STUDY HYPOTHESIS: The acuity and specificity of the clinical presentation of bacterial meningitis are significantly associated with the time to antibiotic administration. DESIGN: Retrospective case series. SETTING: Seven hundred-bed university and 1,000-bed community hospital. PARTICIPANTS: One hundred twenty-two children and adults primarily evaluated in the emergency department and admitted with the diagnosis of suspected bacterial meningitis. METHODS: The ED chart was reviewed for demographic, historical, physical examination, and time data and sequence of interventions. In addition, we categorized patient presentations as "sick" or not and as "classic" or not based on the following predetermined definitions. A "sick" presentation was defined as at least two of the following: temperature of more than 40 C, lethargic or comatose mental status, hypotension, or tachycardia. A "classic" presentation was defined as temperature of more than 39 C and at least one of the following: nuchal rigidity, bulging fontanelle, or abnormal mental status. Association of clinical variables and management practices to time to antibiotics was analyzed by analysis of variance and regression. RESULTS: The geometric mean time from ED registration until antibiotic initiation was 2.7 hours (range, 0.5 to 18 hours). Clinical factors that were associated independently with less time to antibiotics (hours less, P value) were a history of vomiting (0.5 hour, P = .06), no history of headache (0.8 hour, P = .01), hypotension (1.0 hour, P = .02), a bulging fontanelle (0.9 hour, P = .01), and a "sick presentation" (0.5 hour, P = .06). Management scenarios in which antibiotics were not administered until after return of results of computed tomography head scan or laboratory cerebrospinal fluid analysis and the practice of initiation of antibiotics on the ward compared with in the ED were associated independently with even greater delays (1.7 to 1.8 hours, P < .0001). CONCLUSION: Certain clinical factors, particularly those associated with acute illness compared with those that suggest the specific diagnosis, are associated with less time to antibiotics. Management practices, such as the order of interventions and the site of initiation of antibiotic therapy, appear to be of much greater importance in predicting antibiotic timeliness and represent an area of potentially avoidable delay for the ED management of suspected bacterial meningitis.

Adolescent↗

PubMed1984

Operative intervention for postinfarction angina.

Thirty-four patients (26 men and 8 women) underwent myocardial revascularization following myocardial infarction (MI) at the Johns Hopkins Hospital during 1980 through 1982. Average age was 59 years. Of the 33 patients with unstable angina, 61% had ischemia in the infarct zone and 39% had "ischemia at a distance." Mean time from MI to operation was 16 days. The MIs were equally divided between a transmural and a subendocardial location. Eleven patients had a history of congestive heart failure. Intraaortic balloon pumping was used preoperatively for anginal stabilization in 14 patients. Mean ejection fraction for the group was 52%. There were 3 operative deaths, all 3 due to myocardial failure. Late follow-up (mean, 13.7 months; range, 6 to 35 months) is complete for 28 patients. There was 1 late death, secondary to cardiac failure. There were no late MIs. Angina had recurred in 5 patients, but only 2 were taking antianginal medication. At the time of follow-up, 52% of patients were in New York Heart Association Functional Class I. This experience suggests that operative intervention for postinfarction angina can be accomplished with an acceptable mortality and thereby increase survival, reduce the later occurrence of MI, and relieve angina in this high-risk group.

Aged↗

PubMed1982

Skin surface lipids of the domestic chicken, and neutral lipid standards as stimuli for the penetration response of Austrobilharzia variglandis cercariae.

Lipids were extracted from the skin of 2-wk-old domestic chickens using sterile cotton gauze dampened with chloroform:methanol (2:1). Preparative thin-layer chromatography separated the skin lipids into six major fractions: phospholipids, free sterols, free fatty acids, triglycerides, methyl esters, sterol esters. The penetration response of the marine avian schistosome cercaria, Austrobilharzia variglandis, to chicken skin lipid fractions, and to neutral lipid standards, was tested by coating lipids on agar in a Petri dish containing a seawater overlay. All neutral lipids tested produced significantly greater penetration responses than the chloroform control. The phospholipid skin fraction killed cercariae. Lipid from whole chicken skin produced the greatest penetration response, followed by free fatty acids and free sterol skin fractions. Of the standards tested, the whole neutral lipid standard, containing cholesterol, oleic acid, triolein, methyl oleate, and cholesteryl oleate, produced the greatest response, followed by the cholesterol standard and the oleic acid standard.

Animals↗