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Biomedical subjects

M A Levitt

Publications and source records attributed to M A Levitt.

At least 37 records · Page 2Linked to original sources
PubMed1998

Alterations in respiratory status: early signs of severe necrotizing enterocolitis.

BACKGROUND: Necrotizing enterocolitis (NEC) presents with well-recognized signs of intestinal inflammation such as bilious vomiting, bloody stool, abdominal distension, and tenderness. The authors observed otherwise unexplained changes in the respiratory status requiring increased respiratory support during the 24 hours before direct evidence of the intestinal disorder in patients with severe NEC. METHODS: To study this observation the authors collected data on 10 consecutive patients in whom NEC required an operation. RESULTS: Eight of these patients were recovering from respiratory distress syndrome (RDS). During the 24 hours before any direct sign of intestinal dysfunction seven of these eight had a respiratory prodrome needing increased respiratory support. Two patients required intubation and mechanical ventilation. Five needed increased supplemental oxygen. This prodrome included decreased oxygenation in seven, increased respiratory rate in five, and increased PCO2 in five, preceded by hypocarbia in three. CONCLUSIONS: These changes in the respiratory condition revisit the concept of high output respiratory failure. This term was introduced to describe the respiratory failure in adult patients who suffer acute intestinal illness. Increased metabolic demand from the intestinal illness was thought to stress the ability of the patient to delivery oxygen and remove carbon dioxide. The ability of the respiratory system to meet the increased demands is limited by the intestinal dysfunction itself (abdominal pain and distension). In our patients recovering from RDS the pulmonary reserve is inherently limited. Because they are carefully monitored, it is easy to retrieve evidence of respiratory changes that precede the direct signs of intestinal disease. In the earliest stages of intestinal illness before the direct signs of intestinal dysfunction, these patients often manifest unexplained signs of respiratory compensation and decompensation and require increased respiratory support. Regardless of the pathophysiology, these alterations in respiratory status represent an early warning sign of NEC.

Enterocolitis, Pseudomembranous↗
PubMed1998

Intraoperative cardiac tamponade complicating esophagogastrectomy.

BACKGROUND: Thoracoabdominal esophagogastrectomy is associated with a number of potential life-threatening complications. PATIENTS: We describe a patient with intraoperative hypotension in which a number of therapeutic maneuvers eventually led to the diagnosis of cardiac tamponade. RESULTS: Once the diagnosis of tamponade was made, it was successfully treated by the release of intrapericardial blood. CONCLUSIONS: Although rare, tamponade should be considered as a cause of hemodynamic instability whenever intraoperative manipulation of the heart has occurred.

Cardiac Tamponade↗
PubMed1997

Continent appendicostomy in the bowel management of fecally incontinent children.

BACKGROUND: Fecal incontinence is common in children who have anorectal malformations, Hirschsprung's Disease, and spina bifida and can negatively impact their emotional and social development. Enemas have been used as an artificial way to keep children clean and to improve their quality of life. This method is unpleasant for many children, particularly when they reach adolescence. Malone in 1990 described an alternative method in which the appendix is used as a conduit to administer an antegrade enema. METHODS: The authors describe their experience with this new procedure, modified by them, and used in 20 patients. In the original procedure, the base of the appendix is divided, inverted, and reimplanted into the cecum with an antireflux technique. The authors simplify this by plicating the cecum around the appendix to create a one-way valve mechanism but leaving the appendix in its original position. The authors also mobilize the cecum and exteriorize the appendix at the umbilicus to create an inconspicuous stoma. If the native appendix is absent a neoappendix was created from a flap of cecum. RESULTS: Nineteen of 20 patients (95%) are now completely clean 24 hours a day. Stricture of the stoma occurred in two patients and required revision. Leakage at the appendicostomy site occurred in three patients, and two required a tighter plication. CONCLUSIONS: The technique is used to change the route of enema administration, and is only used in patients for whom bowel management with rectal enemas has been proven successful. The appendix must be preserved whenever possible in patients at risk for fecal incontinence.

Adolescent↗
PubMed1997

The tethered spinal cord in patients with anorectal malformations.

The aims of this study were to find the prevalence of tethered cord in patients with anorectal malformations; to determine if the presence of tethered cord relates to the severity of the anorectal defect, and to certain symptoms, signs, radiologic findings, and associated anomalies; and finally to determine whether tethered cord impacted on a patient's functional prognosis and whether surgical untethering improved the patient. The authors studied 934 patients with anorectal malformations, 111 of whom had magnetic resonance imaging (MRI) of the spine. We compared patients with and without tethered cord by using parametric and nonparametric statistical tests. Tethered cord occurred in 24% of the patients. The prevalence varied according to the type of anorectal defect from 43% in the complex group to 11% in patients with rectovestibular fistula. Patients with tethered cord had a lateral sacral ratio lower than that of patients without tethered cord (0.410 versus 0.702). Tethered cord was present in 90% of patients with myelodysplasia, 60% of patients with a presacral mass, 57% of patients with sacral hemivertebrae, and 56% of patients with a single kidney. The greater number of associated anomalies a patient had, the greater the risk of having tethered cord (P < .05 for all differences). The authors noted differences between patients with and without tethered cord in the presence of voluntary bowel movements (46% versus 70%), fecal soiling (91% versus 63%), constipation (21% versus 43%), and urinary incontinence (86% versus 42%). The data indicate that patients with tethered cord have a worse functional prognosis than patients without tethered cord. However, the incontinence in our patients was also predictable based on the type of anorectal defect and the character of the sacrum irrespective of the presence of tethered cord. Eighteen patients underwent surgical untethering of the cord, and none had any significant change in bowel or urinary function postoperatively. No patient with tethered cord experienced incontinence that could be attributed to the cord defect alone. This study suggests that tethered cord occurs more frequently in patients with severe anorectal defects, sacral hypodevelopment, myelodysplasia, presacral mass, sacral hemivertebrae, or a single kidney, or in those with an anorectal defect with poor functional prognosis. At present no solid evidence supports the concept that tethered cord by itself affects the functional prognosis of patients with anorectal malformations. Also, there is no good evidence demonstrating that surgical untethering improves the prognosis.

Abnormalities, Multiple↗
PubMed1997

Abbreviated educational session improves cranial computed tomography scan interpretations by emergency physicians.

STUDY OBJECTIVE: Previously published research (phase I) demonstrated a concerning misinterpretation rate of cranial computed tomography (CT) scans by emergency physicians. This study (phase II) determined whether an abbreviated educational session would improve emergency physician interpretation skills of cranial CT scans. METHODS: Participants in this prospective, interventional study in a county hospital ED were patients undergoing cranial CT scanning during ED evaluations and attending level emergency physicians. An abbreviated educational session on cranial CT interpretation skills was given to the same attending emergency physicians who participated in phase I. The educational session included basic CT interpretation skills and misinterpreted CT scans from phase I. We determined the postsession accuracy rate of the emergency physicians on 324 ED patient CT scans. The CT interpretation accuracy rates were then compared between phase I and phase II to determine the effectiveness of the educational session. RESULTS: The radiology/ED CT scan concordance rate improved from 61.3% (kappa = .22) to 88.6% (kappa = .70; P < .0001). Potentially clinically significant CT scan misinterpretations decreased from 24.1% to 4.0% (P < .0001). Most importantly, major missed findings on CT scans decreased from 11.4% to 2.8% (P < .0001). Continuous quality improvement monitoring found no instance of clinically significant patient mismanagement. CONCLUSION: Within the limits of this study, we conclude that emergency physicians' interpretation skills of cranial CT scans may be improved using a 1-hour educational session.

Brain Diseases↗
PubMed1997

Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation.

STUDY OBJECTIVE: To compare the use of real-time-ultrasound guidance with the standard landmark-oriented approach for obtaining femoral vein catheterization in patients requiring intravenous access during CPR. METHODS: Prospective, randomized, paired subject-controlled clinical trial in the setting of an urban teaching county hospital emergency department. The study comprised a convenience sample of 20 patients presenting with apnea and pulselessness in the ED. Each patient received bilateral femoral lines, one by ultrasound guidance and one by the landmark approach (control). Randomization determined which technique and which side would be attempted first. The following parameters were recorded: time to initial flash of blood, time to completion of catheterization, number of needle passes, and rate of arterial catheterization. CPR and Advanced Cardiac Life Support protocols were continued during both procedures. RESULTS: Real-time ultrasound-guided catheterization had a higher success rate (90% versus 65%, P = .058), a lower number of needle passes (2.3 +/- 3 versus 5.0 +/- 5, P = .0057), and a lower rate of arterial catheterization (0% versus 20%, P = .025) than the standard landmark-oriented approach. Ultrasound was also slightly faster in time to blood flash and in time to catheterization. An incidental finding of interest was that real-time ultrasound demonstrated the presence of femoral vein pulsations during CPR. CONCLUSION: Real-time ultrasound-guided femoral vein catheterization was faster and produced a lower rate of inadvertent arterial catheterization and a higher rate of success during CPR than the standard landmark-oriented approach. Also, ultrasound demonstrated that palpable femoral pulsation during CPR is venous rather than arterial.

Adult↗
PubMed1996

Combined cardiac marker approach with adjunct two-dimensional echocardiography to diagnose acute myocardial infarction in the emergency department.

STUDY OBJECTIVE: To evaluate a combined cardiac marker approach with adjunct two-dimensional echocardiography in diagnosing acute myocardial infarction (AMI) in the emergency department. METHODS: This prospective, cohort study enrolled 190 patients aged 18 years and older who presented to the ED of a county teaching hospital and were admitted with chest pain suggestive of AMI. A standardized history and physical examination were performed. Serum sampling for myoglobin and creatine kinase-MB (CK-MB) was done at the time of presentation (time 0) and 3 hours later (time 3 hours). An echocardiographic study was obtained, and a left ventricular wall motion score was derived. RESULTS: Using World Health Organization criteria, 21 patients (11.2%) with AMI were identified. The serum markers were found to be clinically and statistically different between AMI and non-AMI groups at both time 0 and time 3 hours. Receiver operator characteristic curves were used to determine a "positive" myoglobin level at 88.7 ng/mL or higher at either time point, and a "positive" CK-MB level at 11.9 ng/mL or higher; these were used as the optimal cutoff values to predict AMI in the ED. Serum myoglobin was a more sensitive marker (90.5%) than CK-MB (81.0%). However, CK-MB was more specific (99.4%) than myoglobin (88.4%). A combination of both tests, which was rated positive if either test was positive, was a superior predictor overall, with a 100% capture rate of AMI patients and a 91.2% specificity. No significant difference in echocardiographic scores was appreciated in the AMI group compared with the non-AMI group (16.9 +/- 1.5 versus 15.3 +/- .5, respectively; P = .3252). CONCLUSION: Serum myoglobin shows greater sensitivity but is less specific than CK-MB in the early detection of AMI. Use of a combination of both rapid assays during a 3-hour time period in the ED appears to be superior to use of either enzyme assay alone. Two-dimensional echocardiography does not appear to be helpful in diagnosing AMI in the ED.

Aged↗
PubMed1996

Randomized, double-blind, placebo-controlled trial of intravenous ketamine in acute asthma.

STUDY OBJECTIVE: To evaluate the efficacy of IV ketamine in the management of acute, severe asthma. METHODS: This prospective, randomized, double-blind, placebo-controlled clinical trial at an urban teaching hospital emergency department involved 53 consecutive patients aged 18 to 65 with a clinical diagnosis of acute asthmatic exacerbation and a peak expiratory flow of less than 40% of the predicted value after three albuterol nebulizer treatments. All patients received oxygen, continuous nebulized albuterol, and methylprednisolone sodium succinate (Solu-Medrol). Patients then received either ketamine hydrochloride in a bolus of .2 mg/kg followed by IV infusion of .5 mg/kg per hour for 3 hours or a placebo bolus and infusion for 3 hours. Because of the occurrence of dysphoric reactions, the bolus dose was lowered to .1 mg/kg after the first 9 patients; the infusion dose was kept the same. RESULTS: The first nine patients were eliminated from analysis. Repeated ANOVA testing on the remaining 44 patients determined significant improvements over time within each treatment group in peak flow (F=3.637, P=.004). Borg score (F=22.959, P=.001), respiratory rate (F=8.11, P=.0001). and 1-second forced expiratory volume (F=9.076, P=.001). However, no difference could be detected over time between treatment groups (power, 80%). Patients receiving ketamine gave the treatment a rating of 4.3 on a scale of 1 to 5, whereas those receiving placebo scored their treatment 3.7 (P=.0285). The hospital admission rate was not different between treatment groups (P=.1088). CONCLUSION: IV ketamine at a dose low enough to avoid dysphoric reactions demonstrated no increased bronchodilatory effect compared with standard therapy in treating exacerbations of asthma in the ED. Although there was a slight increase in satisfaction in the ketamine group, no clinical benefit in terms of hospital admission rate was noted.

Adolescent↗
PubMed1996

A prospective evaluation of the safety and efficacy of methohexital in the emergency department.

A prospective observational study in an inner-city teaching hospital was conducted to evaluate the safety and efficacy of intravenous methohexital (MTX) in the emergency department (ED). Pulse oximetry, vital signs and Glasgow Coma Scale (GCS) scores were recorded serially for 30 minutes after the administration of MTX to 76 adult patients. Likert scales of 1 to 5 were used to record the physician's assessment of the adequacy of sedation and the patient's assessments of recall and pain of the procedure. Patients received an average of 88 +/- 21 mg of MTX for a variety of indications (orthopedic procedures, 78%; sedation for other procedures, 14%; intubation, 5%; and psychiatric interview, 3%). No patient had clinically significant changes in heart rate or blood pressure. Eight (10.5%) had apnea, although only one patient had oxygen saturations of less than 90%. Each episode was brief and easily managed with bag-valve-mask ventilation. Risk factors for apnea included a history of alcoholism (P = .0003) and recent recreational narcotic use (P = .0139). Patients were maximally sedated in an average of 37 +/- 42 seconds. In the subset of initially alert patients, GCS scores decreased from 15 at baseline to 5.9 +/- 4.5. The physician's assessment of the adequacy of sedation was excellent (4.7 +/- 0.7). Patients reported little recall (1.3 +/- 0.9) or pain (1.3 +/- 0.8). It was concluded that MTX caused clinically insignificant changes in hemodynamics or oxygenation, although respiratory depression did occur; significant respiratory depression was brief and easily managed. MTX provided rapid and excellent levels of sedation with little or no patient recall or pain.

Adult↗
PubMed1996

Agreement between emergency physicians and psychiatrists regarding admission decisions.

OBJECTIVE: To determine the level of agreement between emergency physicians (EPs) and psychiatrists regarding the need for acute psychiatric hospitalization and treatment for patients presenting with alleged psychiatric complaints. METHODS: A prospective, cross-sectional assessment of concordance between EPs and psychiatrists in psychiatric admission decisions was performed at an urban county, teaching hospital ED. The participants had been brought to the ED for psychiatric evaluation. The patients were interviewed by an attending EP or a senior-level resident, and a tentative impression and disposition were determined prior to an independent examination and final disposition by a psychiatrist. Strength of physician group agreement was determined using the kappa statistic. RESULTS: The patient mean age was 37.5 +/- 15 years; 51% were men. The most common reasons for evaluation were disruptive behavior (28%), overdose (24%), and danger to self (23%). Of the 156 patients, 47 (28.7%) were sent home without treatment, 10 (6.3%) were determined to need only medical treatment, and 6 (3.7%) were released with outpatient psychiatric treatment. There were 84 (55.7%) patients admitted for psychiatric treatment. The EPs and psychiatrists had only moderate agreement regarding danger to self (kappa = 0.44), danger to others (kappa = 0.40), substance abuse as the primary problem (kappa = 0.50), and need for psychiatric hospitalization (kappa = 0.54). CONCLUSION: Moderate agreement between EPs and psychiatrists in key impressions and admission decisions suggests that shared training in psychiatric decision making, especially during residency training, is desired in this setting.

Adult↗
PubMed1995

Comparative trial of continuous nebulization versus metered-dose inhaler in the treatment of acute bronchospasm.

STUDY OBJECTIVE: To compare continuous nebulization with the use of a metered-dose inhaler (MDI) with spacer device for delivery of albuterol in acute bronchospastic episodes in the emergency department. DESIGN: Prospective, randomized, double-blinded, placebo-controlled clinical trial. SETTING: Urban ED with a 28,000 annual census. PARTICIPANTS: Patients older than 18 years of age presenting to the ED with an acute bronchospastic episode. INTERVENTION: After conducting evaluation and collecting baseline data, we treated each patient with a continuous-flow nebulizer set to deliver 15 mg/hour of albuterol or a placebo by face mask. Subsequently, each patient received four puffs (albuterol or placebo) from an MDI with a spacer device. The four MDI puffs were followed by 5 minutes on nebulization, and this sequence was continued until predetermined therapeutic end points were reached or side effects developed. The optimal MDI dose was then determined and repeated each hour for the 3-hour time period of the study. RESULTS: Repeated-measures ANOVA testing revealed statistically and clinically significant improvements over time within each treatment group in peak flow (F = 3.864, P = .0057), Borg score (F = 14.77, P = .0001), pulse (F = 9.642, P = .0001), and respiratory rate (F = 3.081, P = .0093). However, no significant differences could be detected between treatment groups over time except for systolic blood pressure (F = 8.231, P = .0141), and this change was not considered clinically significant. CONCLUSION: On the basis of the findings of this study, we conclude that continuous nebulization is equally effective as MDI with spacer device for delivery of albuterol to treat acute bronchospastic episodes in the ED. Each method of delivery offers advantages. Each ED should decide which modality to use on the basis of its own resources.

Acute Disease↗
PubMed1995

Accuracy of interpretation of cranial computed tomography scans in an emergency medicine residency program.

STUDY OBJECTIVES: To determine the concordance of emergency physicians and radiologists in interpreting cranial computed tomography (CT) scans. The study also sought to determine the clinical significance of misinterpretations of cranial CT scans by emergency physicians. DESIGN: Prospective cohort study. SETTING: A county hospital emergency medicine residency program. PARTICIPANTS: Five hundred fifty-five patients undergoing CT scanning during emergency department evaluation. RESULTS: Forty-nine percent (272) of the indications for CT scanning were for trauma, 14.2% (79) were for cerebrovascular accident, 25.1% (139) were for headache, 15.1% (84) were for seizure, and 13.7% (76) were for miscellaneous reasons. The radiologists interpreted 46.1% (256) of the CT scans as abnormal. The most frequent abnormalities were scalp hematoma, 15.2% (39); infarction, 14.1% (36); calcification, 6.3% (16); contusion, 6.3% (16); parenchymal hemorrhage, 5.1% (13); and mass, 5.1% (13). Nonconcordance between radiologists and emergency physicians was found in 38.7% (206) of the cases. Potentially clinically significant misinterpretations were found in 24.1% (131) of the total sample. These misinterpretations included 62 missed major findings (11.4% of total sample): 25 new infarcts, 10 mass lesions, 8 cases of cerebral edema, 8 parenchymal hemorrhages, 5 contusions, 4 subarachnoid hemorrhages, 1 epidural hematoma, and 1 subdural hematoma. However, on chart review, only three patients (0.6%) were found to have been managed inappropriately, and none had an adverse outcome. CONCLUSION: The misinterpretation rate of cranial CT scans by emergency physicians is of potential clinical concern. However, clinical mismanagement is rare. We recommend that more formal education in CT interpretation be included in residency training and continuing medical education programs for emergency physicians.

Brain Diseases↗
PubMed1995

Biochemical markers of cerebral injury in patients with minor head trauma and ethanol intoxication.

OBJECTIVE: To determine whether biochemical markers can selectively identify those intoxicated patients with presumed minor head injuries who are likely to have CT evidence of intracranial injury. METHODS: Patients presenting to the ED with simultaneous presumed minor head trauma and ethanol intoxication were prospectively entered into this cross-sectional study. Following phlebotomy, all patients received cranial CT. Associations between the presence of an abnormal CT scan for injury and serum levels of the following biochemical markers were sought: serum catecholamines, creatine kinase-brain band (CK-BB), and serum amylase. Serum levels are reported as mean +/- SEM. RESULTS: Nine of the 107 patients (8.4%; 95% CI 3.9-15.4%) had evidence of intracranial injury on CT. Mean serum CK-BB (16.1 +/- 3.7 vs 13.2 +/- 9.6 ng/mL), serum norepinephrine (913 +/- 117 vs 1,089 +/- 76 pg/mL), and serum amylase (64.9 +/- 14.8 vs 84 +/- 4.7 U/L) levels were not significantly different in patients with and without CT evidence of intracranial injury, respectively. Mean serum epinephrine (298 +/- 54 vs 167 +/- 18 pg/mL; p = 0.03) and serum dopamine (218 +/- 50 vs 130 +/- 9 pg/mL; p = 0.014) levels were significantly elevated in the group with intracranial injury on CT. A threshold level of serum dopamine > or = 140 pg/mL yields a sensitivity of 89% (95% CI 52-100%) and a specificity of 80% (95% CI 70-87%) for CT-evident injury. A threshold level of serum epinephrine > or = 218 pg/mL yields a sensitivity of 89% (95% CI 52-100%) and a specificity of 80% (95% CI 70-87%) for CT-evident injury. CONCLUSION: Elevated serum epinephrine and dopamine levels are associated with intracranial CT-evident injury for ethanol-intoxicated patients with presumed minor head injuries. The potential use of these biochemical markers to guide a more selective approach to cranial CT scanning warrants further evaluation.

Alcoholic Intoxication↗