Dr. Richard Wuerz's Emergency Severity Index.
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Emergency Medicine↗
Biomedical subjects
R Walls
Publications and source records attributed to R Walls.
In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review.
A literature search was undertaken for evidence of the effect of succinylcholine (SCH) on the intracranial pressure (ICP) of patients with acute brain injury and whether pretreatment with a defasciculating dose of competitive neuromuscular blocker is beneficial in this patient group. The authors could find no definitive evidence that SCH caused a rise in ICP in patients with brain injury. However, these studies were often weak and small. For those patients suffering acute traumatic brain injury the authors could find no studies that investigated the issue of pretreatment with defasciculating doses of competitive neuromuscular blockers and their effect on ICP in patients given SCH. There is level 2 evidence that SCH caused an increase in ICP for patients undergoing neurosurgery for brain tumours with elective anaesthesia and that pretreatment with defasciculating doses of neuromuscular blockers reduced such increases. It is unknown if this affects neurological outcome for this patient group.
Cerebrovascular Circulation↗
Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort (I).
BACKGROUND: The aim of this study is to formulate criteria for the definition of allergic rhinitis. Other studies have sought to develop scoring systems to categorize the severity of allergic rhinitis symptoms but it was never used for the formulation of diagnostic criteria. These other scoring systems were arbitrarily chosen and were not derived by any statistical analysis. To date, a study of this kind has not been performed. OBJECTIVE: The hypothesis of this study is that it is possible to formulate criteria for the definition of allergic rhinitis. This is the first study to systematically examine and evaluate the relative importance of symptoms, signs and investigative tests in allergic rhinitis. We sought to statistically rank, from the most to the least important, the multiplicity of symptoms, signs and test results. METHODS: Forty-seven allergic rhinitis and 23 normal subjects were evaluated with a detailed questionnaire and history, physical examination, serum total immunoglobulin E, skin prick tests and serum enzyme allergosorbent tests (EAST). RESULTS: Statistical ranking of variables indicated rhinitis symptoms (nasal, ocular and oronasal) were the most commonly occurring, followed by a history of allergen provocation, then serum total IgE, positive skin prick tests and positive EAST's to house dust mite, perennial rye and bermuda/couch grass. Throat symptoms ranked even lower whilst EAST's to cat epithelia, plantain and cockroach were the least important. Not all symptoms, signs and tests evaluated proved to be statistically significant when compared to a control group; this included symtoms and signs which had been considered historically to be traditionally associated with allergic rhinitis, e.g. sore throat and bleeding nose. CONCLUSION: In performing statistical analyses, we were able to rank from most to least important, the multiplicity of symptoms signs and test results. The most important symptoms and signs were identified for the first time, even though some of these were not included in our original selection criteria for defining the disease cohort i.e. sniffing, postnasal drip, oedematous nasal mucosa, impaired sense of smell, mouth breathing, itchy nose and many of the specific provocation factors.
Adult↗
Value of additional two-hour myoglobin for the diagnosis of myocardial infarction in the emergency department.
Myoglobin has been described as an early marker of myocardial injury. It increases within 1 to 3 hours of myocardial injury, and falls back to normal early after the event. Few data suggest that myoglobin can be used to triage patients with chest pain. To assess the diagnostic utility of second myoglobin levels drawn within 2 to 3 hours after presentation to the emergency department for detecting myocardial infarction, we prospectively collected myoglobin levels in 368 patients aged > or = 30 years who were admitted with chest pain. Myoglobin levels were measured at admission and 2 to 3 hours later. Sensitivity and specificity for detecting acute myocardial infarction for a twofold increase in myoglobin level from baseline were 39% and 98%, respectively. The early diagnostic performance of myoglobin at admission, the second level drawn 2 to 3 hours later, and creatine kinase-MB mass drawn at admission were similar (receiver-operating characteristic curves 0.80, 0.86, and 0.85). The diagnostic performance of each of these markers was significantly superior to the absolute change from baseline to second myoglobin (receiver-operating characteristic curve 0.77). In patients who presented within 4 hours of symptom onset, myoglobin drawn 2 to 3 hours later had the highest yield for detecting myocardial infarction. These results suggest that serial myoglobin measurement aiming to detect changes over time is not superior to single marker determinations. Myoglobin measured in 2 to 3 hours from admission may be helpful in triaging patients who present within 4 hours from onset of symptoms.
Creatine Kinase↗
Cardiac troponin I as a predictor of major cardiac events in emergency department patients with acute chest pain.
OBJECTIVES: We sought to evaluate the diagnostic and prognostic value of cardiac troponin I (cTnI) in emergency department (ED) patients with chest pain. BACKGROUND: Although cTnI has been shown to correlate with an increased risk for complications in patients with unstable angina, the prognostic significance of this assay in the heterogeneous population of patients who present to the ED with chest pain is unclear. METHODS: cTnI and creatine kinase-MB fraction (CK-MB) mass concentration were collected serially during the first 48 h from onset of symptoms in 1,047 patients > or =30 years old admitted for acute chest pain. Sensitivity, specificity and receiver operating characteristic curves were calculated for cTnI and CK-MB collected in the first 24 h. RESULTS: The sensitivity, specificity and positive predictive value of cTnI for major cardiac events were 47%, 80% and 19%, respectively. Among patients were who ruled out for myocardial infarction, cTnI was elevated in 26% who had major cardiac complications compared with 5% for CK-MB; the positive predictive value for an abnormal cTnI result was 8%. Elevated cTnI in the presence of ischemia on the electrocardiogram was associated with an adjusted odds ratio of 1.8 (95% confidence interval 1.1 to 2.9) for major cardiac events within 72 h. Among patients without a myocardial infarction or unstable angina, cTnI was not an independent correlate of complications. CONCLUSIONS: In patients presenting to the ED with acute chest pain, cTnI was an independent predictor of major cardiac events, However, the positive predictive value of an abnormal assay result was not high in this heterogeneous cohort.
Adult↗
Correlates of disruptive behavior in severely cognitively impaired nursing home residents.
This article provides information about correlates of "disruptive behaviors" among nursing home residents with dementia. We used averages of multiple observations for a wide range of behaviors (n = 45) across 11 months to gather this information. We placed behaviors into four separate categories: physically aggressive, physically non-aggressive, vocally agitated, and vocally aggressive. Then, we tested associations between these categories and demographic, cognitive, and health variables. Cognitive status and selected demographic variables were associated with the behavior categories; adding health variables did not improve prediction. Lower cognitive status was associated with more disruptive behaviors. Our findings suggest that cognitive status, but not health variables, predicts disruptive behavior among nursing home residents with dementia.
Aged↗
Sensitivity of aerosol bolus behavior to methacholine-induced bronchoconstriction.
STUDY OBJECTIVES: Airway narrowing causes alterations in the shape of an exhaled aerosol bolus that can serve as indexes of airway changes during bronchoprovocation. We compared the sensitivities of aerosol bolus behavior and specific airway conductance (SGaw) during bronchoprovocation in normal subjects. DESIGN AND PARTICIPANTS: Fifteen normal, nonsmoking subjects were studied. Doubling methacholine (MCh) concentrations were delivered during tidal breathing. After each dose, SGaw was determined followed by inhalation of narrow pulses of 1-microm particles introduced into 1-L breaths. Inhaled and exhaled particle concentrations were measured with light scattering photometry. Using plots of concentration vs volume, the exhaled bolus was compared with the inhaled bolus for measurements of volumetric change in mode location (modal shift), particle deposition, and dispersion. To determine baseline intrasubject variability, sham studies using buffer solution were performed on five subjects. RESULTS: MCh caused a proximal modal shift, and increased dispersion and deposition of the exhaled bolus. At most doses, a greater percentage of subjects showed significant change (p<0.05) from baseline for modal shift and deposition than for SGaw. Aerosol bolus behavior displayed less intrasubject variability than did SGaw during sham studies. CONCLUSION: Aerosol bolus behavior is at least as sensitive as SGaw in detecting MCh-induced airway constriction in normal subjects and exhibits less intrasubject variability.
Administration, Inhalation↗
A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact.
BACKGROUND: Use of resources for patients with acute chest pain may be improved with clinical strategies that integrate research, Bayesian analysis, and expert opinion. OBJECTIVES: To 1) develop a critical pathway for management of patients with acute chest pain who are at low risk for complications of ischemic heart disease and 2) assess the potential effects of implementation of the pathway on patient safety and resource use. DESIGN: Evidence-based consensus and prospective cohort study. SETTING: Urban teaching hospital. PATIENTS: Patients at least 30 years of age who were seen in the emergency department for chest pain and who did not have a history of trauma or abnormalities on radiologic study. INTERVENTION: Physician-opinion leaders defined criteria for patient inclusion in the pathway and for remaining on the pathway after 6 or 12 hours of observation. Criteria were defined for appropriateness of direct admission, direct discharge, or 6 hours of observation followed by exercise treadmill testing. MEASUREMENTS: Number of patients admitted to the hospital, number of days that patients were hospitalized, and clinical outcome. RESULTS: 2898 of 4585 patients (63%) were admitted to the hospital; of the 2898, 1152 (40%) were classified as potentially eligible for the pathway and 1068 (93%) had a benign clinical course during the initial observation period. The 1068 patients had a mean length of stay of 2.8 +/- 4.8 days. If 47% of these patients had been discharged after observation and exercise testing, implementation of the pathway would have reduced the number of admissions by 505 (17%) and days of hospitalization by 1407 (11%). CONCLUSIONS: Retrospective analysis suggests that a critical pathway for patients with acute chest pain may substantially reduce resource use. Prospective study is needed to ensure increased efficiency without increased adverse outcomes.
Acute Disease↗
The differentiating agent phenylacetate increases prostate-specific antigen production by prostate cancer cells.
The prostatic-specific antigen (PSA) is the tumor marker most widely relied upon for the monitoring of patients with prostate cancer. Recently, declines in the serum concentrations of PSA have been advocated as a surrogate marker of tumor response in clinical trials of investigational antitumor agents. We examined the hypothesis that this postulate may not apply to the evaluation of drugs such as phenylacetate, a differentiating agent endowed with mechanisms of action different from those of classic cytotoxic chemotherapy. Using human prostatic carcinoma LNCaP cells as a model, we show that phenylacetate induces PSA production despite inhibition of tumor cell proliferation. Incubation of LNCaP cultures with cytostatic doses of phenylacetate (3-10 mM) resulted in a three- to fourfold increase in PSA secretion per cell. This appears to result from upregulation of PSA gene expression, as indicated by elevated PSA mRNA steady-state levels in treated cells. The increase in PSA production per cell was confirmed in rats bearing subcutaneous LNCaP tumor implants that were treated systemically with phenylacetate. Further comparative studies indicate that upregulation of PSA is common to various differentiation inducers, including all-trans-retinoic acid, 1,25-dihydroxyvitamin D3, and butyrate but is not induced by other antitumor agents of clinical interest such as suramin. We conclude that declines in PSA may be treatment specific and that the exclusive use of this criterion as a marker of disease response may mislead the proper evaluation of differentiating agents in prostate cancer patients.
Animals↗
Personality and stress: an exploratory comparison of rheumatoid arthritis and osteoarthritis.
OBJECTIVE: To characterize and investigate the relationship between stress and personality in people with rheumatoid arthritis (RA) compared to those with osteoarthritis (OA). DESIGN: Survey of personality characteristics determined by using Cattell's 16 Personality Factor (16PF) questionnaire and stressful life events at disease onset determined by using the Social Readjustment Rating Scale of Holmes and Rahe. SETTING: Inpatients of an arthritis hospital and outpatients of a clinic, both of which specialize in rheumatic diseases and musculoskeletal problems. PARTICIPANTS: Diagnosed as "definite" or "classical" RA (N = 128) according to the ARA Diagnostic Criteria for Rheumatoid Arthritis (1958 Revision) or as OA (N = 79) according to radiological and clinical evidence; randomly selected, resulting in a close match for gender, age at disease onset, duration of disease, functional classification, and pattern of disease progress. All individuals approached participated. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Twenty personality characteristics, as well as amount of stressful life events at disease onset (Life Change Units). RESULTS: The RA subjects had significantly (p < .001) more stress at disease onset compared to the OA subjects. A subgroup of high-stress-at-onset RA subjects experienced a higher degree of disease severity (p < .01) than did the RA subjects with no stress at onset. Although the mean personality scores for those with RA were not significantly different from those with OA, the RA personality frequency distributions were different. Some of these differences could be explained by the stress-at-onset subgroup personality characteristics. CONCLUSIONS: As a group, subjects with RA exhibited more stress at disease onset than those with OA. Although mean personality scores were not different between RA and OA subjects, they did exhibit different frequency distributions. There appeared to be a high-stress-at-onset subgroup of RA patients who had a worse disease prognosis and who corresponded to a personality frequency subgroup. The interaction between these variables is more complex than implied by the "RA personality" concept.
Arthritis, Rheumatoid↗
Histamine skin prick testing: evaluation of various container materials for long-term storage of histamine solutions.
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Drug Packaging↗
Time as an Adjunctive Agent to Thrombolytic Therapy.
Thrombolytic therapy has dramatically reduced mortality following acute myocardial infarction (MI) with the major effect coming from early achievement of infarct-related artery patency. A major factor in achieving rapid reperfusion is early treatment with thrombolytic therapy. Recent trials have shown that mortality can be reduced if time to treatment is shortened: In the Thrombolysis in Myocardial Infarction (TIMI) 2 trial, for each hour earlier that thrombolytic therapy was started, approximately 10 lives were saved per 1000 patients treated. Thus, one must consider time as an adjunctive agent to thrombolytic therapy. There are four components of the time delay between the onset of MI and achievement of reperfusion: (1) patient delays in seeking medical attention; (2) transport delays; (3) the so-called door to needle time, the interval between the patient's arrival at the medical facility and the initiation of thrombolytic therapy; and (4) thrombolytic reperfusion time, the time between the administration of thrombolytic therapy and the achievement of roperfusion, Efforts to reduce each of these components will lead to additive benefits in improving time to reperfusion and survival of patients with acute MI.
Journal Article↗
Quantitative vasoconstrictor assay for topical corticosteroids: the puzzling case of fluocinolone acetonide.
BACKGROUND: The validity of the vasoconstrictor test has been questioned because of the apparent nonequivalence of some generic corticosteroid products. OBJECTIVE: Our purpose was to determine the vasoconstrictor activity of a generic 0.025% fluocinolone acetonide ointment by two different methods, dilution by volume and dilution by area of application. METHODS: Vasoconstrictor activity on a visual 4-point scale was measured in 20 volunteers. Topical fluocinolone acetonide ointment (0.025%) was tested by comparing dilution by volume (1:1, 1:3, and 1:7) in petrolatum and dilution by area of application. Fluocinolone release from the diluted ointments was also measured with an in vitro method. RESULTS: Dilution by area gave the expected results, a decreasing average vasoconstrictor score; but dilution by volume did not. Both the 1:1 and 1:3 dilutions inexplicably showed greater activity than the full-strength product; this finding was similarly reflected in the in vitro studies that showed a greater rate of drug release from the 1:1 and 1:3 dilutions. CONCLUSION: Dilution by area provides a useful quantitative assay for comparative vasoconstrictor activity.
Adult↗
Candidiasis-endocrinopathy syndrome with progressive myopathy.
A women suffering from the candidiasis-endocrinopathy syndrome, developed severe myopathy in her fourth decade and died from it at the age of 37 years. Associated conditions were hypoparathyroidism, vitiligo, chronic mucocutaneous candidiasis, short stature, intellectual disability, ovarian failure and alopecia totalis. Muscle biopsy findings were non-specific with focal atrophy of type 2 fibres. Serum immunoglobulin levels were normal. The only demonstrable abnormalities of her immune system were impaired T-cell function and antibody production by B-cells (detectable to smooth muscle, mitochondria and gastric parietal cells). The T-cell abnormality may have been part of a more generalized cell defect, resulting from an unidentified genetic abnormality, whilst the circulating antibodies could have been a response to tissue damage. There was no convincing evidence of primary autoimmune damage.
Adult↗
Diameter, cell type, and survival in stage I primary non-small-cell lung cancer.
We analyzed 384 veterans who had "curative" (sometimes conservative) resection from 1966 through 1986 for stage I, non-small-cell primary lung cancer to identify significant variables influencing survival. Operative mortality was 3.1%, mainly from heart attacks. Most patients were asymptomatic, presenting with other diseases of smoking. Five-year survival was 43%; deaths from lung cancer only, 63% (T1, 73%; T2, 49%). Two hundred fourteen (57.5%) of the 372 operative survivors had T1 and 158 (42.5%) had T2 disease. Sixty-five percent had peripheral nodules (84%, T1; 38% T2). Pure squamous cell predominated, in 63% overall (T1, 55%; T2, 74%). Systemic metastases caused most cancer deaths. Within T1, diameter was highly significant. Cell type and time of operation (before or after Dec 31, 1980) were also significant. Under T2, only scarring and differentiation were significant. Veterans in this group live longer if they have small squamous cell tumors.
Adenocarcinoma↗
The effect of in utero exposure to hexachlorobenzene on the developing immune response of BALB/c mice.
BALB/c mice were exposed to 0.0, 0.5 and 5.0 mg/kg maternal body weight hexachlorobenzene (HCB) throughout gestation by daily per os dosing of the females. At 45 days of age selected immune functions of the offspring were assessed. The delayed-type hypersensitivity (DTH) response to oxazolone was severely depressed in animals exposed to either 0.5 or 5.0 mg/kg HCB, however, only those animals exposed to 5.0 mg/kg HCB showed a significant decrease in their mixed lymphocyte response (MLR) levels. The ability of isolated spleen cells to undergo a blastogenic response to concanavalin A (ConA), phytohemagglutinin (PHA) and lipopolysaccharide (LPS) showed no significant changes due to HCB exposure. Similarly, no significant difference in the induction of direct hemolytic plaque-forming cells was seen. A significant increase in the relative distribution of splenic T cells and a significant decrease in splenic B cells was measured in the offspring of HCB-treated females. These results suggest that HCB is capable of affecting the development or maturation of the immune response in mice, perhaps at the T cell level.
Animals↗
Comparison of a videotape instructional program with a traditional lecture series for medical student emergency medicine teaching.
An emergency medicine faculty has reported that the use of the videotape medium for presenting curricular material to medical students is both cost effective and well suited to the educational milieu of the emergency department. In order to compare the effectiveness of videotape instruction with that of a traditional lecture, groups of students received instruction in one topic by videotape and in another topic by lecture. The students' retention of material was tested by a multiple-choice examination administered ten days later. The students scored 76.1% (683 of 898 questions) on material taught by lecture and 76.2% (673 of 883 questions) on material taught by videotape (P greater than 0.7). We conclude that videotape instruction is as effective an educational tool as the traditional lecture for an emergency medicine course.
Curriculum↗
The effectiveness of an organized emergency department follow-up system.
Half the patients discharged home from our emergency department with the diagnoses of acute infection, cervicolumbar strain, bronchospasm, allergic reaction, headache, syncope, vaginal hemorrhage, and undiagnosed chest/abdominal pain were randomly assigned to receive a follow-up telephone call two to three days after their visit. Patients in the follow-up call group were telephoned by an ED nurse who questioned them about changes in their clinical status and clarified the aftercare and referral instructions received during the ED visit. Seven days after the visit, a questionnaire that rated patient satisfaction about six aspects of the ED visit was sent to those patients who had been contacted successfully (study group), and to a diagnosis-matched group of patients (control) who did not receive a follow-up call. A nurse was able to reach 144 of the 297 patients assigned to the study group. Significant referral and aftercare interventions were made in 53 (37%) cases including three patients who were instructed to return to the ED. Questionnaires were returned by 83 of 144 (49%) of the study group and by 94 of 262 (35%) of the control group. Male study group patients consistently rated five of six aspects of their visit higher than did the male controls. No difference was observed in questionnaire ratings between the female study and control groups. We conclude that male patients reached by a follow-up telephone call have a more positive perception of their ED visit. A follow-up call also can be useful for reinforcing aftercare instructions, follow-up referrals, and problem-patient identification.
Adult↗