Erabulenols, inhibitors of cholesteryl ester transfer protein produced by Penicillium sp. FO-5637. II. Structure elucidation of erabulenols A and B

OBJECTIVES: To determine the risk for bacteremia, in the post-Haemophilus influenzae type b era, in a prospective cohort of well-appearing febrile children 3 to 36 months of age with no obvious source of infection; and to compare the predictive abilities of objective criteria in identification of children with occult pneumococcal bacteremia from those at risk. DESIGN: All children seen from 1993 through 1996, 3 to 36 months of age with a temperature of 39.0 degrees C or higher, no identified source of infection (except otitis media), and discharged to home were considered to be at risk for occult bacteremia and included in the study. SETTING: Urban pediatric emergency department. RESULTS: Of 199868 patient visits to the emergency department, 1911 children were considered to be at risk for occult bacteremia. Blood cultures were obtained from 9465 (79%). A total of 149 blood cultures contained pathogenic organisms, indicating a rate of occult bacteremia of 1.57% (95% confidence intervals: 1.32%-1.83%). White blood cell count and absolute neutrophil count were the best predictors for occult pneumococcal bacteremia. Using a white blood cell count cutoff value of 15 cells x 10(9)/L (sensitivity, 86%; specificity, 77%; and positive predictive value, 5.1%) would result in the treatment of approximately 19 nonbacteremic children for each bacteremic child treated. CONCLUSIONS: The prevalence of occult bacteremia in children 3 to 36 months old with temperatures of 39.0 degrees C or higher and no obvious source of infection is 1.6%. The white blood cell and absolute neutrophil counts are the most accurate predictors of occult pneumococcal bacteremia and when available should be used if presumptive antibiotic therapy is being considered.     

Frequency and yield of postoperative fever evaluation

OBJECTIVE: In women undergoing major gynecologic surgery, we wish to determine the frequency and yield of blood culture, urine culture, and chest X-ray evaluation of postoperative fever. METHODS: A retrospective review of 537 consecutive patients undergoing major gynecologic surgery was performed. In patients who developed postoperative fever, it was determined whether blood culture, urine culture, and/or chest X-ray were performed, and, if so, the frequency of positive results was evaluated. RESULTS: Two hundred eleven patients (39%) developed postoperative fever. Blood cultures were obtained in 77 of 211 (37%) febrile patients, urine cultures in 106 of 211 (50%) febrile patients, and chest X-ray in 54 of 211 (26%) febrile patients. Zero of 77 blood cultures were positive, 11 of 106 (10%) urine cultures were positive, and 5 of 54 (9%) chest X-rays were positive. Logistic regression revealed that late onset fever predicted for positive urine cultures and early onset fever and advanced age predicted for pneumonia. Eighty percent of patients with pneumonia were symptomatic. In 92% of patients with postoperative fever, no infections or pathologic process were diagnosed. CONCLUSION: Although postoperative fever is frequently evaluated by blood culture, urine culture, and chest X-ray, evaluation rarely yields positive results.     

Emergency department-based home care

STUDY OBJECTIVE: To assess the feasibility of coordinating home care services from an inner-city emergency department. INTERVENTION: In a preintervention survey, the home care needs of 650 consecutive patients being discharged from the ED were evaluated. A nurse-coordinator who arranged and managed rapidly deployed home care services then was assigned to the ED for eight months. Patients were referred, and home care services were provided regardless of insurance status. SETTING: Teaching hospital serving a large indigent population. PARTICIPANTS: Adult patients about to be discharged home from the ED. MAIN RESULTS: Forty-five of 650 (7%) surveyed patients were not receiving home care services for which they were eligible. In the subsequent eight-month period, 670 patients were referred for home care on discharge from the ED (2% of all discharges). Seventy-six percent of these patients were women, and the average age was 73.5 years. Four hundred fifty patients (67%) received visits from home care providers managed by the ED coordinator. For 99 of these patients (22%), the availability of rapidly deployed home care services obviated the need for emergency admission to the hospital. Net billings to third-party payers exceeded the costs of the program. CONCLUSION: A significant proportion of elderly patients being discharged from the ED need home health services. Access to rapidly deployed home care services can obviate the need for hospital admission for a select group of debilitated patients. The provision of home care services from the ED is economically feasible.     

Measurement of cardiac troponin T is an effective method for predicting complications among emergency department patients with chest pain

STUDY OBJECTIVES: To determine the test performance characteristics of serum cardiac troponin T (cTnT) measurement for diagnosis of acute myocardial infarction (AMI), and to determine the ability of cTnT to stratify emergency department patients with chest pain into high- and low-risk groups for cardiac complications. METHODS: We conducted a prospective observational cohort study with convenience sampling in a tertiary care, urban ED. The study sample comprised 667 patients presenting to the ED with a complaint of chest pain or other symptoms suggesting acute ischemic coronary syndrome (AICS). Patients were assigned to different blood sampling protocols for cTnT therapy on the basis of their ECG at presentation: nondiagnostic for AMI at 0, 3, 6, 9, 12, and 24 hours after ED presentation; or ECG diagnostic for AMI at 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 18, and 24 hours after ED presentation. RESULTS: Of 667 patients, 34 had AMI diagnosed within 24 hours of ED arrival. Using a .2 microgram/L discrimination level for cTnT, sensitivity for AMI within 24 hours of ED arrival was 97% (95% confidence interval, 91.4% to 99.9%), and specificity was 92% (89.8%-94.1%). When the effects of age, race, sex, and creatine kinase-MB isoenzyme subunit test results were controlled, a patient with cTnT of .2 microgram/L or greater was 3.5 (1.4 to 9.1) times more likely to have a cardiac complication within 60 days of ED arrival than a patient with a cTnT value below .2 microgram/L. CONCLUSION: Measurement of cTnT will accurately identify myocardial necrosis in patients presenting to the ED with possible AICS. Elevated cTnT values identify patients at increased risk of cardiac complications.     

Serious group A beta-hemolytic streptococcal infections complicating varicella

STUDY OBJECTIVE: To alert practicing emergency physicians to an important and possibly increasing relationship between life-threatening group A beta-hemolytic streptococcal (GABHS) infections and children recovering from varicella. DESIGN: A case series of six patients managed from January through March 1993. SETTING: A university-affiliated pediatric specialty emergency department. TYPE OF PARTICIPANTS: Six previously healthy immunocompetent children between 1 and 5 years of age seen in our ED over a nine-week period. RESULTS: Six children had onset of varicella two days to two weeks before developing a serious life-threatening GABHS infection. Children presented with clinical symptoms of invasive GABHS infection with bacteremia (one patient); streptococcal toxic shock syndrome with negative blood culture (two), pneumonia with pleural effusion and streptococcal toxic shock syndrome (one), pneumonia with pleural effusion (one), and pyomyositis of the thigh (one). Four of six patients required intensive care admissions and aggressive support of vital signs. All six survived. CONCLUSION: Emergency physicians should be aware of the association between varicella and serious GABHS infections and be prepared to recognize and aggressively manage serious complications should they occur.     

Compliance with the law and appropriate medical standards during interhospital transfers

Interhospital transfer patients constitute a significant proportion of medical center emergency department (ED) patients in Taiwan. Many such transfers are poorly planned and put the patient at risk. We wished to evaluate the safety and compliance with the Taiwan Medical Law among patients transferred to the Linkou Chang Gung Memorial Hospital ED from other health care centers. We performed a prospective, cross-sectional, observational study on 1,056 patients transferred from August 15 to September 30, 1997. Of these patients, 357 were critically ill or injured and only 160 received adequate pretransfer stabilization. The major omissions included: 1) failure to intubate in 121 (55%) of the 220 patients in severe respiratory distress or unprotected patent airways; 2) no intravenous line in 74 (20.7%) of the 357; and 3) inadequate IV lines in 36 (63.2%) of the 57 severely hypotensive patients. Overall, 894 patients were sent with transfer notes, but few indicated whether the referral was to the ED or outpatient department. This added an unnecessary burden for patients with stable longstanding problems who claimed they had been referred to the ED. While the majority of patients (49.4%) were transferred at the request of physicians for further treatment, 28% of the critically ill patients were transferred because of family requests. Physicians accompanied these patients only on seven occasions and nurses on 84 occasions. Despite the 1993 Department of Health policy of pretransfer phone contact with the receiving hospital for critically ill patients, such contact occurred only 10.6% of the time. While the Taiwan emergency medical system, Emergency Medicine, and Critical Care Medicine are all in their developmental stages, a medical and legal noncompliance rate of above 55% for critically ill transfer patients is unacceptably high. The appropriate medical societies and the Department of Health should work in concert to upgrade existing transfer practices.     

The role of neuroimaging in the initial management of patients with minor head injury

STUDY OBJECTIVE: To determine whether omitting neuroimaging in the primary assessment of patients with minor head injuries in the emergency department is safe. DESIGN: Prospective cohort study. SETTING: University hospital, Copenhagen County Hospital, Glostrup, Denmark. PARTICIPANTS: The study group consisted of 2,204 patients presenting to the ED after sustaining minor head injuries. Only patients able to talk and walk were included. MEASUREMENTS AND MAIN RESULTS: The decision to admit was based exclusively on clinical guidelines in which the findings in the ED were of highest priority. Seven patients (0.3%) had a skull radiograph; computed tomography was not used in the primary evaluation. Four hundred thirty patients (19.5%) were admitted. After hospitalization, four patients developed intracranial complications. One required surgery, two required hyperventilation, and one was observed. Follow-up demonstrated that no patient with an intracranial complication had been missed. CONCLUSION: We found it safe to exclude neuroimaging in the primary assessment of patients with minor head injuries in the ED, and to rely instead on clinical criteria.     

Ambulatory health care use by patients in a public hospital emergency department

OBJECTIVE: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study. SETTING: A public hospital in Atlanta, Georgia. PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse. CONCLUSIONS: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.     

Postcesarean endometritis. Clinical risk factors predictive of positive blood cultures

OBJECTIVE: To identify peripartum risk factors that are predictive of positive blood cultures in patients with postcesarean endometritis. STUDY DESIGN: A retrospective review of 179 patients diagnosed with postcesarean endometritis was conducted. Patients with positive and negative blood cultures obtained at the time of diagnosis were compared. Patient's charts were reviewed for intrapartum, intraoperative and postpartum factors. Chi-square and nonpaired Student's tests were used when appropriate, with P < .05 considered significant. RESULTS: During this period, 179 (20%) postcesarean patients developed endometritis. One hundred sixty-eight (94%) of those patients had blood cultures. Eleven (6.5%) were positive; however, one of these grew a skin contaminant and was disregarded. When patients with positive blood cultures were compared to those with negative blood cultures, length of labor, number of vaginal examinations, postoperative day when the diagnosis was established, estimated blood loss at the time of cesarean delivery, presence of intrapartum chorioamnionitis, number of hours of ruptured membranes, white blood cell count at the time of diagnosis, use of prophylactic antibiotics, development of wound infection or other infectious etiologies were not shown to be predictive. There were no positive blood cultures among patients with a temperature < 38.5 degrees C. At a temperature < 38.8 degrees C, 1/126 (0.79%) had a positive blood culture. At a temperature > or = 38.8 degrees C, 9/42 (21.4%) had a positive blood culture (P < .001). Approximately $5,890 was spent on obtaining positive blood cultures in patients with temperatures < 38.8 degrees C. In contrast, $218 was spent per positive blood culture obtained from patients with a temperature > or = 38.8 degrees C. CONCLUSION: The traditional practice of obtaining blood cultures at a temperature > or = 38.0 degrees C is not justified but elevating the threshold to 38.8 degrees C is equally effective and less costly.     

Membranoproliferative glomerulonephritis associated with HCV infection in native kidneys and renal allograft

STUDY OBJECTIVE: We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit's impact in reducing inpatient admissions and facilitating bed closures. METHODS: We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit. RESULTS: Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents-not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents. CONCLUSION: Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources.     

Medicolegal errors in the ED related to the involuntary confinement of psychiatric patients

To determine the effectiveness of emergency department (ED) physicians properly and correctly completing documents required for emergency confinement of psychiatric patients, 1,000 Physician Emergency Certificates filed by ED physicians in the Shreveport, Louisiana, region were reviewed for appropriateness and for correctness of completion based on the applicable state law. Of the Physician Emergency Certificates reviewed 4.2% were incomplete or inappropriate. The most significant sources of error involved incomplete documentation of the mental status examination and not documenting the specific reason (dangerous to self, dangerous to others, or gravely disabled) for the patient meeting requirements for involuntary confinement. Other errors included confinement for reasons not appropriate for a psychiatric unit. This study suggests that ED physicians should be more cautious and thorough in completing the documents required for emergency confinement of psychiatric patients, so that the physician is less likely to be sued for malpractice or charged with the false imprisonment of such patients, and the patient's civil liberties are protected.     

The impact of blood culture reporting and clinical liaison on the empiric treatment of bacteraemia

AIMS: To assess the impact of blood culture results and early clinical liaison on the treatment of patients with bacteraemia. METHODS: 123 patients with significant positive blood cultures were followed over a nine month period in a 620 bed teaching hospital. The impact of early blood culture reporting and clinical liaison on the cost and appropriateness of treatment was assessed. RESULTS: Empiric treatment was started before the Gram stain result in 107 (87%) patients. Treatment was altered on the basis of the Gram stain result in 39 (36%) of these patients, and on culture and sensitivity results in 53 (50%). The spectrum of antibiotic treatment was narrowed in 58 (54%) of these; 20 (19%) on Gram stain result alone. This resulted in a 42% reduction in daily antibiotic costs in patients who had received empiric treatment. Empiric treatment did not follow the hospital antibiotic policy in 49 (46%) of the patients treated. In patients where empiric treatment was not in accordance with hospital policy, 21 (44%) had an isolate resistant to the empiric treatment used; while in patients who received agents in accordance with hospital policy only one (1.7%) had a resistant isolate (p < 0.05). Patients who died (11 (9%)) were less likely to have received empiric treatment in accordance with the antibiotic policy, although this did not reach statistical significance (p = 0.1). CONCLUSION: Early reporting of Gram stain results from blood cultures, combined with early clinical liaison, results in more rational and cost effective treatment.     

Incidence, antimicrobial resistance and mortality in bloodstream infections in the critically ill

Bloodstream infections (BSI) are 7-fold more common in patients admitted to the intensive care unit (ICU) rather than to other hospital wards. The epidemiology of BSI in critically ill patients in Israel has not been systematically addressed. We examined the annual trends in BSI in patients in a general ICU of evolving patterns of antimicrobial resistance and associated mortality rates for the years 1994-1996. The presence of the systemic inflammatory response syndrome (SIRS) when the first positive blood cultures are taken was a prerequisite for its definition as clinically significant. The unit site, staff, practice guidelines, and type of patient were unchanged during the study period. Blood cultures were positive in 220.7-332.0 patients per 1000 ICU admissions, 18-22-fold more common than in regular ward patients. SIRS was a universal finding in these ICU patients. There was multi-drug resistance for the majority of species cultured, reaching 100% in some cases. Crude hospital mortality of ICU patients, with and without positive blood cultures, was 31-54% and 5-14%, respectively. The introduction of a new blood culture system (Bactec 9240) in 1996 was associated with a 61% increase in the rate of patients with positive blood cultures, accounted for mostly by increased isolation of coagulase-negative staphylococci. However the mortality rate for the latter decreased by 59%, suggesting the possibility of a selective increase in detection of contaminated cultures. Although highly prevalent in the study population and generally defining a patient group with high mortality risk, the specificity of SIRS-associated positive blood cultures may be species and culture-system dependent. These findings re-emphasize the need for both improved control measures for the epidemic proportions of BSI and multi-drug antimicrobial resistance, as well as more specific indicators of the clinical relevance of positive blood cultures in critically ill patients.     

Dialysis catheter-related septicaemia--focus on Staphylococcus aureus septicaemia

BACKGROUND: Dialysis catheters are a common cause of nosocomial septicaemia in haemodialysis units usually due to staphylococci, of which Staphylococcus aureus is the most pathogenic. In this study, the epidemiology and pathogenesis of dialysis catheter-related infections were studied, and methods to identify patients with these infections were evaluated. METHODS: A one-year prospective study of 67 catheters in 43 haemodialysis patients was performed. Details about patients and catheters were obtained successively during the catheter period, and biochemical parameters expected to be related to infection were measured. After catheter insertion, all patients were screened for nasal carriage of S. aureus, and a culture was taken from the skin overlying the catheter insertion site. Once a week, cultures were taken from the insertion site and from the hub, and aerobic and anaerobic blood cultures were drawn from the catheter. If clinical signs of septicaemia occurred, peripheral blood cultures were also performed, when it was possible. RESULTS: The incidence of septicaemia was 49% (21/43) in patients, and 56% of all cases were caused by S. aureus. The mortality was 14% (3/21) and the incidence of severe secondary complications to septicaemia was 24% (5/31). In all, 80% of all severe complications and 75% of all deaths from septicaemia were due to S. aureus. With respect to S. aureus septicaemia, the predictive values of positive (P) and negative (N) S. aureus cultures were as follows: nasal culture, P=36% (10/28), N=90% (35/39); culture from the insertion site, P=72% (13/18), N=98% (48/49); and culture from the hub, P=75% (3/4), N=83% (52/63). The risk ratio for S. aureus septicaemia was 26.2 (6.1-113), P=0.0001, according to the presence of S. aureus at the insertion site, and 3.3 (0.74-15.1), P=0.12 according to nasal carriage of S. aureus. The frequency of S. aureus phage-type Group 2 (43%) was much higher than the general frequency of this phage-type in Denmark, which is about 23%. Catheter blood cultures were positive although there were no clinical signs of septicaemia in 34% (23/67) of all catheter periods--84% of these were due to coagulase-negative staphylococci. CONCLUSIONS: Dialysis catheter-related S. aureus septicaemia was highly unlikely if the patient had not been carrying S. aureus in the nose or at the insertion site during the time the catheter was in place. The best predictor of dialysis catheter-related S. aureus septicaemia was a positive S. aureus culture from the insertion site. Positive catheter blood cultures unrelated to any clinical signs of septicaemia occurred in one-third of all catheter periods, and 84% of these were due to coagulase-negative staphylococci.     

The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial

OBJECTIVE: To determine whether the use of noninvasive positive pressure ventilation (NPPV) in the emergency department (ED) will reduce the need for tracheal intubation and mechanical ventilation. DESIGN: Randomized, controlled, prospective clinical trial. SETTING: ED of Barnes-Jewish Hospital, a university-affiliated teaching hospital. PATIENTS: Twenty-seven patients meeting a predetermined definition of acute respiratory distress requiring hospital admission. INTERVENTIONS: Conventional medical therapy for the various etiologies of acute respiratory distress and the application of NPPV. MEASUREMENTS AND RESULTS: The primary outcome measure was the need for tracheal intubation and mechanical ventilation. Secondary outcomes also assessed included hospital mortality, hospital length of stay, acquired organ system derangements, and the utilization of respiratory care personnel. Sixteen patients (59.3%) were randomly assigned to receive conventional medical therapy plus NPPV, and 11 patients (40.7%) were randomly assigned to receive conventional medical therapy without NPPV. The two groups were similar at the time of randomization in the ED with regard to demographic characteristics, hospital admission diagnoses, and severity of illness. Tracheal intubation and mechanical ventilation was required in seven patients (43.8%) receiving conventional medical therapy plus NPPV and in five patients (45.5%) receiving conventional medical therapy alone (relative risk=0.96; 95% confidence interval=0.41 to 2.26; p=0.930). There was a trend towards a greater hospital mortality rate among patients in the NPPV group (25%) compared to patients in the conventional medical therapy group (0.0%) (p=0.123). Among patients who subsequently required mechanical ventilation, those in the NPPV group had a longer time interval from ED arrival to the start of mechanical ventilation compared to patients in the conventional medical therapy group (26.0+/-27.0 h vs 4.8+/-6.9 h; p=0.055). CONCLUSIONS: We conclude that the application of NPPV in the ED may delay tracheal intubation and the initiation of mechanical ventilation in some patients with acute respiratory distress. We also demonstrated that the application of NPPV was associated with an increased hospital mortality rate. Based on these preliminary observations, larger clinical investigations are required to determine if adverse patient outcomes can be attributed to the early application of NPPV in the ED. Additionally, improved patient selection criteria for the optimal administration of NPPV in the ED need to be developed.     

The possibility for treating certain forms of endometrial and ovarian carcinomas with GnRH agonists]

The purpose of this study was to quantify the proportion of men and women seen in a university emergency department (ED) for treatment of injuries resulting from intimate partner violence (IPV) that require reports to law enforcement authorities. A total of 1,516 adult ED patients were asked to complete a written survey instrument; 1,003 patients (66.2%) completed the survey. Two percent of patients reported they presented to the ED for treatment of injuries resulting from IPV. Three percent reported IPV within the last year, and 10% reported that they had ever been physically abused by a partner. Six percent of respondents reported that they had ever been threatened with a gun or knife by a partner, 2% within the past year. Only the lifetime prevalence of IPV was significantly greater among female patients, 15% versus 6% (P < .001). Approximately 2% of our ED patients require law enforcement intervention for IPV.     

Predictors of intracranial pathologic findings in patients who seek emergency care because of headache

BACKGROUND: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. OBJECTIVE: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. DESIGN: Case-control, consecutive sample. SETTING: Major metropolitan trauma center emergency department. PATIENTS AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. DATA ANALYSIS: Nonparametric statistical analysis. RESULTS: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or nonfocal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomographic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.     

Results of culture form colonoscopically obtained specimens for bacteria and fungi in HIV-infected patients with diarrhea

BACKGROUND: The aim of our study was to determine the diagnostic yield of culture for bacteria and fungi from colonic biopsy specimens in 290 consecutive HIV-infected patients with diarrhea. METHODS: During each colonoscopy, three biopsy specimens were homogenized and cultured on media for Salmonella and Shigella and for Campylobacter and Yersinia, on Loewenstein medium and on Sabouraud medium. RESULTS: Cultures were found positive for one (n = 32) or two (n = 5) infectious agents in 37 cases, i.e., in 12.8% of the patients. Bacteria were isolated in 24 cases, and identified as Campylobacter jejunl-coli (n = 14), Salmonella (n = 2), Shigella (n = 1), or Pseudomonas aeruginosa (n = 7). Among the 14 patients with C. jejuni-coli intestinal infection, 11 had normal-appearing mucosa at colonoscopy, and 3 had a concomitant stool culture negative for Campylobacter. Mycobacterial cultures were positive for Mycobacterium avium intracellulare in 6 patients, who were already known as having a disseminated M. avium intracellulare infection from positive blood cultures. Fungal cultures were positive for Candida in 10 cases, without clear clinical significance. CONCLUSIONS: The overall yield of culture for bacterial pathogens from colonic tissue in HIV-infected patients with diarrhea is low, but some individual cases of C. jejuni-coli infections may be detected from colonic tissue culture and not diagnosed by concomitant stool culture.     

Coronary ischemia during radiofrequency ablation of left lateral accessory pathway in an infant

This study compared patterns of parenteral antibiotic treatment by emergency physicians with literature-derived guidelines in the management of wound care. All patients who received parenteral antibiotics as part of wound management in an urban general emergency department (ED) (annual volume 65,000) and did not receive subsequent consultation or admission were prospectively studied for 4 weeks (July 18 to August 15, 1994). Data collected included age, sex, antibiotic, route of administration, dose, cost, diagnosis, and board certification of emergency physician. Antibiotic choice and dose were reviewed by study-blinded physicians and compared with criteria based on a review of the current wound care literature. Wound characteristics justifying antibiotic prophylaxis were derived from the literature and included immunocompromised patient, wounds with debris or occurring under contaminated circumstances, wounds with cellulitis or purulent drainage, wounds older than 18 hours, and crush injuries. The study included 72 patients, and 13 (18%) antibiotic discrepancies were found. Cefazolin (n = 49 [64%]) and ceftriaxone (n = 25 [35%]) were the most commonly prescribed parenteral antibiotics, with cefazolin used in 9 (69%) and ceftriaxone in 4 (31%) of discrepant cases. There were not significant differences in discrepant parenteral antibiotic by emergency physicians' board certification. There were no significant demographic differences between patients receiving discrepant and nondiscrepant antibiotics. The excess cost of discrepant parenteral antibiotics during this small study period was $380. Approximately one fifth of the parenteral antibiotics prescribed during wound care administered in the ED were discrepant with current recommendations derived from the literature.