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Biomedical subjects

S M Isaacs

Publications and source records attributed to S M Isaacs.

8 recordsLinked to original sources
PubMed2001

A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus.

BACKGROUND: It is uncertain whether the administration of benzodiazepines by paramedics is an effective and safe treatment for out-of-hospital status epilepticus. METHODS: We conducted a randomized, double-blind trial to evaluate intravenous benzodiazepines administered by paramedics for the treatment of out-of-hospital status epilepticus. Adults with prolonged (lasting five minutes or more) or repetitive generalized convulsive seizures received intravenous diazepam (5 mg), lorazepam (2 mg), or placebo. An identical second injection was given if needed. RESULTS: Of the 205 patients enrolled, 66 received lorazepam, 68 received diazepam, and 71 received placebo. Status epilepticus had been terminated on arrival at the emergency department in more patients treated with lorazepam (59.1 percent) or diazepam (42.6 percent) than patients given placebo (21.1 percent) (P=0.001). After adjustment for covariates, the odds ratio for termination of status epilepticus by the time of arrival in the lorazepam group as compared with the placebo group was 4.8 (95 percent confidence interval, 1.9 to 13.0). The odds ratio was 1.9 (95 percent confidence interval, 0.8 to 4.4) in the lorazepam group as compared with the diazepam group and 2.3 (95 percent confidence interval, 1.0 to 5.9) in the diazepam group as compared with the placebo group. The rates of respiratory or circulatory complications (indicated by bag valve-mask ventilation or an attempt at intubation, hypotension, or cardiac dysrhythmia) after the study treatment was administered were 10.6 percent for the lorazepam group, 10.3 percent for the diazepam group, and 22.5 percent for the placebo group (P=0.08). CONCLUSIONS: Benzodiazepines are safe and effective when administered by paramedics for out-of-hospital status epilepticus in adults. Lorazepam is likely to be a better therapy than diazepam.

Adult↗
PubMed2001

The prehospital treatment of status epilepticus (PHTSE) study: design and methodology.

Status epilepticus is a neurological emergency that is typically first encountered and managed in the prehospital environment. Although aggressive pharmacological treatment of status epilepticus is well established in the emergency department and hospital settings, the relative risks and benefits of active therapy for status epilepticus in the prehospital setting are not known. The Prehospital Treatment of Status Epilepticus (PHTSE) study is a prospective, randomized, double-blind, placebo-controlled study designed to address the following aims: (1) to determine whether administration of benzodiazepines by paramedics is an effective and safe means of treating status epilepticus in the prehospital setting and whether this therapy influences longer-term patient outcome, (2) to determine whether lorazepam is superior to diazepam for the treatment of status epilepticus in the prehospital setting, and (3) to determine whether control of status epilepticus prior to arrival to the emergency department influences patient disposition. The initial phase of the PHTSE study began in January 1994 and was completed in February 1999 after the successful enrollment of 205 patients into the three treatment arms. In this paper, we describe the rationale for the conceptualization of the study and details of the study design and methodology, and emphasize some aspects of study implementation that are unique to research involving the emergency medical system.

Adult↗
PubMed1996

Out-of-hospital treatment of opioid overdoses in an urban setting.

OBJECTIVES: To investigate clinical outcomes in a cohort of opioid overdose patients treated in an out-of-hospital urban setting noted for a high prevalence of i.v. opioid use. METHODS: A retrospective review was performed of presumed opioid overdoses that were managed in 1993 by the emergency medical services (EMS) system in a single-tiered, urban advanced life support (ALS) EMS system. Specifically, all patients administered naloxone by the country paramedics were reviewed. Those patients with at least 3 of 5 objective criteria of an opioid overdose [respiratory rate < 6/min, pinpoint pupils, evidence of i.v. drug use. Glasgow Coma Scale (GCS) score < 12, or cyanosis] were included. A response to naloxone was defined as improvement to a GCS > or = 14 and a respiratory rate > or = 10/min within 5 minutes of naloxone administration. ED dispositions of opioid-overdose patients brought to the county hospital were reviewed. All medical examiner's cases deemed to be opioid-overdose-related deaths by postmortem toxicologic levels also were reviewed. RESULTS: There were 726 patients identified with presumed opioid overdoses. Most patients (609/726, 85.4%) had an initial pulse and blood pressure (BP). Most (94%) of this group responded to naloxone and all were transported. Of the remainder, 101 (14%) had obvious signs of death and 16 (2.2%) were in cardiopulmonary arrest without obvious signs of death. Of the patients in full arrest, 2 had return of spontaneous circulation but neither survived. Of the 609 patients who had initial BPs, 487 (80%) received naloxone i.m. (plus bag-valve-mask ventilation) and 122 (20%) received the drug i.v. Responses to naloxone were similar; 94% i.m. vs 90% i.v. Of 443 patients transported to the country hospital, 12 (2.7%) were admitted. The admitted patients had noncardiogenic pulmonary edema (n = 4), pneumonia (n = 2), other infections (n = 2), persistent respiratory depression (n = 2), and persistent alteration in mental status (n = 2). The patients with pulmonary edema were clinically obvious upon ED arrival. Hypotension was never noted and bradycardia was seen in only 2% of our presumed-opioid-overdose population. CONCLUSIONS: The majority of the opioid-overdose patients who had initial BPs responded readily to naloxone, with few patients requiring admission. Noncardiogenic pulmonary edema was uncommon and when present, hypoxia was evident upon arrival to the ED. Naloxone administered i.m. in conjunction with bag-valve-mask ventilation was effective in this patient population. The opioid-overdose patients in cardiopulmonary arrest did not survive.

Adult↗
PubMed1994

Fulminant reexpansion pulmonary edema in a patient with AIDS.

A 23-year-old man with AIDS presented to the emergency department with recurrent spontaneous pneumothoraces secondary to recent Pneumocystis carinii pneumonia. Shortly after placement of bilateral pigtail catheters for chest reexpansion, he developed fatal unilateral reexpansion pulmonary edema. The association between P carinii pneumonia and pneumothorax, and the risk factors and pathophysiology of reexpansion pulmonary edema are reviewed. Emergency physicians should recognize that reexpansion pulmonary edema is an important complication in the treatment of prolonged spontaneous pneumothorax that can lead rapidly to severe hypoxia, hypotension, and death.

AIDS-Related Opportunistic Infections↗
PubMedDate not supplied

Improved paramedic sensitivity in identifying stroke victims in the prehospital setting.

OBJECTIVE: The authors have previously shown that San Francisco paramedics without specific training in stroke recognition identified acute stroke victims with a 61% sensitivity and a 77% positive predictive value (PPV). The authors implemented an educational program on stroke to improve paramedic accuracy in stroke recognition. METHODS: Twenty-two paramedics volunteered to attend a four-hour seminar about stroke and then were followed prospectively for six months. All encounters with adult patients who were evaluated by both trained and untrained paramedics and were transported to two university hospitals were reviewed. Subjects were identified by paramedic assessment as stroke/transient ischemic attack (TIA) and/or final hospital discharge diagnosis of stroke/TIA after detailed chart review. Sensitivity and PPV for paramedic identification of stroke were calculated. RESULTS: During the prospective six-month phase, 84 confirmed stroke patients were transported to the target hospitals. Of the 32 who were transported by trained paramedics, all but three were identified as having stroke/TIA, resulting in a sensitivity of 91%. This is significantly higher than the 61% previously found (p=0.01). Nontrained paramedics also increased their sensitivity to 90%. Thirty-eight false-positive patients were identified, resulting in PPVs of 64% for trained paramedics and 69% for all other paramedics. CONCLUSIONS: Institution of an educational stroke program was associated with a significant increase in sensitivity in stroke identification by the paramedics; however, educational influences outside this training program may have contributed to the increased sensitivity. Better education for paramedics, combined with rapid response to stroke victims once identified, may result in improved care for victims of acute stroke.

Adult↗
PubMedDate not supplied

Population-based health promotion: a new agenda for public health nurses.

The role of Public Health Nurses (PHNs) involves participation in the development and implementation of population-based health promotion activities. To support encourage and facilitate such participation, the Nursing Division of the Hamilton-Wentworth Department of Public Health Services initiated a "New Agenda" that would help to realize these PHN roles. The New Agenda involved a commitment by the Nursing Division to support population-based health promotion activities by PHNs through changes in Nursing Division policies and practices, and the advancement of a consensus among PHNs regarding the practice of population-based health promotion. A series of four workshops were designed and introduced to ensure that structural barriers to developing PHN roles were eliminated. PHNs stated they achieved role clarification and role acceptance through the New Agenda interventions.

Attitude of Health Personnel↗
PubMedDate not supplied

Effectiveness of public health interventions in food safety: a systematic review.

PURPOSE: To summarize evidence on the effectiveness of public health interventions regarding food safety at restaurants, institutions, homes and other community-based settings. METHOD: This systematic review of published and unpublished studies involved a comprehensive literature search, screening for relevance, quality assessment of relevant studies, data extraction and synthesis. RESULTS: The interventions identified in 15 studies included in this review were grouped into three categories: inspections, food handler training, and community-based education. The evidence suggests that: routine inspection (at least once per year) of food service premises is effective in reducing the risk of foodborne illness; food handler training can improve the knowledge and practices of food handlers; and selected community-based education programs can increase public knowledge of food safety. DISCUSSION: There is some evidence for the effectiveness of multiple public health interventions on food safety. Future research needs include evaluation of HACCP and community-based education programs.

Food Contamination↗