Indication for hyperbaric oxygen treatment as a predictor of tympanostomy tube placement.

INTRODUCTION: Hyperbaric oxygen therapy (HBO2) has been utilized for many years for a multitude of disease entities. One commonly encountered side-effect is otic barotrauma. OBJECTIVE: To determine if patients with specific disease processes are at increased risk of requiring tympanostomy tubes during HBO2. METHODS: Data was obtained from Jan. 2000 to Dec. 2004, retrospectively. The requirement for tympanostomy tubes during a course of HBO2 was established. RESULTS: 325 met inclusion criteria. Fifteen percent of patients overall (95% CI= 11-19%) required tympanostomy tubes. Tubes were required in: 5% necrotizing soft tissue infection (p=0.33); 10% failed/threatened graft (p=0.39); 15% problem wounds; 17% chronic refractory osteomyelitis (CRO) (p=0.64); 22% soft tissue radionecrosis (STRN)/osteoradionecrosis (ORN) (p=0.02); 33% of crush injuries (p=0.10). Twenty-nine percent of nasopharyngeal radiation injury patients (p=0.001) and 10% of the non-nasopharyngeal radiation patients (p=0.36) received tympanostomy tubes. CONCLUSION: A significant increase in tympanostomy tubes were required in nasopharyngeal radiation injury patients.

The demographics of e-mail for emergency medicine research.

Escalating costs of research combined with increasing use of e-mail by emergency physicians (EP), justifies studying whether electronic surveying (ES) is a valid methodology for research. Our primary study object is to delineate the demographics of EP with e-mail. Secondary objectives are to ascertain ES response rates and to identify response bias between "individual" versus "bulk" e-mailings. The 1999 American College of Emergency Physicians Membership Guide identified a pool of e-mail addresses. Of the 1,752 EP surveyed, 1,386 (79%) had valid e-mail addresses and 574 responded. A response rate of 41% questions the validity of ES for research. Demographic data of EP regarding mean age (38.2 years); gender (82.4% men); title (86.8% MD); practice (87% ED); practice location (49.6% urban); training (56% EM residency); research participation (65.5%); screening e-mail (7%); is representative of EP overall. Finally, comparison of individual versus bulk e-mail to survey participants showed a 13.6% (5.5-21.7; 95% CI) improvement in overall response.

Triage nurse application of the Ottawa knee rule.

OBJECTIVE: To determine interobserver agreement between triage registered nurses (RNs) and emergency physicians (EPs) regarding indication for knee radiographs by applying the Ottawa knee rule (OKR) and individual components of the rule. METHODS: This was a prospective, observational study in a suburban, teaching emergency department. The study enrolled a convenience sample of patients aged >17 years with traumatic knee injuries less than one week old. Patients with prior knee surgery or distracting conditions were excluded. Before study initiation, the RNs and EPs were in-serviced in the OKR. Nurses and EPs independently examined each patient for OKR criteria, blinded to the other's assessment. Knee radiographs were ordered at the discretion of the EP and were interpreted by board-certified radiologists. All patients received follow-up with a structured telephone interview to identify any undetected fractures. Kappa was calculated for each component and the overall application of the OKR to assess interobserver agreement. RESULTS: Ninety-six patients were enrolled. The mean age was 39.6 +/- 18.7 years; 50% were male. Eight patients (8%) had knee fractures. Interobserver agreements between the RNs and EPs for individual components of the OKR were: age > or =55 years (kappa = 0.97); inability to weight bear (kappa = 0.51); inability to bend knee to 90 degrees (kappa = 0.52); fibular head tenderness (kappa = 0.45); and isolated patellar tenderness (kappa = 0.40). The EPs and RNs agreed with OKR criteria for x-ray 71% of the time (kappa = 0.41). CONCLUSIONS: The only criterion that resulted in almost perfect agreement between the RNs and EPs was patient age; agreement for the other four criteria and the overall decision to order x-rays was moderate.

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.