treatment homes. All three groups saw themselves as facing somewhat less risk than the target others. However, this perception of relative invulnerability was no more pronounced for adolescents than for adults. Indeed, the parents were viewed as less vulnerable than their teenage children by both the adults and those teens. These results are consistent with others showing small differences in the cognitive decision-making processes of adolescents and adults. Underestimating teens' competence can mean misdiagnosing the sources of their risk behaviors, denying them deserved freedoms, and failing to provide needed assistance.

PIP: Policy choices depend in part of political values and assumptions about adolescents' decision making abilities. The focus of this article is on judging the probability of adverse outcomes and the tendency to be overconfident. Discussion is directed to adolescent and adult invulnerability and evidence of other decision making skills. The conclusion from the review of evidence is that invulnerability is not particularly larger during adolescence. The hypothesis of this study directly tests adolescent invulnerability. A sample of 86 pairs of low-risk teens and parents and 95 high-risk teens were obtained from recruitment efforts at public high schools. The mean age of students was 15 years; the mean age of adults was 43 years. Low-risk persons were primarily girls and adults, more primarily mothers of teens. 23% of high risk teens were girls. Eight events were chosen to reflect high and low controlability (auto accident injury, alcohol dependency, unplanned pregnancy, mugging, sickness from air pollution or pesticides or radiation poisoning, and injury in a fire explosion). Evaluation for each event was made for controlability, probability of occurrence, preventive effort, and experience with the event. Subjects also evaluated 2-3 target individuals. The results pertain to the probability response mode as an ordinal scale; to control, prevention, and experience judgments; and to an examination of the absolute invulnerability hypothesis for group, target, and event factors. 43% of the time adolescents did not perceive any differences between their own level of risk and the target's. Otherwise, respondents were twice as likely to assign a higher risk probability to targets. 10% of the time, subjects assigned a risk of 0 or no chance. 33% of the time, the risk was less than 1 in 10,000. Risk was not any greater for teens than adults. Teens tended to overdifferentiate their situation, as indicated in the Elkind fable. Risk was gauged higher for the more active events. Teens were sensitive to how the question was posed; i.e. one time vs repeated actions. Low-risk teens and adults were moderately overconfident; high risk teens showed greater overconfidence. The theoretical and policy implications are dependent on the event; further research might focus on why adults view teens so harshly and deny them the right to govern their own actions.

Oral labetalol versus oral clonidine in the emergency treatment of severe hypertension.

This study was designed to compare the clinical efficacy and safety of oral clonidine and oral labetalol in the treatment of severe hypertension in an emergency department setting. Thirty-six patients with severely elevated blood pressure (mean baseline blood pressure 199/132 mm Hg) without acute end-organ dysfunction were treated with either oral labetalol or oral clonidine in a randomized double-blind prospective study. Labetalol was administered as an initial dose of 200 mg, followed by hourly 200 mg doses up to 1,200 mg. Clonidine was administered as an initial dose of 0.2 mg, followed by hourly 0.1 mg doses up to 0.7 mg. Labetalol reduced diastolic blood pressure in 94% of the patients within 6 hours, with a mean reduction in blood pressure of 54/37 mm Hg. Clonidine reduced diastolic blood pressure in 83% of the patients within 6 hours, with a mean reduction in blood pressure of 57/32 mm Hg. The authors conclude that oral labetalol was comparable to clonidine in efficacy, had a similar incidence of side effects, and offered the clinician a useful alternative for the treatment of severe hypertension in an emergency department setting. Further studies are indicated to determine appropriate dosing regimens for oral labetalol in the acute treatment of severe hypertension.

Successful CPR in a severely hypothermic patient using continuous thoracostomy lavage.

Severe hypothermia with cardiopulmonary arrest often requires prolonged resuscitation while rewarming procedures are implemented. A 63-year-old male in cardiopulmonary arrest with a core body temperature of 23.7 C was resuscitated successfully after core rewarming by means of a two-chest-tube continuous thoracostomy lavage procedure. This lavage procedure resulted in effective and rapid rewarming after other conventional rewarming methods had failed.

Development and change of young adults' preventive health beliefs and behavior: influence from parents and peers.

A longitudinal data set is employed to explore the sources of stability and change in young adults' health beliefs and behavior concerning drinking, diet, exercise, and wearing seat belts. There is substantial change in the performance of health behaviors during the first three years of college, and peers have a strong impact on the magnitude of that change. In total, however, parents are much more important than peers as sources of influence over these beliefs and behaviors. Of the various social influence processes considered, the direct modeling of behavior appears to be the most important avenue of influence for both parents and peers. These data, along with previous papers in our research program, suggest a pattern of gradually increasing parental influence on their children's health beliefs and behavior while the children are living at home, and the persistence of that influence at least through the college years.

A multivariate analysis of adolescents' orientations toward physician use.

Health professionals know surprisingly little about the origins of the health beliefs and orientations they often seek to change, and they do not know about when, or if, changes in these orientations are likely to occur. This study is aimed at increasing our understanding of the origins and development of health beliefs and attitudes by focusing on the impact of parents' orientations toward physician utilization (inclination to consult a doctor when experiencing somatic symptoms) on the comparable orientations of their adolescent children. Hypotheses regarding direct parent-adolescent links are examined within a multivariate structural equations model relating demographics, adolescents' interpersonal competencies, and parental variables to adolescents' orientations toward physician utilization. Evidence for the development of these orientations is obtained by comparing influences across two groups of adolescents: 12- to 13-year-olds and 16- to 18-year-olds. Findings indicate that adolescents' orientations toward physician use are associated with those of their parents and that this link is generally stronger and more specific during late adolescence. The model also suggests that these orientations conform to social and cultural variables related to differences in social stratification.