Fever in the clinical diagnosis of acute pyelonephritis.

Acute pyelonephritis is a clinical syndrome that can be confused with other conditions. To investigate this problem, a retrospective cohort study was conducted using two mutually exclusive sets of clinical criteria for acute pyelonephritis in women 15 years of age or older who presented to the emergency department of a university hospital. All patients had pyuria, and one group had documented fever (temperature of > or = 37.8 degrees C) while the other group had a temperature of < 37.8 degrees C but had other evidence of possible upper tract infection. The study cohort was comprised of 103 febrile and 201 afebrile patients. Afebrile hospitalized patients were ultimately found to have another diagnosis more often than were the febrile hospitalized patients (35% v 7%; P = .02), and the afebrile nonhospitalized patients were more likely to have another diagnosis than were the febrile nonhospitalized patients (13% v 0%; P = .004). Other diagnoses included cholecystitis, pelvic inflammatory disease, and diverticulitis. The positive predictive value of the definition of pyelonephritis in the febrile group was 0.98, and it was 0.84 for the afebrile group. Physicians examining patients with clinical evidence of acute pyelonephritis but without objective fever should be alert for alternative diagnoses.

Multiphasic anaphylaxis: an uncommon event in the emergency department.

OBJECTIVE: To determine the rate of clinically significant recurrence of symptoms in patients treated for anaphylaxis in the ED. METHODS: Retrospective chart review of out-of-hospital, ED, and hospital records over 4.5-year period (July 1991 to December 1995) at a university hospital ED with an annual patient volume of 60,000. Subjects were ED anaphylaxis patients with > or = 2 of the following 3 organ systems involved: cutaneous, respiratory, and cardiovascular. The major outcome criterion was recurrence of symptoms after ED release. Recurrences were sought at the primary treatment hospital and at surrounding hospitals (radius of 75 miles from the primary institution) within a 7-day period from the initial visit. Review of the state death registry also was made to verify the absence of out-of-hospital deaths. RESULTS: The medical records of 1,261 allergic reaction patients were reviewed, with 67 (5.3%) cases of anaphylaxis identified. Symptoms and signs in patients during the ED phase included: dyspnea, 42 (63%); pruritus, 38 (57%); emesis, 27 (41%); throat/chest tightness, 25 (37%); orthostatic complaints, 12 (18%); urticaria, 47 (70%); circulatory shock, 32 (48%); upper airway angioedema, 7 (33%); stridor, 11 (16%); and bronchospasm, 20 (30%). Of the 67 patients, 93% had immediate resolution and remained asymptomatic for a mean time of 4.2 hours in the ED. Protracted reaction occurred in 5 cases (3 using beta-adrenergic blocking agents). For 19 (28%) patients admitted to hospital, the mean hospital length of stay was 63 hours. Only 2 (3%) recurrent cases were identified, both manifested solely by urticaria. CONCLUSION: Recurrent anaphylactic reactions were rare, occurring in 3% of cases and without life threat in this patient population. Selective outpatient management of patients with severe anaphylactic reactions that promptly respond to therapy with complete, rapid resolution may be reasonable. Further study of this medical emergency is required to develop criteria to guide the choice of an outpatient disposition.

Treatment of out-of-hospital supraventricular tachycardia: adenosine vs verapamil.

OBJECTIVE: To compare the use of adenosine and the use of verapamil as out-of-hospital therapy for supraventricular tachycardia (SVT). METHODS: A period of prospective adenosine use (March 1993 to February 1994) was compared with a historical control period of verapamil use (March 1990 to February 1991) for SVT. Data were obtained for SVT patients treated in a metropolitan, fire-department-based paramedic system serving a population of approximately 1 million persons. Standard drug protocols were used and patient outcomes (i.e., conversion rates, complications, and recurrences) were monitored. RESULTS: During the adenosine treatment period, 105 patients had SVT; 87 (83%) received adenosine, of whom 60 (69%) converted to a sinus rhythm (SR). Vagal maneuvers (VM) resulted in restoration of SR in 8 patients (7.6%). Some patients received adenosine for non-SVT rhythms: 7 sinus tachycardia, 18 atrial fibrilation, 7 wide-complex tachycardia (WCT), and 2 ventricular tachycardia; no non-SVT rhythm converted to SR and none of these patients experienced an adverse effect. Twenty-five patients were hemodynamically unstable (systolic blood pressure < 90 mm Hg), with 20 receiving drug and 13 converting to SR; 8 patients required electrical cardioversion. Four patients experienced adverse effects related to adenosine (chest pain dyspnea, prolonged bradycardia, and ventricular tachycardia). In the verapamil period, 106 patients had SVT: 52 (49%) received verapamil (p < 0.001, compared with the adenosine period), of whom 43 (88%) converted to SR (p = 0.11). Two patients received verapamil for WCT; neither converted to SR and both experienced cardiovascular collapse. VM resulted in restoration of SR in 12 patients (11.0%) (p = 0.52). Sixteen patients were hemodynamically unstable, with 5 receiving drug (p = 0.005) and 5 converting to SR; 9 patients required electrical cardioversion (p = 0.48). Four patients experienced adverse effects related to verapamil (hypotension ventricular tachycardia, ventricular fibrillation). Recurrence of SVT was noted in 2 adenosine patients and 2 verapamil patients in the out-of-hospital setting and in 23 adenosine patients and 15 verapamil patients after ED arrival, necessitating additional therapy (p = 0.48 and 0.88, for recurrence rates and types of additional therapies, respectively). Hospital diagnoses, outcomes, and ED dispositions were similar for the 2 groups. CONCLUSION: Adenosine and verapamil were equally successful in converting out-of-hospital SVT in patients with similar etiologies responsible for the SVT. Recurrence of SVT occurred at similar rates for the 2 medications. Rhythm misidentification remains a common issue in out-of-hospital cardiac care in this emergency medical services system.

Hospital and flight program reimbursement for patients transferred by helicopter.

To determine the reimbursement status of a helicopter aeromedical program and its sponsoring hospital, the financial records of all patients transported by a university hospital-based helicopter aeromedical service during a one-year period of time were examined. The flight program was able to collect only 43% of patient charges, recouping only 24% of its operating costs. The hospital collected 57% of its total charges to patients transported by the helicopter aeromedical program. Reimbursers paying on a per-diem basis comprised 36% of the payors and had collection rates of 50% and 10% for the hospital and flight program, respectively. Cost-based insurers constituted 20% of the payors, provided 44% of program revenue, and had collection rates of 92% for the hospital and the flight program. If cost-based payors had reimbursed on rates similar to the per-diem payors, the hospital would have recovered only 49% of its charges and the flight program, would have recovered only 26% of its charges, recouping only 15% of its operating costs. In conclusion, reimbursement for helicopter aeromedical services and for the care provided in aeromedically transferred patients is poor. Sponsoring institutions are consequently subjected to significant financial stress that possibly challenges the fiscal viability of some programs.

Out-of-hospital provider use of epinephrine for allergic reactions: pilot program.

OBJECTIVE: To describe experience with an out-of-hospital provider program for the recognition and field management of allergic reactions by advanced life support (ALS) and basic life support (BLS) providers. METHODS: Data sheets completed between June 1, 1988, and August 31, 1993, and records from receiving sites (physicians' offices or EDs) were reviewed for information regarding the presentation of the allergic reaction, the time course and treatment provided out of hospital, and the clinical outcome at the receiving health care facility. RESULTS: Thirty-seven data sheets were completed during the study period. Fourteen (38%) of the providers were BLS providers. The epinephrine was supplied from the emergency medical services (EMS) provider's personal kit in 35% of the cases, from an EMS vehicle in 57% of the cases, and by the patient in 8% of the cases. Availability of the kits allowed administration of epinephrine prior to the arrival of the first EMS vehicle in 41% of the instances and prior to physician on-line medical command in 65% of all the instances (predominantly by BLS providers). Overall, 77% of the patients experienced alleviation of their symptoms of respiratory difficulty, swelling, or rash after epinephrine administration, while 20% were unchanged and 3% worsened. All patients receiving epinephrine had an ED diagnosis of allergic reaction, and no adverse event was encountered on follow-up of the patients treated. CONCLUSIONS: Severe allergic reactions can be reliably identified and safely managed by out-of-hospital providers, including BLS providers. Providing personal anaphylactic treatment kits and increasing the pool of providers trained to manage allergic reactions (including BLS providers) can often decrease the time to treatment.

Abdominal wall hematoma in an elderly man.

This report describes an abdominal wall hematoma that occurred in an unusual location and resulted in significant hemorrhage in a generally healthy individual. Angiography-directed therapeutic embolization was halted due to an embolic complication. Evidence of continued hemorrhage led to surgical intervention. After a right flank incision was made, fresh blood as well as approximately 1 L of clotted blood were evacuated from the abdominal wall. After resection of a portion of the twelfth rib, the twelfth intercostal artery was noted to be actively bleeding and was ligated. This operative procedure controlled the patient's blood loss. The etiologies, presenting findings, diagnostic studies, and modes of therapy reported for abdominal wall hematomas are reviewed.

ED management of acute pyelonephritis in women: a cohort study.

Various treatment strategies are currently used in the management of acute pyelonephritis, with some patients being treated as inpatients and others as outpatients. To better describe the clinical course of patients with this condition and the management strategies of physicians treating these patients, a retrospective cohort study of febrile nonpregnant women presenting to the emergency department with clinical evidence of acute pyelonephritis was conducted. Acute pyelonephritis was defined as infected urine (> or = 7 white blood cells/high-power field and/or urine culture with > or = 10(4) colony-forming units [CFU]/mL) and fewer (> or = 37.8 degrees C) without other source. Between October 1990 and September 1991, 28 hospitalized and 83 nonhospitalized patients satisfied these criteria. Data were abstracted from hospital charts, and clinical outcomes were determined from chart reviews and telephone or mailed questionnaires. The hospitalized patients were significantly older (odds ratio [OR] = 1.07), had higher temperatures (OR = 6.12), and were more likely to have diabetes (OR = 10.57), genitourinary tract abnormalities (OR = 10.53), and vomiting (OR = 12.17) than the nonhospitalized patients. Sixty-six (80%) of the nonhospitalized patients were treated with a single dose of parenteral antibiotic (usually gentamicin or ceftriaxone) before discharge on oral antibiotics. Seventy-one (86%) were treated with oral trimethoprim-sulfamethoxazole. Follow-up was obtained for 75 (90%) of the nonhospitalized patients. Nine (12%) of the 75 returned because of symptoms of acute pyelonephritis, with 8 returning within 1 day of the initial visit. Seven of those returning were admitted. All responded to additional antibiotic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Reimbursement patterns in a hospital-based fixed-wing aeromedical service.

Reimbursement, expressed as a percentage of total charges recovered, was examined for inpatients transported by a university hospital-based, dedicated, fixed-wing aeromedical service between July 1, 1988 and June 30, 1990. A total of 410 patients were transported; account information was available for 404 patients (98%). Patients transported from in-state institutions (n = 174) had a hospital reimbursement rate of 53.3%, whereas the flight program recovered 46.1% of transportation charges. Patients transported from out-of-state institutions (n = 150) had a hospital reimbursement rate of 51.3%, whereas the flight program recovered 69.3% of charges. More patients referred from in-state sources were covered by Medicaid than from out-of-state sources (31% vs 11%), and less were covered by Medicare (17% vs 30%). Reimbursement for hospital charges was low for patients covered by Medicaid (44% for in-state and 16% for out-of-state), and Medicaid reimbursed no flight charges for either in-state or out-of-state patients. The flight program recovered 86.7% of charges for "triangle" flights, which transported patients between two hospitals other than the sponsoring institution (n = 80). The overall hospital reimbursement rate for inpatients was 70% during the study period. The flight program recovered 53.7% of its operating costs from payment of charges for transport services. Aeromedically transported patients may represent a financial "high-risk" group of patients for the sponsoring institution.

Aeromedical evacuation of rural victims of nontraumatic cardiac arrest.

STUDY OBJECTIVES: To determine if the deployment of a helicopter-borne nurse/paramedic team contributed to survival of victims of nontraumatic cardiac arrest in a rural setting. DESIGN: Retrospective chart review. SETTING: A university hospital-based helicopter aeromedical program serving a primarily rural region with a volunteer basic life support/advanced life support ground emergency medical services system. PARTICIPANTS: Victims of nontraumatic cardiac arrest, older than 15 years, in cardiac arrest at the time of request for air evacuation. MEASUREMENTS AND MAIN RESULTS: Eighty-four patients were identified who met the study inclusion criteria between January 1, 1986, and December 31, 1989. Basic life support care was always available before aeromedical crew arrival; advanced life support care was available in 58% of cases before helicopter arrival. Resuscitative efforts were terminated in the field in 55 cases; of 29 patients transported to the emergency department, only ten (12%) survived to hospital admission. Only one patient (1%) survived to hospital discharge; this patient was resuscitated by ground advanced life support providers before helicopter arrival. CONCLUSION: Despite providing improved availability of advanced life support care in some cases, deployment of aeromedical teams had a negligible effect on patient survival from nontraumatic cardiac arrest in a rural setting.

Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Cellulitis.

Most patients with cellulitis can be managed on an outpatient basis, frequently with a single dose of parenteral antibiotic followed by oral therapy. Cellulitis must first be differentiated from more serious soft tissue infections that require aggressive inpatient therapy and perhaps surgery. Patients with preexisting medical conditions, such as diabetes, need to be carefully followed if treated as outpatients.

Outpatient parenteral antibiotic therapy. Managemnt of serious infections. Part II: Amenable infections and models for delivery. Emergency department and urgent care center.

Two approaches to outpatient parenteral antibiotic therapy are commonly used in the emergency care setting. One is daily administration of a parenteral antibiotic followed by oral therapy if clinical response has been satisfactory. The other is administration of a single parenteral dose to initiate a course of oral therapy. Both treatment strategies have proved effective in preliminary studies.

Effects on sleep stages and EEG power density of different degrees of exercise in fit subjects.

In order to study the effects of exercise on sleep, 6 fit male subjects between 30 and 35 years of age were exposed to 4 conditions--sleep after a day with no running, sleep after a day with a moderate training run (15-20 km), the first night after an extremely exacting race (30 or 43 km), the second night after the race. All measurements were obtained in the respective homes of the subjects. The main effects of the race condition were a delay and decrease of REM sleep, an increase of stage 2 sleep and a weak decrease of SWS latency. Spectral analysis (FFT) of the EEG showed an increase of total power density as well as power in the delta band. The increase was significant also within SWS. By the second night all values had returned to baseline. The training run had virtually no effect on the sleep parameters although the values usually fell between baseline and race night values. Catecholamine excretion during the night and heart rate at bed-time and rising increased with increasing prior exertion. Subjective ratings showed no significant differences between the conditions. It was concluded that exercise effects mainly REM sleep, but although no SWS response was found in this age group, the increase of EEG power density after physical activity could lend some support to a hypothesized recovery theory.