Oral antibiotic use without consulting a physician: a survey of ED patients.

The purpose of our study was to determine the extent to which patients use antibiotics without consulting a physician and to examine patient characteristics associated with such oral antibiotic misuse. The study design was a prospective survey. The setting was a suburban, community, emergency department (ED). The participants were a convenience sample of oriented, ED patients who were enrolled during an 8-week period. Subjects provided written answers to standardized questions regarding their use of oral antibiotics over the 12 months preceding their ED visit. Categorical and continuous data were analyzed by chi-square and t-tests respectively. All test were 2-tailed with alpha set at 0.05. One thousand three hundred sixty three subjects were enrolled; 80% were White, 54% were female, 58% had attended college, 85% had a private physician, and 88% had health insurance. The mean age was 45 +/- 19 years. 43% of patients had used oral antibiotics within the past year. Twenty-two percent of patients indicated that their physicians routinely prescribed antibiotics for their cold symptoms. Seventeen percent of patients had taken "left-over" antibiotics without consulting their physician, most commonly for a cough (11%) or sore throat (42%), and much less frequently for urinary tract infection symptoms (0.7%). Women (19% versus 15% men; P =.04) and patients who attended college (19% versus 14% no college; P =.01) were more likely to have taken "left-over" antibiotics. A significant percentage of our ED patients had taken oral antibiotics without consulting a physician for symptoms frequently caused by viruses. Further study is warranted to examine whether local patterns of outpatient self-prescribing affect community oral antibiotic resistance.

The emergency department as a potential site for smoking cessation intervention: a randomized, controlled trial.

OBJECTIVE: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program. METHODS: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05. RESULTS: One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]. CONCLUSION: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.

Safety and efficacy of diclofenac ophthalmic solution in the treatment of corneal abrasions.

STUDY OBJECTIVE: To determine whether the use of diclofenac ophthalmic solution is a safe and effective analgesic in the treatment of traumatic corneal abrasions in the emergency department. METHODS: We conducted a prospective, randomized, double-blinded, placebo-controlled clinical trial. Consenting consecutive patients with corneal abrasions who presented to a community-based ED from August through February 1998 were randomly assigned to receive either diclofenac or control vehicle drops. Pain relief was measured using a visual Numeric Pain Intensity Scale (NPIS) before and after treatment. Exclusion criteria were as follows: age younger than 18 years, pregnancy, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hours, minimal pain (NPIS score <3), and any allergy to diclofenac or nonsteroidal anti-inflammatory drugs. Patients were discharged with study drug or control vehicle solution, a topical antibiotic, oxycodone-acetaminophen as a rescue analgesic, and a pain diary. The outcome measurements were improvement in NPIS score 2 hours after treatment, use of oxycodone-acetaminophen, and occurrence of any adverse effects. RESULTS: Forty-nine patients were enrolled in the study; 25 received diclofenac and 24 received control vehicle drops. Both groups were similar in gender, age, pretreatment pain duration, NPIS score, and analgesic use. There was significantly greater improvement in the 2-hour NPIS score in the diclofenac group (3.1; 95% confidence interval [CI] 2.3 to 4) compared with the control group (1.0; 95% CI 0.1 to 2.0). The difference between the 2 groups was 2.1+/-1.3 (95% CI 0.8 to 3.4). There was a trend toward fewer patients taking rescue oxycodone-acetaminophen in the diclofenac group (20%; 95% CI 4% to 36%) versus the control group (42%; 95% CI 22% to 62%). Other than transient mild stinging, there were no complications associated with diclofenac use. CONCLUSION: Diclofenac ophthalmic solution appears to be a safe and effective analgesic in the treatment of traumatic corneal abrasions in the ED.

Prevalence of smokers and nicotine-addicted patients in a suburban emergency department.

OBJECTIVE: To define the prevalence of smokers and nicotine-addicted patients in a suburban, community ED. METHODS: This was a prospective survey of consecutive ED patients seen in a suburban ED with an annual patient census of 48,000. Medically stable patients aged 18 years or older were eligible for inclusion. Patients were excluded if they had predominantly psychiatric complaints or were critically ill. Patients were queried about their smoking habits by a closed-question survey, which included the previously validated Fagerstrom Test for Nicotine Dependence. The study was conducted during a six-week period, only at times when there were dedicated research associates available to ensure consecutive patient entry. Continuous variables were analyzed by Student's t-tests. Clinical variables were analyzed by chi-square tests. All tests were two-tailed with alpha at 0.05. RESULTS: 1,515 patients comprised the study group. The mean age (+/-SD) was 45.6 (+/-18.9) years; 52% were female, 25% were nonwhite, and 47% were college graduates. There were 317 (21%) smokers. Patients having private physicians were less likely to smoke (18% vs 29%, p = 0.001). Of all smokers, 46% were moderately to severely nicotine-dependent, 69% wanted to quit, and 30% expressed an interest in joining a smoking cessation program. CONCLUSION: A substantial percentage of ED patients smoke, many of them are nicotine-addicted, and the majority would like to quit. Randomized, controlled trials are needed to determine whether interventions by physicians in the ED can have an impact on the smoking habits of these patients.

Droperidol for acute migraine headache.

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.

The effect of the menstrual cycle on asthma presentations in the emergency department.

BACKGROUND: Seventy-five percent of all adult hospital admissions for asthma are women. OBJECTIVE: To determine whether a relationship exists between phases of the menstrual cycle and asthma exacerbations in adult females. METHODS: Data were analyzed from 182 nonpregnant, adult females with asthma aged 13 years to menopause. Date of presentation, patient age, duration of asthma attack, date of last menstrual period, regular interval between menses, presenting peak expiratory flow rate, and admission and discharge decision were recorded prospectively. Treatment interventions abstracted retrospectively from patient charts included use of oxygen, xanthines, beta-adrenergic agonists, corticosteroids, and magnesium sulfate. The menstrual cycle was divided into 4 phases based on fluctuations in serum estradiol levels. The 4 intervals were preovulatory (days 5-11), periovulatory (days 12-18), postovulatory (days 19-25), and perimenstrual (days 26-4). RESULTS: Data were analyzed with a goodness-of-fit chi 2. Between June 1991 and May 1992, 182 females (mean +/- SD age, 28.5 +/- 8.0 years) were surveyed. No significant differences were noted for use of oxygen, beta-adrenergic agonists, xanthines, or magnesium among members of the 4 menstrual groups. Intervention with corticosteroids was least in the postovulatory interval (y:n) 0.5:1 and greatest in the preovulatory interval 3.0:1 (alpha = .03) Presentations by menstrual interval were as follows: preovulatory, 36 (20%); periovulatory, 43 (24%); postovulatory, 18 (10%); and perimenstrual, 85 (46%) (alpha < .01). CONCLUSIONS: Asthma presentations are least frequent when serum estradiol levels are at a sustained peak. We observed a 4-fold variation in asthma presentations during the perimenstrual interval, when serum estradiol levels decrease sharply after that prolonged peak. These findings suggest that monthly variations in serum estradiol levels may influence the severity of asthma in adult females.

Age-related changes in cardiac norepinephrine release: role of calcium movement.

The purpose of this study was to determine if the age-related decrease in norepinephrine (NE) release from cardiac adrenergic nerve terminals is due to a defect in Ca2+ movement into the nerve terminal or to an alteration in Ca2+ activation of intracellular events leading to NE release. NE release was assessed in cardiac synaptosomes prepared from 6- and 24-month-old male F344 rats. K(+)-induced NE release was significantly greater in young vs old rats. Raising extracellular [Ca2+] increased NE release, but NE release always remained higher in the younger animals. Ionomycin, a Ca2+ ionophore, induced NE release from cardiac synaptosomes, and there was no age difference in the response. The age-related reduction in NE release induced by K+ and the capacity of ionomycin to induce similar NE release in young and old cardiac synaptosomes points to a reduction in Ca2+ movement during depolarization.

Effect of age on cardiac norepinephrine release in the female rat.

We previously demonstrated an age-related decline in K(+)-induced norepinephrine (NE) release from cardiac synaptosomes prepared from 6- and 24-month-old male F344 rats. The purpose of the present study was to determine if the age-related decrease in NE release seen in male F344 rats is also present in female F344 rats. K(+)-induced NE release was assessed in cardiac synaptosomes prepared from 6-, 12-, 18-, and 24-month-old male and female F344 rats. NE release was significantly greater in young male rats, compared to old male rats. However, no age-related decrease in NE release was observed in the female rats. In contrast to previous observations in male rats, raising extracellular [Mg2+], an inorganic Ca2+ channel blocker, reduced NE release to the same extent in all female ages. Omega-conotoxin, an organic Ca2+ channel blocker, also decreased NE release to the same extent in all female ages. These studies suggest that in contrast to aging male rats, cardiac adrenergic nerve terminals of aging female rats maintain their capacity to release NE.

Different tissue responses for iodine and iodide in rat thyroid and mammary glands.

This research describes the effects of short-term elemental iodine (I2) and iodide (I-) replacement on thyroid glands and mammary glands of iodine-deficient (ID) Sprague-Dawley female rats. Iodine deficiency causes atypical tissue and physiologic changes in both glands. Tissue histopathology and the endocrine metabolic parameters, such as serum TT4, tissue and body weights, and vaginal smears, are compared. A moderate reduction in thyroid size from the ID control (IDC) was noted with both I- and I2, whereas serum total thyroxine approached the normal control with both I- and I2, but was lower in IDC. Thyroid gland IDC hyperplasia was reduced modestly with I2, but eliminated with I-. Lobular hyperplasia of the mammary glands decreased with I2 and increased with I- when compared with the IDC; extraductal secretions remained the same as IDC with I2, but increased with I-; and periductal fibrosis was markedly reduced with I2, but remained severe with I-. Thus, orally administered I2 or I- in trace doses with similar iodine availability caused different histopathological and endocrine patterns in thyroid and mammary glands of ID rats. The significance of this is that replacement therapy with various forms of iodine are tissue-specific.

Prolactin secretion following repetitive seizures.

We studied serum prolactin levels after 24 seizures occurring in eight subjects. Video-EEG intracranial monitoring confirmed temporal or frontal partial seizures. Seizure type, focus, and duration were similar for seizures with and without significant postictal prolactin elevations. The seizure-free interval (the time between seizures) varied considerably. Seizures occurring after longer seizure-free intervals (31.75 to 240 hours) showed robust prolactin responses. After shorter seizure-free intervals (1.07 to 25.42 hours), prolactin responses were reduced. This suggests that the amount of releasable prolactin is limited, depleted by seizures, or perhaps inhibited by prolactin feedback. Seizure-free intervals should be considered when interpreting prolactin levels.

Iodine replacement in fibrocystic disease of the breast.

OBJECTIVE: To determine the response of patients with fibrocystic breast disease to iodine replacement therapy. DESIGN: Review of three clinical studies beginning in 1975: an uncontrolled study with sodium iodide and protein-bound iodide; a prospective, control, crossover study from iodide to molecular iodine; and a prospective, control, double-blind study with molecular iodine. SETTING: University affiliated breast-treatment clinics. PATIENTS: Study 1: 233 volunteers received sodium iodide for 2 years and 588 received protein-bound iodide for 5 years. Study 2: the treatment of 145 patients from study 1 treated with protein-bound iodide for several months who still had symptoms was switched to molecular iodine 0.08 mg/kg; 108 volunteers were treated initially with molecular iodine. Study 3: 23 patients received molecular iodine, 0.07 to 0.09 mg/kg body weight; 33 received an aqueous mixture of brown vegetable dye and quinine. The numbers in study 2 increased over the review period so that 1365 volunteers were being treated with molecular iodine by 1989. INTERVENTIONS: All patients in study 3 had pre- and post-treatment mammography and measurement of serum triiodothyronine, thyroxine and thyroid-stimulating hormone levels. MAIN OUTCOME MEASURES: Subjective evaluation--freedom from pain--and objective evaluation--resolution of fibrosis. RESULTS: Study 1: 70% of subjects treated with sodium iodide had clinical improvement in their breast disease, but the rate of side effects was high; 40% of patients treated with protein-bound iodide had clinical improvement. Study 2: 74% of patients in the crossover series had clinical improvement, and objective improvement was noted in 72% of those who received molecular iodine initially. Study 3: in the treatment group 65% had subjective and objective improvement; in the control group there was a subjective placebo effect in 33% and an objective deterioration of 3%. CONCLUSIONS: The fibrocystic breast reacts differently to sodium iodide, protein-bound iodide and molecular iodine. Molecular iodine is nonthyrotropic and was the most beneficial.

Ovulation induction with clomiphene and the rise in heterotopic pregnancies. A report of two cases.

Two women were treated for heterotopic pregnancies, the simultaneous occurrence of an intrauterine pregnancy and an ectopic pregnancy. The commonly accepted incidence is 1:30,000. The actual rate appears to be significantly higher; the two most prominent reasons are today's increased rate of ectopic pregnancies and the increased use of clomiphene in infertile women. A rigorous evaluation is required in all early pregnancies in which an ectopic is suspected to rule out the presence of a heterotopic pregnancy.

Iodoprotein formation by rat mammary glands during pregnancy and early postpartum period.

Iodide organification by rat mammary glands was studied during the trimesters of pregnancy and early postpartum period. Organification was followed by measuring trichloroacetic acid (TCA) precipitation of delipidated tissue homogenates. The radiolabeled material was sensitive to proteolytic cleavage by a bacterial protease indicating that the 125I was protein-bound. Gel filtration column chromatography in the presence of sodium dodecyl sulfate (SDS) of delipidated mammary tissue homogenates of pregnant and postpartum rats reproducibly resolved several iodoproteins from free iodide. The Kav value for each iodoprotein peak was calculated and was used to estimate each subunit molecular weight which averaged 37,500, 25,100, and 8500. Another iodoprotein with a very large subunit molecular weight of greater than 300,000 was also detected in mammary tissue. Incorporation of 125I-iodide into the three smaller iodoproteins increased logarithmically from the start of the second trimester of pregnancy through the early postpartum period when approximately 20% of the total 125I uptake by mammary tissue was incorporated into protein. Hyperplasia, acinar development, and intracytoplasmic vacuolization of mammary tissue correlated with the increased incorporation of 125I-iodide into these iodoproteins. The characterization and quantitation of specific iodoproteins in mammary tissue may be important as organification of iodide is believed to be a marker for normal hormone-responsive cells.

Evidence that multiple species of aminoacylated transfer RNA are present in regenerating optic axons of goldfish.

This study reports that 4S RNA present in regenerating optic axons of goldfish is likely to be transfer RNA. Evidence is also presented which indicates that this transfer RNA is similar to transfer RNA found in tectal cells and that its aminocylation is likely to occur both in retinal ganglion cells prior to axonal transport as well as in the axon itself. Fish with regenerating optic nerves received intraocular injections of [3H]uridine followed 4 days later by intracranial injections of [14C]uridine. Radioactive tectal 4S RNA was isolated 6 days after [3H]uridine injections and chromatographed by BD cellulose chromatography. Optical density as well as radioactivity profiles for both [14C]4S RNA (from tectal cells) and [3H]4S RNA (90% of which originated from regenerating optic axons) were found to be similar to E. coli transfer RNA optical density profiles, indicating that the intra-axonal 4S RNA is likely to be transfer RNA. Moreover, comparisons of 3H/14C suggest that intra-axonal and cellular 4S RNAs are composed of similar species of transfer RNA. Results of other experiments indicate that aminoacylation of axonally transported tRNA occurs both in the retina and in optic axons subsequent to axonal transport.

Iodine and breast cancer A 1982 update.

Research has been directed towards investigating the role of the trace element, iodine, in breast cancer etiology, diagnosis, and therapy. In many controled studies, iodine has been established as a requirement for breast tissue normalcy, since deficiency of the element results in histopathology consistent with dysplasia and atypia in rodents. Clinically severe hyperplasia and fibrocystic disease is seen in the breasts of women who have low iodine levels. These precancerous lesions result in a high-risk state as well as persistent symptomatology in women. Iodine replacement therapy has been shown to be efficacious in reducing these conditions in clinical trials. Basic research is directed towards intracellular pathways and metabolism for breast iodide, emulating those seen in the thyroid gland. Thus, using a rat model, iodine intracellular organification is being correlated with risk factors for breast cancer including early and late pregnancies, onset of puberty, menopause, and aging. From our research there is significant evidence that iodine maintains homeostasis in reproductive, effected tissues and is responsible for breast tissue growth and development.

Pure gonadal dysgenesis with microscopic ovarian streak and gonadoblastoma.

A phenotypic female with an XY karyotype and no grossly demonstrable streak gonads is described. She had a microscopic focus of gonadoblastoma developing in a 3 X 2 mm area in the region of the ovarian vessels. The case stresses the importance of a careful search of the pelvic cavity in phenotypic females with a 46, XY karyotype.