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Biomedical subjects

R C Levy

Publications and source records attributed to R C Levy.

At least 19 recordsLinked to original sources
PubMed1995

A rapid diagnostic and treatment center for patients with chest pain in the emergency department.

STUDY OBJECTIVE: To evaluate a comprehensive diagnostic 9-hour evaluation (Heart ER Program) for patients with possible acute ischemic coronary syndromes. DESIGN: Retrospective review of consecutive patients. SETTING: Urban tertiary care emergency department. PARTICIPANTS: A total of 1,010 patients with symptoms suggestive of acute ischemic coronary syndrome was enrolled in the Heart ER Program over the first 32 months of operation. Patients with history of coronary artery disease, hemodynamic instability, acute ST-segment elevation or depression of more than 1 mm, or a clinical syndrome consistent with unstable angina were directly admitted to the hospital. INTERVENTION: Patients underwent serial testing for creatine kinase (CK-MB) on presentation to the Heart ER and 3, 6, and 9 hours later with continuous 12-lead ECGs/serial ST-segment trend monitoring for 9 hours. Two-dimensional echocardiography and graded exercise testing were performed in the ED after the 9-hour evaluation period. RESULTS: Of 1,010 patients, 829 (82.1%) were released home from the ED; 153 (15.1%) required admission for further cardiac evaluation. Fifty-two of 153 (33.9%) admitted patients were found to have a cardiac cause for their symptoms; 43 had acute ischemic coronary syndromes (12, acute myocardial infarction; 31, angina or unstable angina). CONCLUSION: The Heart ER program provides an effective method for evaluating low- to moderate-risk patients with possible acute ischemic coronary syndrome in the ED setting.

Adult↗
PubMed1994

Role of emergency medicine residency programs in determining emergency medicine career choice among medical students.

STUDY OBJECTIVE: To characterize the role of emergency medicine residency programs in determining emergency medicine career choice among medical students. DESIGN: Observational, cross-sectional, descriptive study. Information on student career choice was obtained through a targeted query of the National Resident Matching Program data base, simultaneously stratified by specialty and school, and adjusted for class size. PARTICIPANTS: All accredited emergency medicine residency programs and four-year allopathic medical schools. RESULTS: Fifty-two schools (42%) had a closely affiliated emergency medicine residency program, ie, one based primarily at the institution's main teaching hospital(s). This configuration was associated with a 70% increase in the median proportion of students choosing emergency medicine as a career when compared to the 73 schools with no closely affiliated emergency medicine residency (5.1% vs 3.0%, P < .0001). When institutions were stratified by overall commitment to emergency medicine, the median proportion of students choosing emergency medicine as a career was 2.9% for institutions with a minimal commitment to emergency medicine (neither an academic department of emergency medicine nor a closely affiliated emergency medicine residency), 4.1% for institutions with a moderate commitment to emergency medicine (either a department of emergency medicine or an emergency medicine residency, but not both), and 5.7% for institutions with a substantial commitment to emergency medicine (a department of emergency medicine and an emergency medicine residency) (P < .0001). When institutional commitment to emergency medicine was examined in a simple multivariate model, only the presence of an emergency medicine residency was associated independently with student career choice (P < .001). CONCLUSION: An emergency medicine residency program that is closely affiliated with a medical school is strongly and independently associated with a quantitatively and statistically significant increase in the proportion of students from that school who choose a career in emergency medicine. These data support the proposition that, if emergency medicine is to meet national manpower shortage needs by attracting students to the specialty, it must establish residency programs within the primary teaching hospital(s) of medical schools. Such a configuration does not currently exist in the majority of schools.

Career Choice↗
PubMed1992

Factors associated with career longevity in residency-trained emergency physicians.

STUDY OBJECTIVE: To test the hypothesis that residency-trained emergency physicians who left the practice of emergency medicine do not differ significantly from those who continue to practice. DESIGN: A retrospective cohort study using a mailed questionnaire. TYPE OF PARTICIPANTS: Eight hundred fifty-eight emergency medicine residency graduates from 1978 through 1982. METHODS: A mailed questionnaire was used to obtain data from the study population. Individuals who did not respond to the first mailing were sent a second survey six weeks later. A sample of 10% of nonrespondents was contacted by telephone and compared with respondents on five variables. Respondents were divided into physicians who continued to practice emergency medicine and those who had elected to leave the specialty. The variables used to compare the two groups included personal and professional demographics, career satisfaction, and satisfaction with training. chi 2, Fisher's exact t-test, and logistic regression were used to analyze the data with an a priori level of significance set at .05. MEASUREMENTS AND MAIN RESULTS: There were 539 complete responses for a response rate of 62.8%. No statistical differences between responders and nonresponders were identified. The ten-year survival rate of respondents was 84.9%. Those who left emergency medicine were less likely to be board certified in emergency medicine (P less than .001), were more likely to be board certified in another field (P = .001), were less likely to work with residents during their emergency medicine practice (P = .009), and were more likely to report an annual gross income of less than $100,000 per year (P less than .001). Emergency physicians who have left the field were less likely to report being satisfied or very satisfied with their initial choice of emergency medicine as a specialty (P = .001). There was no difference in satisfaction with the quality of emergency medicine residency training (P = .183). CONCLUSION: Career longevity of residency-trained emergency physicians has been greater than early predictions. Interactions with residents, higher income, satisfaction with training decision, and board certification in emergency medicine are variables associated with a higher retention rate.

Adult↗
PubMed1985

Bilateral pneumothorax in an intravenous drug abuser.

Pneumothorax is a condition commonly encountered by emergency physicians. Bilateral pneumothorax is a rare occurrence. We present a case of self-induced bilateral pneumothorax in an intravenous drug abuser. Causes of bilateral pneumothorax are reviewed.

Adult↗
PubMed1985

Single-dose ceftriaxone treatment of urinary tract infections.

Single-dose antibiotic therapy for urinary tract infections in which no underlying structural or neurologic lesions are present holds the promise of greater patient compliance and convenience. We present the results of a study comparing a single intramuscular dose of a long-acting, third-generation cephalosporin, ceftriaxone, with a standard, five-day regimen of trimethoprim-sulfamethoxazole (TMS). Fifty-two patients were entered into the study. After randomization, 26 were assigned to the TMS group and 26 were assigned to the ceftriaxone group. Of the patients who completed the study, 13 of the TMS group had positive cultures at the time of initial presentation, and 20 of the ceftriaxone group had positive cultures. There was no statistical difference between the groups in symptoms of dysuria, hematuria, frequency, flank pain, and nocturia (alpha = .05). The physical parameters of age, blood pressure, pulse, and temperature were similar in the two groups (alpha = .05), as were the types of infecting organisms (alpha = .05). When comparing the two regimens, the ceftriaxone group cure rate (18 of 20, 90%) was not found to be significantly different from that of the TMS-treated control group (13 of 13) (alpha = .05).

Administration, Oral↗
PubMed1985

Treatment of cutaneous abscess: a double-blind clinical study.

Controversy exists about the value of antibiotic therapy following incision and drainage of cutaneous abscess. We undertook a randomized double-blind study to clarify the controversy. Adult patients with cutaneous abscesses who received outpatient surgical therapy were entered into the study. Following incision and drainage, patients received cephradine or placebo for seven days using a randomized code in a double-blind fashion. At the end of seven days, patients were reevaluated. Twenty-seven patients were treated with cephradine, and 23 with placebo. Ninety-six percent of the patients in each group were improved clinically after seven days. We conclude that cephradine did not alter the outcome of cutaneous abscesses at one week after incision and drainage. The implications are twofold: patients are not exposed to the potential side effects and allergic reactions of antibiotics, and the cost of health care can be reduced by not prescribing antibiotics in these patients.

Abscess↗
PubMed1984

Cutaneous abscesses: natural history and management in an outpatient facility.

This study investigated the natural history and treatment of cutaneous abscesses in an outpatient setting. Incision, drainage, aerobic and anaerobic cultures were done on all 78 patients entered in the study. Tenderness and fluctuance were noted in more than 80% of the patients; erythema and induration in more than 60%. Forty-one percent of all abscesses were in the anogenital region. Forty-two percent of cultured abscesses grew aerobes exclusively, 28% grew anaerobes exclusively, and 27% grew a mixture of aerobes and anaerobes. The predominant aerobic organisms were Staphylococcus and Streptococcus, which were mostly isolated from the head/neck, extremities, and axillary regions. The predominant anaerobic organisms were Peptococcus and Bacteroides, which were primarily isolated from the anogenital regions. Nearly 60% of the patients returned for reevaluation. They were equally divided between those patients taking antibiotics and those not on antibiotics. However, all patients were clinically improved.

Abscess↗
PubMed1984

High carboxyhemoglobin level without acute or chronic findings.

The clinical effects of carbon monoxide in humans have been well studied and described. Carboxyhemoglobin levels usually correlate with the degree of symptomatology; however, some investigators have noted that there may be a wide disparity between absolute carboxyhemoglobin levels and clinical status. A case is reported here of a young man with a potentially lethal level of carbon monoxide who developed neither significant symptomatology nor long-term sequelae. Until a more sensitive indicator of clinical outcome is found, clinicians must rely on carboxyhemoglobin levels and clinical history and examination to make treatment decisions, realizing that clinical presentation and absolute carboxyhemoglobin levels may correlate poorly.

Adult↗
PubMed1984

Emergency phenytoin loading by constant intravenous infusion.

We evaluated the efficacy of constant intravenous (IV) phenytoin infusion. Thirty-eight patients were evaluated prospectively for complications of continuous-infusion phenytoin loading. A total dose of 18 mg/kg was administered as a solution of 500 mg phenytoin in 50 mL normal saline using a constant infusion pump. The initial delivery rate was 40 mg/min. Cardiac rhythm was monitored by telemetry, and rhythm strips and vital signs were obtained every 15 minutes during infusion. Therapeutic phenytoin blood levels (greater than 10 micrograms/mL) were achieved in 37 patients (97%). Infusion was discontinued in one patient because of IV site irritation shortly after initiation of the infusion. Phenytoin levels in the toxic range were seen immediately postinfusion in 22 patients and in the four-hour postinfusion samples of 16 patients. Thirteen of 18 levels drawn 12 to 24 hours after infusion were therapeutic. Phenytoin levels greater than 20 micrograms/mL were tolerated without significant change in rhythm, QRS interval, or QT interval. A small statistically significant (P less than .05) decrease in systolic and mean arterial pressure was noted during the infusion. Complications included burning at the IV infusion site in four patients; the discomfort was relieved in three cases by reducing the rate of infusion to 20 mg/min. Seizures occurred in two patients during the infusion, requiring the additional use of diazepam or phenobarbital. Administration of a loading phenytoin dose by constant IV infusion is an effective means for achieving therapeutic levels quickly.

Adolescent↗
PubMed1983

Male sexual assault.

Reported cases of sexual assault in the United States increased 21% from 1974 to 1978. Recent literature discusses the medical, legal, and psychological management of the female sexual assault victim, but little has been written regarding appropriate management of male sexual assault. Twenty-nine male sexual assault victims were examined at University Hospital from 1976 to 1980. This study reviews evidence of genital and extragenital trauma and the percentage of those requiring gonorrhea prophylaxis. It further studies the background and characteristics of the sexual assault victim, characterization of the assailant, as well as the details and time of the assault. Information concerning male sexual assault and the unique problems associated with this group is scarce. This study is intended to aid in the development of an effective protocol in dealing with this group of patients and to sensitize physicians to this group of patients.

Adolescent↗
PubMed1983

Transcutaneous cardiac pacing: determination of myocardial injury in a canine model.

Transcutaneous cardiac pacing holds promise as the initial cardiac pacing technique for emergency patients. Determination of the extent of myocardial injury associated with the use of commercial transcutaneous pacemaker devices has been limited. This study was undertaken to document electrocardiographic, enzymatic, and histologic changes following transcutaneous pacing. Ten mongrel dogs were paced with a transcutaneous cardiac pacemaker for 30 minutes. Electrical pulses of 100 mA lasting 20 ms each were delivered at a rate of 80/min via cutaneous electrodes on the anterior and posterior thorax. Myocardial damage was assessed by serial electrocardiograms (ECGs), serial creatine kinase (CK) determinations with myocardial band (MB) fractionation, and gross and microscopic pathologic examination. Double blind reading of the ECGs showed no significant changes after pacing. CK levels peaked an average of 78 units over baseline levels at 4 hours; however, there was no rise in the CK MB fraction. Pathologic examination revealed micro-infarcts adjacent to intramural vessels in 5 animals, but no clinically significant myocardial injury in the 10 dogs. The absence of enzymatic, cardiographic, and clinically significant pathologic findings was statistically significant (P less than .05). Transcutaneous pacing at low currents and for short periods appears to be a safe technique. This pacing technique deserves further evaluation, and may hold promise as a clinical tool during resuscitation.

Animals↗
PubMed1983

Pilot study on disposition and pain relief after i.m. administration of meperidine during the day or night.

Two groups (four patients each) of sickle cell anemia patients with severe pain were studied. One group comprised patients admitted to emergency unit in the morning (5:40 to 9:15) and the other patients admitted in the evening (18:53 to 22:50). All patients received intramuscular meperidine (1.5 mg/kg). Pain intensity and pain relief were followed for 4 h; blood samples were taken up to 6 h after drug administration. Significant differences in drug disposition were found between the day and night groups, as the elimination half-life was 46% shorter during the night and the total serum clearance was 70% greater during the night. Whereas a positive correlation was found between drug concentration and pain relief for the day group, no such correlation was found for th night group. Even though peak concentrations were higher during the night, analgesia was lower. This pilot study suggests that much higher meperidine doses might be required during the night to achieve equieffective analgesia.

Adult↗
PubMed1981

Lidocaine levels during CPR: differences after peripheral venous, central venous, and intracardiac injections.

Drug administration via peripheral vein, central vein, and intracardiac routes is generally assumed to be equally effective during cardiopulmonary resuscitation (CPR). Experiments were performed in an animal model to evaluate this assumption. Twelve mongrel dogs weighing greater than 20 kg were studied. Arterial blood pressure and electrocardiogram were monitored continuously. Cardiac outputs were evaluated before CPR to determine control. After thoracotomy and fibrillation of the heart, cardiac massage was started and the rate of compression adjusted to give 30% of control cardiac output. A lidocaine bolus of 1.5 mg/kg was given via peripheral vein in four dogs, central vein in four dogs, and intracardiac (left ventricle) in four dogs. Drug levels were sampled through an aortic catheter at the level of the coronary artery ostia every 20 sec for five min, every 30 sec for 10 min, and every 60 sec for 15 min. There was no significant difference in the appearance of effective levels or time of peak levels in the three groups. The peak levels were highest in the central venous group, while peripheral venous and intracardiac peak levels were 63% and 31%, respectively, of the central venous peak. Duration of effective levels was 20 min in the intracardiac group, 14.5 min in the central venous group, and 9.6 min in the peripheral venous group. Further studies are needed to determine whether changes are needed in drug administration during CPR in man.

Animals↗
PubMed1981

Experimental design for study of cardiopulmonary resuscitation in dogs.

Many different designs for studies of various aspects of cardiopulmonary resuscitation (CPR) in dogs are described in the literature. No single technique is generally accepted. We present a systematized approach to the study of CPR in the canine model. Cardiac output, arterial blood pressure, and electrocardiogram were recorded for three different methods. The methods studied were closed chest compression, closed chest compression with an automatic gas-powered chest compressor, and open chest manual cardiac massage. Cardiac output for both types of external chest compression were less than 17% of control in all cases. With open chest cardiac massage, systemic arterial blood pressures were in the 50 mm Hg to 100 mm Hg range and cardiac output of up to 70% of control was achieved. Using a metronome to obtain compression rate and the arterial blood pressure to guide the efficacy of compression, consistent levels of cardiac output could be achieved for up to 30 minutes using open chest cardiac massage. Closed chest massage in man results in a cardiac output of 25% to 30% of normal when performed under optimal conditions. A cardiac output of 25% to 30% of control cannot be achieved in large dogs with external chest compression, and hence is not a good model to stimulate CPR in man.

Animals↗