Guidelines for the management of postoperative soiling in children with Hirschsprung disease.

Although most children with Hirschsprung disease ultimately achieve functional and comfortable stooling, some will experience a variety of problems after pull-through surgery. The most common problems include soiling, obstructive symptoms, enterocolitis, and failure to thrive. The purpose of this guideline is to present a rational approach to the management of postoperative soiling in children with Hirschsprung disease. The American Pediatric Surgical Association Hirschsprung Disease Interest Group engaged in a literature review and group discussions. Expert consensus was then used to summarize the current state of knowledge regarding causes, methods of diagnosis, and treatment approaches to children with soiling symptoms following pull-through for Hirschsprung disease. Causes of soiling after pull-through are broadly categorized as abnormalities in sensation, abnormalities in sphincter control, and "pseudo-incontinence." A stepwise algorithm for the diagnosis and management of soiling after a pull-through for Hirschsprung disease is presented; it is our hope that this rational approach will facilitate treatment and optimize outcomes.

Segmental colonic dilation is associated with premature termination of high-amplitude propagating contractions in children with intractable functional constipation.

BACKGROUND: Colonic dilation is common in children with intractable functional constipation (FC). Our aim was to describe the association between segmental colonic dilation and colonic dysmotility in children with FC. METHODS: We performed a retrospective study on 30 children with intractable FC (according to the Rome III criteria) who had undergone colonic manometry and contrast enema within a 12-month time period. Colonic diameter was measured at 5 cm intervals from the anal verge up to the splenic flexure. Moreover, the distance between the lateral margins of the pedicles of vertebra L2 was measured to provide a ratio (colonic diameter or length/distance between the lateral margins; "standardized colon size" [SCS]). All manometry recordings were visually inspected for the presence of high-amplitude propagating contractions (HAPCs); a parameter for colonic motility integrity. The intracolonic location of the manometry catheter sensors was assessed using an abdominal X-ray. KEY RESULTS: Colonic segments with HAPCs had a significantly smaller median diameter than colonic segments without HAPCs (4.08 cm vs 5.48 cm, P<.001; SCS 1.14 vs 1.66, P=.001). Children with prematurely terminating HAPCs had significantly larger SCS ratios for colonic diameter than children with fully propagating HAPCs (P=.008). SCS ratios for the length of the rectosigmoid and the descending colon and the SCS ratio for sigmoid colon diameter were significantly larger in children with FC compared to a previously described normative population (P<.0001, P<.0001 and P=.0007 respectively). CONCLUSIONS & INFERENCES: Segmental colonic dilation was associated with prematurely terminating HAPCs and may be a useful indicator of colonic dysmotility.

Rectal atresia and anal stenosis: the difference in the operative technique for these two distinct congenital anorectal malformations.

Rectal atresia and anal stenosis are rare forms of anorectal malformations. The aim of the definitive surgical repair in such cases is to preserve the anal canal, the dentate line, and the sphincter complex. We present a case of rectal atresia and anal stenosis to demonstrate the differences in the operative repair. The techniques described leave the anterior wall of the very distal anal canal untouched in both rectal stenosis and anal atresia; however, the dissection of the rectum differs. The atretic rectum in rectal atresia is mobilized and sutured to the anal canal circumferentially. In anal stenosis, the posterior rectum is mobilized in the form of rectal advancement, and the posterior 180° is anastomosed directly to the skin (as in a standard PSARP) with preservation of the anal canal as the anterior 180° of the final anoplasty. These patients have an excellent prognosis for bowel control and fecal continence, and therefore, complete mobilization and resection of the anal canal must be avoided.

The Gonzalez hernia revisited: use of the ischiorectal fat pad to aid in the repair of rectovaginal and rectourethral fistulae.

INTRODUCTION: During the development of the posterior sagittal approach to anorectal malformations a vital technical challenge was a precise midline dissection, which if off, allowed for the ischiorectal fat pad to bulge into the wound. This occurrence became affectionately known as a "Gonzalez hernia", after a trainee of Dr Pena's (and a co-author of this paper). We describe here an innovative use of the ischiorectal fat pad to aid in the repair of acquired rectovaginal and rectourethral fistulae. METHODS: Patients with recurrent vaginal or urethral fistulae were selected for review. The ischiorectal fat pad was deliberately mobilized (via a posterior sagittal or transanal approach) and used to buttress the repair of the posterior vagina or urethra. RESULTS: The ischiorectal fat pad technique was used in 9 patients. All had an acquired fistula (6 rectovaginal fistula, 3 rectourethral fistulas). We used the posterior sagittal approach in 7 and in 2 the transanal approach. Six patients had had at least two prior attempts at fistula repair. Six patients had a stoma, and 3 did not. There were no recurrences in greater than six month follow-up. DISCUSSION: The ischiorectal fat pad is easily visualized and mobilized, either via a posterior sagittal or transanal approach, providing excellent coverage with native, well-vascularized tissue, in an area that is difficult to heal. It is an excellent option for recurrent rectovaginal and rectovaginal fistulae and may have other additional creative applications.

Minimally invasive treatment of fecal incontinence and constipation in children.

The capacity for voluntary bowel movements and thus fecal incontinence may be limited in children born with anorectal anomalies and Hirschsprung's disease, as well as for many patients with spinal problems. Some of these patients have severe constipation which if not properly managed causes overflow pseudoincontinence and some have true fecal incontinence. For patients with anorectal malformations and those with idiopathic constipation with overflow pseudoincontinence, disimpaction, followed by an aggressive laxative regimen, often makes them continent, i.e. capable of having voluntary bowel movements. Surgical resection of a dilated rectosigmoid can dramatically reduce or eliminate these patients' daily laxative requirement, and improve their quality of life. For patients with true fecal incontinence, a bowel management program with a daily enema allows them to be kept artificially clean. For these patients, a surgical procedure whereby the daily enema is given antegrade is ideal, but it is the enema itself not its route which is the key to success. It is vital for the clinician to distinguish between these groups. Their initial presentations are quite similar, i.e. "fecal incontinence" or soiling but the treatments and surgical options differ dramatically. Much of what we have learned in the care of pediatric fecal incontinence can be extrapolated to adults.

Variability of inguinal hernia surgical technique: A survey of North American pediatric surgeons.

BACKGROUND/PURPOSE: The tradition of learning from mentors is a unique aspect of surgical training. With this in mind, the authors sought to document our roots by analyzing the technical variability of how pediatric surgeons perform their most frequent operation, the inguinal hernia, and compare these data with the original description by Drs William Ladd and Robert Gross. METHODS: A survey compiling the operative steps of an inguinal hernia repair as well as several key clinical situations involving hernias was mailed to pediatric surgeons in North America. These results then were compared with the original inguinal hernia technique by Drs Ladd and Gross. Results are recorded as the percent who concurred with their original description. RESULTS: A total of 447 of 640 (70%) surveys were returned. Geneologic data show that 81% of surgeons' hernia lineage could be traced to Drs Ladd and Gross. When compared with all respondents, Drs Ladd and Gross' hernia repair steps included incising Scarpa's fascia (61%), defining the external ring by pushing down with retractors (34%), incising the external oblique with scissors (18%), identifying the ileoinguinal nerve (81%), cleaning one underside of the external oblique (22%), bluntly spreading the cremasteric fibers (90%), elevating the sac with sharp dissection of the vessels (53%), opening the sac and inserting the forefinger into it (0%), bluntly dissecting the sac with forefinger and gauze (0%), ligating the sac with single ligature (22%) without twisting it (34%), leaving the distal sac untouched other than to drain fluid (78%), not inspecting the testicle (79%), performing a formal floor repair bringing external and internal oblique down to Poupart's ligament (10%), tightening the internal ring in both boys and girls (19% and 41%), using no local anesthetic (14%), closing Scarpa's fascia (94%), closing the skin with interrupted subcuticular sutures (49%), covering the incision with Collodion (48%), using the Stiles' dressing (0%), and only exploring the contralateral side if a hernia is suggested by history or physical examination (87% for boys, 60% for girls). The various other options surgeons use for their technique and their management decisions also are described. CONCLUSIONS: There is significant variability in the way pediatric surgeons perform inguinal herniorraphy. The differences from Drs Ladd and Gross' original description likely result from evolving techniques, experiences, and analysis of outcomes.

A prospective, randomized trial of BiPAP in severe acute congestive heart failure.

Noninvasive positive pressure ventilation has been found to be efficacious in the setting of acute respiratory failure, specifically in chronic obstructive pulmonary disease exacerbations. Its use in congestive heart failure (CHF) is less well established. Additionally, it has been reported that there is an increase in acute myocardial infarction (AMI) rate with the use of bilevel positive pressure ventilation (BiPAP) in CHF patients. This study examined whether BiPAP decreases the intubation rate or improves cardiopulmonary parameters in severe CHF patients compared to high flow O(2) by mask (MASK), and whether there is an increase in AMI rate with the use of BiPAP. A prospective, randomized clinical trial at a county hospital teaching Emergency Department was conducted by enrolling 38 patients who were in severe CHF. Patients were randomized to receive either BiPAP or MASK in addition to adjunct therapy. Age and gender were not different between the groups. Heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, and pulse oximetry all showed no significant difference in change over time between groups, but there was a significant change over time within groups. Arterial pH, pCO(2), and pO(2) also showed no significant difference in change over time between groups, but there was a significant change over time within groups. The intubation rate for BiPAP was 23.8% (5) vs. MASK at 41.2% (7). The AMI rate was 19% (4) in the BiPAP group and 29.4% (5) in the MASK group. No true differences were detected between groups for increased oxygenation or a reduction in intubation rate. An increase in AMI rate with BiPAP was not found in this study as previously reported. This study provides support for a larger clinical trial assessing the safety and efficacy of BiPAP in acute CHF.

Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized trial of ultrasound in trauma.

OBJECTIVE: There is a paucity of evidence demonstrating that emergency department (ED) ultrasound changes clinical practice in trauma patients. We hypothesized that the presence of ultrasound would affect clinical decision making as evidenced through abdominal computed tomographic (CT) scan use in blunt multiple trauma patients. METHODS: This study used a prospective randomized format in an urban county ED with Level II trauma center status (ED census, 72,000 patients per year). Participants were patients with multiple blunt injuries meeting trauma center triage criteria. Patients were randomized to receive either abdominal ultrasound or no ultrasound (control) during initial ED resuscitation. The primary outcome variable was use of abdominal CT scan in patients with and without ultrasound. RESULTS: Two hundred eight patients were enrolled. The mean age was 40 +/- 18 years, and 62% were men. Mechanism of injury was motor vehicle crash, 56%; automobile versus pedestrian, 18%; motorcycle crash, 16%; falls, 10%; and other, 10%. One hundred four ultrasound and 104 control patients were analyzed. There were no apparent differences between ultrasound and control groups in demographics, injury type, or Injury Severity Score. Fifty-four of 104 (52%) of the control group received abdominal CT scans versus 37 of 104 (36%) abdominal CT scans for the ultrasound group; mean difference in proportions was 15.9 (p < 0.01; 95% confidence interval, 2.6-29.1). CONCLUSION: In this trial, the routine use of abdominal ultrasound in the evaluation of patients with multiple blunt injuries resulted in significantly fewer abdominal CT scans being obtained. A larger trial is needed to more clearly define the clinical and financial impact of ultrasound in the management of blunt abdominal trauma.

Can paramedics using guidelines accurately triage patients?

STUDY OBJECTIVE: We determine whether paramedics, using written guidelines, can accurately triage patients in the field. METHODS: This prospective, descriptive study was conducted at an urban county emergency medical services (EMS) system and county hospital. Paramedics triaged patients, for study purposes only, according to 4 categories: (1) needing to come to the emergency department by advanced life support (ALS) transport, (2) needing to come to the ED by any transport, (3) needing to see a physician within 24 hours, or (4) not needing any further physician evaluation. Medical records that provided patient treatment information to the point of ED disposition were subsequently reviewed (blinded to the paramedic rating) to determine which of the categories was appropriate. The protocol of the EMS system of the study site dictates that all patients should be transported except for those who refuse care and leave against medical advice. Only transported patients were included in the present study. Fifty-four paramedics triaged 1,180 patients. RESULTS: Mean patient age was 43.4+/-17 years; 62.0% were male. Paramedics rated 1,000 (84.7%) of the patients as needing to come to the ED and 180 (15.3%) as not needing to come to the ED. Ratings according to triage category were as follows: 804 (68.1%) category 1, 196 (16.6%) category 2, 148 (12.5%) category 3, and 32 (2.7%) category 4. Seven hundred thirty-six (62.4%) patients were discharged, 298 (25.3%) were admitted, 90 (7.6%) were transferred, 36 (3.1%) left against medical advice, and 20 (1.7%) died. The review panel determined that 113 (9.6%) patients were undertriaged; 55 (48.7%) of these patients were misclassified because the paramedics misused the guidelines. Ninety-nine patients (8.4% of the total sample) were incorrectly classified as not needing to come to the ED. This represented 55% of the patients (99/180) categorized as 3 or 4 by the paramedics. Fourteen patients (1.2% of total) were incorrectly classified as category 4 instead of 3. Of the 113 undertriaged patients, 22 (19.6%) were admitted, 86 (76.1%) were discharged, and 4 (3.5%) were transferred. CONCLUSION: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field.

Modifying a standard industry clinical trial consent form improves patient information retention as part of the informed consent process.

OBJECTIVE: Informed consent is a required part of clinical research. Industry consent forms may be complex and difficult to understand. A comparison was performed between a standard, industry consent form (IF) and a modified, shortened version of the same form (MF) to determine which allows the patient to retain more information in the immediate postconsent period. METHODS: This was a prospective, randomized study performed in an urban, county teaching emergency department (ED). A convenience sample (based on the availability of one of two research assistants being present in the ED) of 100 patients with a history of asthma seen in the ED were enrolled. After reading the consent form, 50 MF and 50 IF patients were given a postconsent test to determine how much information was retained. Mean differences in test scores between the IF and MF were determined. RESULTS: The population had a mean age (+/-SD) of 39.4 +/- 12.1 years (range 18-80); 52% were female. The overall score for the study population was 9.6 (+/-2.0), range 2-12 (maximum 12). The MF score was 10.6 (+/-1.4) vs the IF score of 8.6 (+/-2.1); mean difference = 2.0 (95% CI = 1.3 to 2.7, p < 0.0001). The MF group had significantly more correct answers than the IF group with the following questions (MF%, IF%; mean difference in proportions with 95% CIs): purpose (96, 70; 26, 95% CI = 12 to 40); randomization (78, 44; 34, 95% CI = 16 to 52); study duration (94, 70; 24, 95% CI = 10 to 38); risks (92, 74; 18, 95% CI = 4 to 32); benefits (94, 78; 16, 95% CI = 3 to 29); alternative treatments (88, 70; 18, 95% CI = 2 to 34); confidentiality (98, 88; 10, 95% CI = 0.2 to 20); and voluntary participation (74, 54; 20, 95% CI = 2 to 38). Adverse event compensation had the poorest correct rate (54, 38; 13, 95% CI = -6 to 32). Subsequently, after taking the postconsent test, 98% wrote that they read the entire MF, while only 68% wrote that they read the entire IF (mean difference in proportions 30%, 95% CI = 17% to 43%). CONCLUSIONS: Compared with an industry consent form, a shortened version, focusing on Food and Drug Administration and Department of Health and Human Services informed consent guidelines, allowed patients to retain more information in the immediate postconsent period.

The efficacy of esmolol versus lidocaine to attenuate the hemodynamic response to intubation in isolated head trauma patients.

OBJECTIVE: To assess the effect of esmolol vs lidocaine to attenuate the detrimental rise in heart rate and blood pressure during intubation of patients with isolated head trauma. METHODS: This was a prospective, double-blind, randomized study, performed at an urban, county teaching emergency department. Participants were 30 patients with isolated head trauma. Each underwent a standardized intubation protocol including esmolol or lidocaine, both at 2 mg/kg. RESULTS: Esmolol was used in 16 patients and lidocaine in 14. Mechanisms of injury included 12 assaults, 6 motor vehicle collisions, 6 falls, 4 auto-vs-pedestrian crashes, and 2 bicycle incidents. Mean ethanol level was 0.116+/-0.133 SD (range 0-0.482). Mean Glasgow Coma Scale (GCS) score was 7.9+/-4.0 SD. Cranial computed tomography (CT) hemorrhagic findings included 9 subdural/epidural hematomas, 6 cortex hemorrhages, and 2 multi-hemorrhages. Eleven patients received surgical intervention: 9 patients received a craniotomy, and 2 a ventricular catheter. The 2-minute time interval around intubation was used to assess each drug's efficacy. The mean difference change between groups for heart rate was 4.0 beats/min (95% CI = -17.7 to 9.7 beats/min), for systolic blood pressure was 1.3 mm Hg (95% CI = -27.8 to 30.4 mm Hg), and for diastolic blood pressure was 2.6 mm Hg (95% CI = -27.1 to 21.9 mm Hg). The power of this study was 90% to detect a 20-beat/min difference in heart rate, a 35-mm Hg difference in systolic blood pressure, and a 20-mm Hg difference in diastolic blood pressure. CONCLUSIONS: Esmolol and lidocaine have similar efficacies to attenuate moderate hemodynamic response to intubation of patients with isolated head trauma.

Clinical evaluation of the first medical whole blood, point-of-care testing device for detection of myocardial infarction.

BACKGROUND: Validation of whole blood, point-of-care testing devices for monitoring cardiac markers to aid clinicians in ruling in and ruling out myocardial infarction (MI) is necessary for both laboratory and clinical acceptance. METHODS: This study evaluated the clinical diagnostic sensitivity and specificity of the First Medical Cardiac Test device operated by nursing and laboratory personnel that simultaneously measures cardiac troponin I (cTnI), creatine kinase (CK) MB, myoglobin, and total CK on the Alpha Dx analyzer in whole blood for detection of MI. Over a 6-month period, 369 patients initially presenting to the emergency department with chest pain were evaluated for MI using modified WHO criteria. Eighty-nine patients (24%) were diagnosed with MI. RESULTS: In whole blood samples collected at admission and at 3- to 6-h intervals over 24 h, ROC curve-determined MI decision limits were as follows: cTnI, 0.4 microgram/L; CKMB, 7.0 microgram/L; myoglobin, 180 microgram/L; total CK, 190 microgram/L. Based on peak concentrations within 24 h after presentation, the following sensitivities (+/- 95% confidence intervals) were found: cTnI, 93% +/- 5.5%; myoglobin, 81% +/- 9.7%; CKMB, 90% +/- 6.3%; total CK, 86% +/- 7.5%. Sensitivities were maximal at >90% for both cTnI and CKMB at >12 h in MI patients, without differences between ST-segment elevation and non-ST-segment elevation MI patients. CONCLUSIONS: The First Medical point-of-care device provides cardiac marker assays that can be used by laboratories and clinicians in a variety of hospital settings for ruling in and ruling out MI.

Are diagnostic testing and admission rates higher in non-English-speaking versus English-speaking patients in the emergency department?

STUDY OBJECTIVE: To determine whether non-English-speaking patients who present to an emergency department have more diagnostic tests ordered, higher admission rate, and longer length of stay in the ED than English-speaking patients for 2 common complaints, chest pain and abdominal pain. METHODS: This prospective, comparative, observational study was conducted at a public hospital ED. The study group was composed of 324 patients (172 non-English-speaking and 152 English-speaking) presenting with nontraumatic abdominal pain (148) or chest pain (176). The main outcome measures were admission rates, length of stay in the ED, and diagnostic test and procedure ordering. RESULTS: The mean age for the total sample was 45.8+/-15.5 years (range 14 to 87 years); 45.4% (147/324) of the patients were male. For the non-English-speaking patients, the language distribution was Spanish (31.0%), other (9.0%), Cantonese (5.9%), Hindi (2.5%), Mien (1.5%), Arabic (1.9%), Russian (0.9%), Mandarin (0.6%), and Korean (0.3%). The admission rate was 37.8% for English-speaking patients versus 42.8% for non-English-speaking patients in the total sample (mean difference in proportions 5%, 95% confidence interval [CI] -6% to 16%; 34.2% for English-speaking versus 9.1% for non-English-speaking patients presenting with abdominal pain, mean difference in proportions 5%, 95% CI -11% to 21%) and 40.9% for English-speaking versus 45.8% for non-English-speaking patients presenting with chest pain (mean difference in proportions 5%, 95% CI -10% to 20%). Power was 80% to detect a 15% difference in admission rates at an alpha value of.05. There was no statistically significant difference in ordering of diagnostic tests between the non-English-speaking and English-speaking patients with chest pain. Non-English-speaking patients with abdominal pain had 5 tests ordered more often than English-speaking patients. The mean difference in proportions (with 95% CIs) for these tests were CBC count 18.4% (5.1% to 31.7%), serum electrolytes 17.9% (3.8% to 31. 9%), urinalysis 20.0% (4.5% to 35.6%), ECG 23.4% (8.6% to 38.2%), and abdominal computed tomographic scan 10.9% (1.0% to 20.8%). There was no statistically significant difference between English-speaking and non-English-speaking patients for ED length of stay in the total sample (mean difference 29.8, 95% CI -37.5 to 97.1 minutes; for the abdominal pain subgroup, mean difference 19.5, 95% CI -74.6 to 113.5 minutes; and for the chest pain subgroup, mean difference 37.9, 95% CI -58.0 to 133.8 minutes). CONCLUSION: Significantly more tests are ordered for non-English-speaking patients with abdominal pain in the ED, including 3 times as many abdominal computed tomographic scans. There is no increase in test ordering with non-English-speaking patients with complaints of chest pain in the ED. When comparing English-speaking and non-English-speaking patients, there were no statistically significant differences in admission rates or length of stay in the ED.

Prevalence of cardiac valve abnormalities in afebrile injection drug users.

OBJECTIVES: To determine the prevalence of occult valvular pathology in afebrile injection drug users (IDUs) compared with an afebrile, non-IDU population. To characterize the type of valvular pathology present in light of current recommendations regarding periprocedural antibiotic prophylaxis against endocarditis. METHODS: This was a comparative, cross-sectional study involving a convenience sample of 98 patients with a history of injection drug use, and 99 non-IDU patients presenting to a large urban ED. Patients were excluded if they had one or more of the following: a history of cardiac valve abnormality, a history of endocarditis, fever on presentation, or a cardiac murmur. Data were collected that included demographics, medical history, and details of injection drug use. Transthoracic echocardiography (echo) was performed on each subject in the ED, and read in a blinded fashion by a single board-certified cardiologist. RESULTS: Among 98 IDUs and 99 non-IDUs, 12% of the IDUs had aortic valve thickening, compared with 5.1% of the non-IDUs (99% CI for difference of 7.8% = -3.0% to 18.6%). Forty-four percent of the IDUs had mitral valve thickening, compared with 25% of the non-IDUs (99% CI for difference of 18.3% = 0.9% to 35.7%). Eleven percent of the IDUs vs 1% of the non-IDUs had tricuspid valve thickening (99% CI for difference of 10.4% = 1.6% to 19.2%). No patient had pulmonic valve thickening. Six percent of the IDUs vs 0% of the non-IDUs had mitral annulus thickening (99% CI for difference of 6.3% = -0.1% to 12.8%). Twelve percent of the IDUs vs 3% of the non-IDUs had mitral chordae thickening (99% CI for difference of 9.5% = -0.4% to 19.4%). Tricuspid chordae thickening was recorded in 2% of the IDUs vs 0% of the non-IDUs (99% CI for difference of 2.1% = -1.7% to 6.0%). Most important, the prevalence of valvular regurgitation was small, and evenly distributed in the two groups. No valvular vegetations were seen. CONCLUSION: Both non-IDUs and IDUs have occult valvular pathology. There is an increased prevalence in IDUs of tricuspid and mitral valve thickening. The prevalence of valvular regurgitation, a reported indication for periprocedural antibiotic prophylaxis, was small and the affected valves were not statistically different between the two groups. These findings question the selected routine use of antibiotic prophylaxis in IDU patients undergoing invasive procedures.

Serial use of bedside CKMB/myoglobin device to detect acute myocardial infarction in emergency department chest pain patients.

A qualitative bedside device (Spectral Diagnostics, Toronto, Canada) for CKMB and myoglobin (MYOG) detection was evaluated in emergency department (ED) patients with chest pain to determine performance characteristics. At presentation (0 h) and at three hours (3 h), serum was analyzed in the ED with results considered positive if either 0-h or 3-h CKMB or MYOG bands were visible. The results were compared with the diagnosis of myocardial infarction (MI) per hospital discharge diagnosis (n = 132, 87%) or telephone follow-up (n = 19; 1 patient lost to follow-up). Of 151 study patients, 30 (20%) were diagnosed with MI; all were admitted to hospital. On electrocardiogram (EKG), 17 (57%) MI patients had ST-segment elevation. At 0-h, 26 of 30 (87%) MI patients were positive for CKMB/MYOG. By 3 h, 21 of 23 (91%) MI patients were positive for CKMB/MYOG; 7 MI patients were already admitted to hospital. Combining 0-h and 3-h results, the device sensitivity for MI was 93% (28/30) with specificity of 54%. Combining device results plus diagnostic EKG, sensitivity was found to be 100% (30/30). If the device result was positive, then the odds ratio for having an ischemic complication was 6.5. We conclude that the CKMB/MYOG device identified most MI patients at ED presentation and 3 h later. Combining device results with EKG detected all MI patients in the ED.

Effect of continuously nebulized ipratropium bromide plus albuterol on emergency department length of stay and hospital admission rates in patients with acute bronchospasm. A randomized, controlled trial.

OBJECTIVE: To compare the outcome of patients with acute bronchospasm treated with continuously nebulized albuterol plus ipratropium bromide vs albuterol alone. SETTING: The Emergency Department (ED) at the University of California San Francisco Medical Center. PARTICIPANTS: Patients > or = 18 years old presenting to the ED with acute bronchospasm and a peak expiratory flow rate (PEFR) of < 70% predicted. INTERVENTIONS: This was a prospective, randomized, double-blind, placebo-controlled trial. Subjects were treated with either a combination of albuterol (10 mg/h) plus ipratropium bromide (1.0 mg/h) or albuterol alone via continuous nebulization for a maximum of 3 h. Vital signs, Borg dyspnea score, and PEFR were recorded hourly. Primary outcome measures were improvement in PEFR, hospital admission rates, and length of stay in the ED. MEASUREMENTS AND RESULTS: Data was analyzed for 67 subjects. The mean age (-/+ SD) was 47.5+/-18.8, and mean initial PEFR was 44.8+/-12.5% of predicted. The median length of stay for all subjects was 225 min, and 31% of all subjects were admitted. Patients given combination therapy averaged 6.3% greater improvement in PEFR compared with control subjects (95% confidence interval [CI], -15% to 27%. The odds ratio for admission with combination therapy was 0.88 (95% CI, 0.28 to 2.8). The median length of stay in the ED was 35 min shorter for those receiving combination treatment (210 vs 245 min; p = 0.03). However, when adjusted for initial PEFR, there was no statistically significant difference (p = 0.26). CONCLUSION: Although the direction of all three outcome measures favored combination therapy, there was no statistically significant difference between ED patients with acute bronchospasm receiving continuous albuterol plus ipratropium bromide and those receiving albuterol alone.

Intussusception in adults.

Intussusception in adults is a rare entity that it is generally caused by definable intraluminal pathology. We report four cases of adult intussusception caused by lymphoma of the terminal ileum (2), an inflamed appendix (1) and a mucosal polyp (1). All presented with a variety of nonspecific and chronic symptoms, including abdominal pain, nausea and vomiting, consistent with partial small bowel obstruction. Only one patient had palpable masses in the abdomen. The most useful diagnostic radiological method was computed tomography (CT), which showed "target" lesions. The presence of the characteristic "target" lesion may obviate the need for further studies, including a barium enema. As in the cases reported here, treatment involves more than simple reduction; surgical resection is usually indicated.