Resolution of acyclovir-associated neurotoxicity with the aid of improved clearance estimates using a Bayesian approach: A case report and review of the literature.

WHAT IS KNOWN AND OBJECTIVE: Neurotoxicity is a side effect of acyclovir. We report the first case, to our knowledge, whereby Bayesian-informed clearance estimates supported a therapeutic intervention for acyclovir-associated neurotoxicity. CASE SUMMARY: A 62-year-old male with the diagnosis of disseminated zoster was being treated with intravenous (IV) acyclovir when he developed symptoms of acute neurotoxicity. Acyclovir had been dose-adjusted for renal dysfunction according to traditional creatinine clearance estimates; however, as the patient was also on vancomycin, Bayesian estimates of vancomycin clearances were performed, which revealed a 2-fold lower creatinine clearance. In response to the Bayesian estimates, acyclovir was discontinued, and improvements in mentation were noted within 24 hours. WHAT IS NEW AND CONCLUSION: Alternate approaches to estimate renal function beyond Cockcroft-Gault, such as a Bayesian approach used in our patient, should be considered when population estimates are likely to be inaccurate and potentially dangerous to the patient.

The outcome of North American pediatric unintentional mushroom ingestions with various decontamination treatments: an analysis of 14 years of TESS data.

The optimum empiric decontamination therapy for unintentional pediatric mushroom ingestion is not known. We sought to determine case outcomes for unintentional mushroom ingestions in children by decontamination therapies utilized. The 1992-2005 American Association of Poison Control Centers Toxic Exposure Surveillance System was queried for cases of unintentional acute mushroom ingestions in children age <6 years. Cases were excluded if outcome was unknown, if exposure was coded as unrelated to the symptoms, or if there was co-ingestion of a non-mycoid substance. The treatment subgroups analyzed were ipecac, single-dose activated charcoal, and no gastric decontamination. 82,330 cases met the inclusion criteria with 22,454 cases excluded. There were 16 cases with major effects and no deaths. There were 57,531 cases in the three treatment subgroups. There was a significantly smaller percentage of cases with moderate or major outcomes in the ipecac subgroup compared to the no decontamination subgroup. There was a significantly greater percentage of cases with moderate or major outcomes in the activated charcoal compared to the no decontamination subgroup. If decontamination therapy is being performed, and this data suggests it may not be necessary, syrup of ipecac could still be considered an effective option.

Antithyroid drug regimen for treating Graves' hyperthyroidism.

BACKGROUND: Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. OBJECTIVES: To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (Central), MEDLINE, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, Current Controlled Trials and reference lists. We contacted investigators and hand searched conference abstracts. Most recent search: July 2004. SELECTION CRITERIA: Randomised and quasi-randomised trials of antithyroid medication for Graves' hyperthyroidism were used. DATA COLLECTION AND ANALYSIS: Trial allocation to included, excluded and awaiting assessment categories was made by consensus. Two reviewers independently extracted data and assessed trial quality. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. MAIN RESULTS: Twenty-three randomised trials involving 3115 participants were included. Overall the quality of trials as reported was poor; specifically in terms of allocation concealment, assessor blinding and loss to follow-up. Four trials examined the effect of duration of therapy on relapse rates of Graves' hyperthyroidism. In one trial using the Titration regimen, longer duration therapy (18 months) had significantly fewer relapses (37% versus 58%) than six month therapy (Odds ratio (OR) 0.42, 95% confidence interval (CI) 0.18 to 0.96). In one quasi-randomised trial using the Block-Replace regimen, there was no significant difference between the six and 12 month (relapses rates 41% versus 35%) arms of the study. Extending the duration of therapy to over 18 months was not associated with improved relapse rates (Peto OR 0.75, 95% CI 0.39 to 1.43). Twelve trials examined the effect of Block-Replace versus Titration regimen. The relapse rates were similar in both groups at 51% in the Block-Replace group and 54% in the Titration group (Peto OR 0.86, 95% CI 0.68 to 1.08). Participants reporting rashes (10% versus 5%) and withdrawing due to side effects (16% versus 9%) were significantly higher in the Block-Replace group compared to the Titration group respectively. Three studies considered the addition of thyroxine with continued low dose antithyroid therapy after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups were not significant (Odds ratio 0.58, 95% CI 0.05 to 6.21). Four studies considered the addition of thyroxine alone after initial therapy with antithyroid drugs. There was no significant difference in the relapse rates between the groups after 12 months follow-up with relapse rates being 31% (88/282) with thyroxine and 29% (82/284) with placebo (Peto OR 1.15, 95% CI 0.79 to 1.67). AUTHORS' CONCLUSIONS: The evidence (based on four studies) suggests that the optimal duration of antithyroid drug therapy for the Titration regimen is 12 to 18 months. The six month Block-Replace regimen was found to be as effective as the 12 month treatment in one quasi-randomised study. The Titration (low dose) regimen had fewer adverse effects than the Block-Replace (high dose) regimen and was no less effective in trials (based on 12 trials) of equal duration. Continued thyroxine treatment following initial antithyroid therapy does not appear to provide any benefit in terms of recurrence of hyperthyroidism. The incidence of hypothyroidism was not reported and there were no deaths reported in the study populations.

Antithyroid drug regimen for treating Graves' hyperthyroidism.

BACKGROUND: Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. OBJECTIVES: To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (Central), MEDLINE, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, Current Controlled Trials and reference lists. We contacted investigators and hand searched conference abstracts. Most recent search: June 2002. SELECTION CRITERIA: Randomised and quasi-randomised trials of antithyroid medication for Graves' hyperthyroidism were used. DATA COLLECTION AND ANALYSIS: Trial allocation to included, excluded and awaiting assessment categories was made by consensus. Two reviewers independently extracted data and assessed trial quality. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. MAIN RESULTS: Nineteen randomised trials involving 2233 participants were included. Overall the quality of trials as reported was poor; specifically in terms of allocation concealment, assessor blinding and loss to follow-up. Four trials examined the effect of duration of therapy on relapse rates of Graves' hyperthyroidism. In one trial using the Titration regimen, longer duration therapy (18 months) had significantly fewer relapses (37% vs 58%) than six month therapy (Odds ratio (OR) = 0.42, 95% confidence interval (CI) 0.18 to 0.96). In one quasi-randomised trial using the Block-Replace regimen, there was no significant difference between the six and 12 month (relapses rates 41% versus 35%) arms of the study. Extending the duration of therapy to over 18 months was not associated with improved relapse rates (Peto OR = 0.75, 95% CI 0.39 to 1.43). Ten trials examined the effect of Block-Replace versus Titration regime. Relapse rates were similar in both groups at 54% in the Block-Replace group and 58% in the Titration group (Peto OR = 0.83, 95% CI 0.63 to 1.10). Participants reporting rashes (11% versus 5%) and withdrawing due to side effects (16% versus 9%) were significantly higher in the Block-Replace group compared to the Titration group respectively. Three studies considered the addition of thyroxine after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups were not significant (Odds ratio = 0.58, 95% CI 0.05 to 6.21). REVIEWERS' CONCLUSIONS: The evidence (based on three studies) suggests that the optimal duration of antithyroid drug therapy for the Titration regimen is 12 to 18 months. The six month Block-Replace regimen was found to be as effective as the 12 month treatment in one quasi-randomised study. The Titration (low dose) regimen had fewer adverse effects than the Block-Replace (high dose) regimen and was no less effective in trials (based on 10 trials) of equal duration. The incidence of hypothyroidism was not reported and there were no deaths in the study populations.

Antithyroid drug regimen for treating Graves' hyperthyroidism.

BACKGROUND: Antithyroid drugs are widely used in the therapy of hyperthyroidism. There are wide variations in the dose, regimen or duration of treatment used by health professionals. OBJECTIVES: To assess the effects of dose, regimen and duration of antithyroid drug therapy for Graves' hyperthyroidism. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (Central), MEDLINE, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, Current Controlled Trials and reference lists. We contacted investigators and hand searched conference abstracts. Most recent search: June 2002. SELECTION CRITERIA: Randomised and quasi-randomised trials of antithyroid medication for Graves' hyperthyroidism were used. DATA COLLECTION AND ANALYSIS: Trial allocation to included, excluded and awaiting assessment categories was made by consensus. Two reviewers independently extracted data and assessed trial quality. Pooling of data for primary outcomes, and select exploratory analyses were undertaken. MAIN RESULTS: Nineteen randomised trials involving 2233 participants were included. Overall the quality of trials as reported was poor; specifically in terms of allocation concealment, assessor blinding and loss to follow-up. Four trials examined the effect of duration of therapy on relapse rates of Graves' hyperthyroidism. In one trial using the Titration regimen, longer duration therapy (18 months) had significantly fewer relapses (37% vs 58%) than six month therapy (Odds ratio (OR) = 0.42, 95% confidence interval (CI) 0.18 to 0.96). In one quasi-randomised trial using the Block-Replace regimen, there was no significant difference between the six and 12 month (relapses rates 41% versus 35%) arms of the study. Extending the duration of therapy to over 18 months was not associated with improved relapse rates (Peto OR = 0.75, 95% CI 0.39 to 1.43). Ten trials examined the effect of Block-Replace versus Titration regime. Relapse rates were similar in both groups at 54% in the Block-Replace group and 58% in the Titration group (Peto OR = 0.83, 95% CI 0.63 to 1.10). Participants reporting rashes (11% versus 5%) and withdrawing due to side effects (16% versus 9%) were significantly higher in the Block-Replace group compared to the Titration group respectively. Three studies considered the addition of thyroxine after initial therapy with antithyroid drugs. There was significant heterogeneity between the studies and the difference between the two groups were not significant (Odds ratio = 0.58, 95% CI 0.05 to 6.21). REVIEWER'S CONCLUSIONS: The evidence (based on three studies) suggests that the optimal duration of antithyroid drug therapy for the Titration regimen is 12 to 18 months. The six month Block-Replace regimen was found to be as effective as the 12 month treatment in one quasi-randomised study. The Titration (low dose) regimen had fewer adverse effects than the Block-Replace (high dose) regimen and was no less effective in trials (based on 10 trials) of equal duration. The incidence of hypothyroidism was not reported and there were no deaths in the study populations.

Influence of Temperature and Wetting Period on Inoculum Production by Monilinia fructicola in Peach Twig Cankers.

Overwintering cankers in peach twigs caused by the brown rot fungus, Monilinia fructicola, were studied to identify the relationships of wetting period and temperature on sporulation. Sporulation was observed on blighted blossoms, peduncles, abscission scars, and cankers resulting from contact with infected fruits. The frequency of sporulation on overwintered infected tissues was greater at 15 and 23°C than at 4 or 11°C. Twelve hours of wetting was sufficient at all temperatures studied (5 to 23°C) for sporulation to occur, but the number of twig cankers supporting sporulation increased with time of wetting up to 72 h. Given the additional moisture requirements for spore germination, ingress, and infection, 17 to 30 h of wetting or high humidity during bloom may be needed for blossom blight to occur unless viable conidia are already present as a result of previous wetting periods.

High-dose loratadine exposure in a six-year-old child.

Loratadine is a long-acting antihistamine indicated for the treatment of seasonal allergic rhinitis and chronic idiopathic urticaria in patients 6 years of age and older. The literature contains little information on high-dose loratadine exposures; as a consequence, poison centers are unsure of the loratadine dose that can be managed with observation and the dose that requires treatment. We report an intentional ingestion of 300 mg loratadine by a 6-y-old child that resulted in minor elevation of blood pressure and heart rate when managed with supportive care only. Further studies and case series are needed before a minimum toxic dose can be established.

Presenting clinical features and C-reactive protein in the prediction of a positive stool culture in patients with diarrhoea.

OBJECTIVES: To devise a scoring system by which clinical features and C-reactive protein (CRP) can be used to predict a positive stool culture in patients admitted with acute diarrhoea. METHODS: One hundred and thirty-two patients admitted to the Regional Infection Unit with diarrhoea thought to be due to bacterial gastroenteritis were included. Clinical features, CRP and outcome of stool culture were recorded, together with the final diagnosis. RESULTS: Forty-one patients had bacterial gastroenteritis characterized by the isolation of a bacterial enteropath (BGE). Sixty-three patients had non-specific gastroenteritis, defined as more than three loose stools per day with no bacterial enteropath isolated (NSGE). In 28 patients another diagnosis was made (Others). More of the patients with BGE (91%) had abdominal pain as compared with those with NSGE (67%) and Others (61%) (P=0.01). The mean duration of symptoms was longer in the Others group (6.14 days) as compared with patients with BGE (3.29) and NSGE (3.25) (P=0.01). The mean CRP was significantly higher in those with BGE (113.9mg/l) and Others (116.9mg/l) as compared to the NSGE patients (38.9mg/l) (P=0.001). A scoring system was devised which incorporated the presence or absence of abdominal pain (+10 or 0), the duration of symptoms (-10, for 5 or more days, 0 for less than 5 days of symptoms) and the CRP (CRP<50=0, CRP>50=5). A score of 15 or more predicted 79% of patients with BGE, while a score of <15 predicted 87% of those with NSGE and 86% of those with another diagnosis. CONCLUSIONS: This simple scoring system may be useful in predicting the positivity of stool culture, and therefore may be helpful in targeting those small number of patients who require antimicrobial therapy after hospital admission. We would not, however, favour reliance on this scoring system alone to choose whom to treat with antimicrobials.

Emergency medicine residents' shiftwork tolerance and preference.

OBJECTIVES: To determine the shift lengths currently worked by emergency medicine (EM) residents and their shift length preferences, and to determine factors associated with EM residents' subjective tolerance of shiftwork. METHODS: A survey was sent to EM-2 through EM-4 allopathic EM residents in May 1996. This questionnaire assessed the residents' shift length worked, shift length preferences, night shift schedules, and self-reported ability to overcome drowsiness, sleep flexibility, and morningness-eveningness tendencies. When providing shift length preferences, the residents were asked to assume a constant total number of hours scheduled per month. RESULTS: Seventy-eight programs participated, and 62% of 1,554 eligible residents returned usable surveys. Current shift lengths worked were 8 hours (12%), 10 hours (13%), 12 hours (37%), combinations of 8-hour, 10-hour, or 12-hour (34%) shifts, and other combinations (4%). Seventy-three percent of the respondents indicated that they preferred to work 8-hour or 10-hour shifts, and only 21% preferred a 12-hour shift. Shiftwork tolerance was recorded as: not well at all (2%), not very well (14%), fairly well (70%), and very well (14%). The EM residents' eveningness preference, ability to overcome drowsiness, sleep flexibility, younger age, and having no children at home were all associated with greater shiftwork tolerance. CONCLUSIONS: Emergency medicine residents generally tolerate shiftwork well and prefer 8-hour or 10-hour shift lengths compared with 12-hour shift lengths. Emergency medicine residencies with 12-hour shifts should consider changing residents' shifts to shorter shifts.

Botulism-like syndrome after injections of botulinum toxin.

Botulinum type A toxin (BTA) is an orphan drug used to treat several disorders of muscle spasticity. We report the first known case of systemic botulism-like syndrome induced by BTA therapy which resulted in respiratory arrest. Clinicians should be aware that systemic effects may occur with localized BTA therapy and may be life-threatening.

Percentage of emergency medicine residency graduates who got their first choice of jobs did not change between 1995 and 1997.

The objective of this study was to compare the number of emergency medicine (EM) graduates unable to find a job in the city/area of their first choice in 1995 and 1997. Self-administered questionnaires were distributed to EM residents who graduated in both 1995 and 1997. The survey ascertained resident's practice city and state, whether their job was in the city/area of first choice and how satisfied they were with their practice selection. Eighty (83%) programs and 507 (70%) of eligible residents participated. Thirty-eight percent of graduates chose to practice in the city or metropolitan area where they trained and 75% of respondents were very satisfied with their practice selection. Nineteen percent stated they would not be practicing in the city/area of their first choice; one-third indicated there were no jobs available and two-thirds stated that jobs were available but not desirable. These numbers were similar to the 1995 data (P = .79). Job selection was more important than liking (P < .001) or having lived in (P < .001) a desired city/area of practice location. In conclusion, 1997 EM residency graduates were as successful as 1995 graduates in obtaining their first choice of jobs.

Screening for stimulant use in adult emergency department seizure patients.

OBJECTIVE: The objective of this study was to determine the prevalence of positive plasma drug screening for cocaine or amphetamine in adult emergency department seizure patients. METHODS: This prospective study evaluated consecutive eligible seizure patients who had a plasma sample collected as part of their clinical evaluation. Plasma was tested for amphetamine and the cocaine metabolite benzoylecgonine using enzyme-mediated immunoassay methodology. Plasma samples with benzoylecgonine greater than 150 ng/mL or an amphetamine greater than 500 ng/mL were defined as positive. Patient demographics, history of underlying drug or alcohol-related seizure disorder, estimated time from seizure to sample collection, history or suspicion of cocaine or amphetamine abuse, results of clinical urine testing for drugs of abuse, and assay results were recorded without patient identifiers. RESULTS: Fourteen of 248 (5.6%, 95% CI 2.7%-8.5%) plasma samples were positive by immunoassay testing for benzoylecgonine and no samples (0%, 95% CI 0-1.2%) were positive for amphetamine. Positive test results were more common in patient visits where there was a history or suspicion of cocaine or amphetamine abuse (p < 0.0005). CONCLUSIONS: During this study period, routine plasma screening for cocaine and amphetamines in adult seizure patients had a low yield. As a result, routine plasma screening would yield few cases of stimulant drug in which there was neither a history nor suspicion of drug abuse in this population.

Using statistical process control to demonstrate the effect of operational interventions on quality indicators in the emergency department.

When our emergency department (ED) initiated a continuous quality improvement (CQI) program, we selected as a quality indicator the percentage of patients leaving without being seen (LWBS) by a physician. Because the primary reason for LWBS patients was determined to be dissatisfaction with waiting time, we devised four interventions in clinical operations to decrease delays in patient flow through the ED. Statistical process control (SPC) methodology was then used to assess the effect of these interventions. Because baseline data were available, we constructed control charts of the percentage of LWBS patients versus consecutive months beginning in January 1990 with the mean percentage of LWBS patients and upper and lower control limits. Postintervention data, plotted using control statistics from the baseline period, demonstrated sustained special-cause variation, indicating a fundamental change in the overall system. A new control chart was then constructed using postintervention data. A significantly lowered mean percentage LWBS and a narrowed control limit range were observed, leading to the conclusion that the interventions improved the quality of care as measured by a reduction in percentage LWBS.

The occupational risk of motor vehicle collisions for emergency medicine residents.

OBJECTIVE: To determine the prevalence and risk factors associated with motor vehicle collisions (MVCs) and near-crashes as reported by emergency medicine (EM) residents following various ED shifts. METHODS: A survey was sent to all allopathic EM-2-EM-4 residents in May 1996 asking whether they had ever been involved in an MVC or near-crash while driving home after an ED shift. The residents' night shift schedules, self-reported tolerance of night work, ability to overcome drowsiness, sleep flexibility, and morningness/eveningness tendencies also were collected. RESULTS: Seventy-eight programs participated and 62% of 1,554 eligible residents returned usable surveys. Seventy-six (8%, 95% CI = 6% to 10%) residents reported having 96 crashes and 553 (58%, 95% CI = 55% to 61%) residents reported being involved in 1,446 near-crashes. Nearly three fourths of the MVCs and 80% of the near-crashes followed the night shift. Stepwise logistic regression of all variables demonstrated a cumulative association (R = 0.19, p = 0.0004) that accounted for 4% of the observed variability in MVCs and near-crashes. Univariate analysis showed that MVCs and near-crashes were inversely related to residents' shiftwork tolerance (p = 0.019) and positively related to the number of night shifts worked per month (p = 0.035). CONCLUSIONS: Residents reported being involved in a higher number of MVCs and near-crashes while driving home after a night shift compared with other shifts. Driving home after a night shift appears to be a significant occupational risk for EM residents.

Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration.

A convenience sample of 164 adult patients with 185 glass-caused wounds who presented to an emergency department (ED) and consented to a radiograph was prospectively studied. The purpose was to determine the characteristics of wounds at high risk for foreign body (FB) and the predictive value of patient FB sensation and probing wound exploration for FB retention. Retained glass was located in 28 (15%) wounds. Motor vehicle as a mechanism of injury (P=.003), head as a location (P=.035), and puncture as wound type (P=.002) were more likely to be associated with retained FBs (chi2 analysis). Patients with wounds with glass were more likely to have a positive perception of a foreign body (41%) than those with no glass (17%) (P=.005). The positive predictive value of patient perception was 31%; negative predictive value was 89%. In five cases, wound exploration was negative and subsequent radiograph was positive for FB. In one of these cases, a 4-mm glass FB was removed; in the other four, no FB was found. In conclusion, head wounds resulting from motor vehicle accidents or puncture wounds are more likely to harbor retained glass FBs. Patients with glass FB in wounds are more likely to have a positive perception of FB; however, a positive perception has a low predictive value of glass FB. In this series, a negative wound exploration made the presence of retained FB greater than 2 mm less likely but did not rule out the presence of retained glass.

Skin necrosis and venous thrombosis from subcutaneous injection of charcoal lighter fluid (naptha).

A 33-year-old white man injected approximately 4 cc of charcoal lighter fluid (99.4% naptha/0.6% inert ingredients) subcutaneously into his left antecubital fossa. The injection resulted in the toxic necrosis of his volar forearm skin extending proximally to mid-humerus and distally to the metacarpophalangeal joints of the left hand dorsally over a 6-day period. The patient ultimately required extensive surgical debridement, secondary operative closure, and approximately 150 cm2 of split-thickness skin grafting. This case demonstrates the potential for widespread, delayed toxic necrosis of the skin resulting from subcutaneous injection of naptha. This patient's case appears to represent the most severe and widespread case of toxic necrosis of the skin resulting from the subcutaneous injection of hydrocarbons reported in the literature. This case also demonstrates extensive toxic thrombophlebitis not reported in prior cases involving subcutaneous injection of hydrocarbons.

Enhancing medical student consultation request skills in an academic emergency department.

The purpose of this study was to develop an educational protocol to enhance the communication skills of medical students when requesting specialty consultation. A protocol consisting of a worksheet and oral instructions was created to teach nine criteria of effective consultation requests, derived from the existing literature. Consultation requests made by senior medical students using the protocol were evaluated and compared to consultation requests made by Emergency Medicine residents who did not complete the educational protocol. Forty-two medical student consultation requests and 50 Emergency Medicine resident consultation requests were evaluated. The students included five of the nine criteria in their consultation requests significantly more often than the residents. The median number of criteria included by the students was eight, while the median number of criteria included by the residents was six. This study shows that senior medical students can be taught to communicate effectively with specialists when requesting consultations.

Opioid toxicity recurrence after an initial response to naloxone.

OBJECTIVE: To determine the frequency and potential predictors of opioid toxicity recurrence after a response to naloxone in adult Emergency Department patients. METHODS: A retrospective case-control study of naloxone-treated patients with opioid toxicity over an 8-year period. Both the patient response to naloxone and recurrence of opioid toxicity was determined by an expert Delphi Panel. The frequency of opioid toxicity recurrence was compared by the duration of opioid effect, the route of opioid exposure, and the presence of other CNS depressant drugs. RESULTS: Ninety of 221 (41%) cases with a discharge diagnosis of opioid toxicity were treated with naloxone; six patients were excluded because of a lack of toxicity. There was a response to naloxone in 50% of the 84 cases, and recurrence of toxicity in 31% (95% CI 17-45%) of naloxone responders. The most common opioids were codeine, heroin, propoxyphene, and oxycodone/hydrocodone. Recurrence of toxicity was more common with long-acting opioids (p = 0.04), and was not associated with the route of opioid exposure (p = 0.42), or presence of ethanol and other CNS depressants (p > or = 0.87). CONCLUSION: Opioid toxicity recurrence after a response to naloxone occurred in approximately 1/3 of adult Emergency Department opioid overdose cases. Recurrence was more common with long-acting opioids and was not associated with the route of opioid exposure. Other clinically useful predictors of toxicity recurrence were not identified.

Emergency medicine resident choice of practice location.

STUDY OBJECTIVE: To describe the geographic distribution of practice locations for 1995 emergency medicine residency graduates and factors that are important to residents in their choice of practice location. METHODS: Self-administered questionnaires were distributed to Emergency medicine residents who graduated in 1995. The survey ascertained practice city and state, resident employment characteristics, and the importance of factors that influenced the residents' selection of employment. RESULTS: Eighty-six of 87 programs and 441 (69.4%) of 635 eligible residents participated. Forty-three percent of graduates chose to practice in the city or metropolitan area in which they trained; 46% of these had no personal tie to the area before their residency training. Liking the city was cited as being more important (P<.001) than other factors in picking practice location. Group personality and coworkers' credentials were more important (P< or =.01) than contract and salary arrangement. Twenty percent of respondents were not practicing in the city or area of their first choice. CONCLUSION: Residency training location, regardless of prior ties to the geographical area, appears to be a major factor in the choice of practice location of emergency medicine residency graduates. Coworkers' personalities and credentials are more important factors in job selection than salary and employment arrangements.