Short-Term Topical Tetracaine Is Highly Efficacious for the Treatment of Pain Caused by Corneal Abrasions: A Double-Blind, Randomized Clinical Trial.

STUDY OBJECTIVE: The objective of this study is to show that patients with corneal abrasions would experience more pain relief with short-term topical tetracaine than placebo. METHODS: The study was a prospective, double-blind, randomized trial of tetracaine versus placebo set in the emergency department (ED). A total of 118 adults who presented with uncomplicated corneal abrasions were included and randomized. The intervention was either topical tetracaine or placebo applied every 30 minutes as needed for 24 hours. The primary outcome was the overall numeric rating scale pain score measured at the 24- to 48-hour ED follow-up examination. RESULTS: One hundred eleven patients were included in the final analysis, 56 in the tetracaine group and 55 in the placebo group. At the 24- to 48-hour follow-up, the overall numeric rating scale pain score after use of the study drops was significantly lower in the tetracaine group (1) versus placebo group (8) (Δ7; 95% confidence interval 6 to 8). Patients in the tetracaine group used less hydrocodone than those in the placebo group. The complication rates between the 2 groups were similar. CONCLUSION: Short-term topical tetracaine is an efficacious analgesic for acute corneal abrasions, is associated with less hydrocodone use compared with placebo, and was found to be safe in this sample.

The Dangerous Life of a Storm Chaser: A Lightning Strike Injury Causing Serious Injury.

Lightning strikes to people are rare events that cause significant injuries and mortality when they do occur. We describe an uncommon case of a storm chaser in Oklahoma who was struck by lightning who suffered cutaneous burns, bilateral tympanic membrane ruptures, as well as pulmonary edema, which is an atypical finding in survivors. This case report highlights several injury patterns seen in lightning strike cases and provides evidence that these patients should be managed at a center with multidisciplinary services available.

A Case of Acute Coronary Occlusion in a Morbidly Obese Patient Masked on Electrocardiogram by Low QRS Voltage.

Timely diagnosis of acute coronary occlusion is essential to avoid chronic cardiac impairment and death. We describe an uncommon case of acute myocardial infarction masked by low QRS voltage secondary to morbid obesity. This case highlights the importance of considering the degree of ST-segment elevation proportionally to the QRS amplitude if there is clinical suspicion of acute coronary occlusion.

High Prevalence of Sterile Pyuria in the Setting of Sexually Transmitted Infection in Women Presenting to an Emergency Department.

INTRODUCTION: The clinical presentations for sexually transmitted infections (STI) and urinary tract infections (UTI) often overlap, and symptoms of dysuria and urinary frequency/urgency occur with both STIs and UTIs. Abnormal urinalysis (UA) findings and pyuria are common in both UTIs and STIs, and confirmatory urine cultures are not available to emergency clinicians to aid in decision-making regarding prescribing antibiotics for UTIs. The objective of this study was to determine the frequency of sterile pyuria in women with confirmed STIs, as well as whether the absolute number of leukocytes on microscopy or nitrite on urine dipstick correlated with positive urine cultures in patients with confirmed STIs. We also sought to determine how many patients with STIs were inappropriately prescribed a UTI antibiotic. METHODS: We performed a retrospective chart review of patients aged 18-50 who had a urinalysis and pelvic examination in the emergency department (including cervical cultures), and tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis. Descriptive statistics were obtained for all variables, and associations between various findings were sought using the Fisher's exact test for categorical variables. We calculated comparison of proportions using the N-1 chi-squared analysis. RESULTS: A total of 1,052 female patients tested positive for Neisseria gonorrhoeae, Chlamydia trachomatis, and/or Trichomonas vaginalis and were entered into the database. The prevalence of pyuria in all cases was 394/1,052, 37% (95% confidence interval [CI] [0.34-0.40]). Of the cases with pyuria, 293/394, 74% (95% CI [0.70-0.78]) had sterile pyuria with negative urine cultures. The prevalence of positive urine cultures in our study population was 101/1,052, 9.6% (95% CI [0.08-0.11]). Culture positive urines had a mean of 34 leukocytes per high-power field, and culture negative urines had a mean of 24 leukocytes per high-power field, with a difference of 10, (95% CI [3.46-16.15]), which was statistically significant (p=0.003). Only 123 cases tested positive for nitrite on the urinalysis dipstick; 50/123, 41% (95% CI [0.32-0.49]) had positive urine cultures, and 73/123, 59% (95% CI [0.51-0.68]) had negative urine cultures. Nitrite-positive urines were actually 18% more likely to be associated with negative urine cultures in the setting of positive STI cases, (95% CI [4.95-30.42], p=0.0048). Antibiotics were prescribed for 295 patients with suspected UTI. Of these, 195/295, 66% (95% CI [0.61-0.71]) had negative urine cultures, and 100/295, 34% (0.33, 95% CI [0.28-0.39]) had positive urine cultures. Chi-square analysis yielded a difference of these proportions of 32% (95% CI [23.92-39.62], p<0.0001). CONCLUSION: This study demonstrated that in female patients with STIs who have pyuria, there is a high prevalence of sterile pyuria. Our results suggest that reliance on pyuria or positive nitrite for the decision to add antimicrobial therapy empirically for a presumed urinary tract infection in cases in which an STI is confirmed or highly suspected is likely to result in substantial over-treatment.

Simple infrared thermometry in fever detection: consideration in mass fever screening.

OBJECTIVE: The need to rapidly screen patients during outbreaks has prompted Cutaneous Infrared Thermometry (CIT) use. Little is known of CIT performance in this context. What are the performance characteristics of simple CIT in detecting fever? DESIGN: Prospective cohort, sequential convenience sample. PARTICIPANTS: All patients presenting to the study Emergency Department for care. INTERVENTION: CIT and oral temperature measurements. MAIN OUTCOMES: Fever defined as oral temperature≥38°C. CIT is measured simultaneously with oral temperatures. Comparisons of temperatures are expressed as means and 95% confidence intervals. Means are compared using Student's t test. Limits of agreement are measured using Bland-Altman. Receiver operating characteristics are determined. RESULTS: There are 548 cases comprising 224 males, 324 females, with mean age 26 years. The mean temperature difference is 12.95°C, (13.18-9.08°C) p≤0.0001. Bland-Altman demonstrates bias at 8.680 (-9.084 to -8.275) p≤0.0001 with upper and lower level bias values of 18.124 (18.819-17.435) and 0.768 (0.076-1.459), respectively. Based on Receiver Operator Characteristics analysis, detection of hyperpyrexia at a CIT of 35.3°C provided sensitivity of 0.236 (0.143-0.359), specificity 0.977 (0.959-0.989), positive predictive value 0.589 (0.325-0.810), negative predictive value 0.904 (0.891-0.919), and accuracy of 0.888 (0.861-0.913). CONCLUSIONS: The use of a readily available CIT measurement device predicted hyperpyrexia about 59 percent of the time and the absence of hyperpyrexia about 90 percent of the time. This is consistent with previous reports of more complex infrared measurement devices. Although commonly used in mass fever screening, the current performance characteristics of CIT are limited and may add little to detection of target diseases in a mass screening context.

Risk factors for postpartum depression: a retrospective investigation at 4-weeks postnatal and a review of the literature.

OBJECTIVE: To describe possible correlations between incidence of postpartum depression and the following patient characteristics: age, breastfeeding status, tobacco use, marital status, history of depression, and method of delivery. STUDY DESIGN: Data gathered at routine 4-week postnatal visits were obtained from the patient records of 209 women who gave birth between June 1, 2001, and June 1, 2003, at three university medical clinics in Tulsa, Okla. Inclusion criteria required that the records of potential study subjects contain data on the characteristics noted as well as patient-completed Edinburgh Postnatal Depression Scale forms. RESULTS: Formula feeding in place of breastfeeding, a history of depression, and cigarette smoking were all significant risk factors for an Edinburgh Postnatal Depression Scale score of 13 or higher, indicating probable postpartum depression. CONCLUSION: The authors' findings corroborate the results of previous investigators. To facilitate prophylactic patient education and intervention strategies, a larger study is recommended to determine risk factors for postpartum depression.