Biomedical subjects
W Rennie
Publications and source records attributed to W Rennie.
Duplicate gallbladder cholecystitis after open cholecystectomy.
A 42-year-old man presented with acute right upper quadrant abdominal pain 2 years after open cholecystectomy. Evaluation revealed cholecystitis in a second gallbladder and a second cholecystectomy was performed. Acute right upper quadrant abdominal pain after cholecystectomy presents a wide differential diagnosis, including the often idiopathic and difficult to manage postcholecystectomy syndrome. Emergency physicians should be aware of the most common causes of pain in these patients. Previously unrecognized congenital abnormalities of the biliary system should be considered when the diagnosis is not clear, as highlighted by this case report.
Interobserver variability among faculty in evaluations of residents' clinical skills.
OBJECTIVE: To describe interobserver variability among emergency medicine (EM) faculty when using global assessment (GA) rating scales and performance-based criterion (PBC) checklists to evaluate EM residents' clinical skills during standardized patient (SP) encounters. METHODS: Six EM residents were videotaped during encounters with SPs and subsequently evaluated by 38 EM faculty at four EM residency sites. There were two encounters in which a single SP presented with headache, two in which a second SP presented with chest pain, and two in which a third SP presented with abdominal pain, resulting in two parallel sets of three. Faculty used GA rating scales to evaluate history taking, physical examination, and interpersonal skills for the initial set of three cases. Each encounter in the second set was evaluated with complaint-specific PBC checklists developed by SAEM's National Consensus Group on Clinical Skills Task Force. RESULTS: Standard deviations, computed for each score distribution, were generally similar across evaluation methods. None of the distributions deviated significantly from that of a Gaussian distribution, as indicated by the Kolmogorov-Smirnov goodness-of-fit test. On PBC checklists, 80% agreement among faculty observers was found for 74% of chest pain, 45% of headache, and 30% of abdominal pain items. CONCLUSIONS: When EM faculty evaluate clinical performance of EM residents during videotaped SP encounters, interobserver variabilities are similar, whether a PBC checklist or a GA rating scale is used.
Immunologic response to tetanus toxoid in the elderly: one-year follow-up.
STUDY OBJECTIVE: To determine whether elderly patients documented to have nonprotective titers of anti-tetanus antibodies (ATA) are able to achieve and maintain protective ATA titers for at least 1 year after tetanus immunization. METHODS: Thirty-five outpatients aged 65 or older with documented inadequate ATA titers were given 1 tetanus immunization. Repeat titers were obtained 2 months and 12 months after immunization. Titers were measured with an enzyme-linked immunoassay kit (Bindazyme kit). ATA titers in excess of .17 IU were considered protective. The study was conducted at a large urban geriatric center. RESULTS: The mean age of participants was 78.7 years; 86% (24/28) were women. Repeat ATA titers were obtained an average of 122 days and 493 days after immunization. The mean preimmunization ATA titer was .1 IU, (range .04 to .16 IU). After immunization, the 2-month ATA titer rose a mean of .61 (95% confidence interval [CI] .35 to .87) IU, with 86% (30/35) achieving protective titers. After 1 year only 28 of 35 patients were available for follow-up. Protective titers had been present in all 7 patients lost to follow-up. After 1 year, 82% (23/28) patients had protective titers. The mean ATA titer for the 28 patients was .54 (95% CI -.78 to 1.86) IU, a significant increase from preimmunization levels (P=.002). However, ATA titers changed -.18 (95% CI -.98 to .62) IU between 2 months and 1 year (P=.02). There was no correlation between gender, country of birth, and medical history with development or maintenance of protective titers. CONCLUSION: Administration of 1 tetanus toxoid affords protective immunization to a large portion of the elderly population after 1 year.
Antibody protection to diphtheria in geriatric patients: need for ED compliance with immunization guidelines.
STUDY OBJECTIVE: Because 50% to 70% of geriatric patients have been shown to have nonproductive levels of tetanus antibodies, we postulated that this population might also have inadequate levels of diphtheria antibodies. Emergency physicians have the opportunity to immunize patients against tetanus and diphtheria. We sought to determine the seroprevalence of diphtheria antibodies in patients older than 65 years and to assess compliance with immunization guidelines in EDs. METHODS: Enzyme-linked immunosorbent assay for diphtheria antibodies was conducted in 58 outpatients of geriatric medical facility aged 65 years or older. We considered titers greater than .1 IU/mL protective. Eighteen ED personnel, ages 25 to 40 years, served as comparison subjects. The preparation used for immunization of injured patients--tetanus toxoid or tetanus and diphtheria toxoids adsorbed for adult use--was determined by means of a telephone survey of 64 New York City EDs. RESULTS: The mean age of our patients was 80 years (range, 65 to 95 years). Their mean diphtheria antibody titer was .17 IU/mL (range, .04 to .54 IU/mL). Thirty-three percent (19 of 58; 95% confidence interval [Cl], 21% to 54%) of patients had inadequate levels of diphtheria antibodies. We found no significant differences between protected and nonprotected patients with respect to age, sex, medical history, or military service. Patients with nonprotective levels of diphtheria antibodies were more likely to have inadequate tetanus antibody titers. Sixty-eight percent of patients without protection from diphtheria (13 of 19; 95% Cl, 48% to 88%) were also unprotected from tetanus, and 33% (13 of 39; 95% Cl, 19% to 47%) o those with adequate diphtheria antibodies had nonprotective levels of tetanus antibodies (P = .012). All 18 ED personnel had adequate diphtheria and tetanus antibodies. The telephone survey revealed that 30% (19 of 64) of EDs use only tetanus toxoid for immunization of injured patients. CONCLUSION: A significant percentage of geriatric patients have inadequate diphtheria antibodies. Emergency physicians must comply with immunization guidelines for injured patients to assure adequate protection from both tetanus and diphtheria.
Immunologic response to tetanus toxoid in geriatric patients.
STUDY OBJECTIVE: Tetanus antibody levels have been shown to be inadequate in 50% of patients older than 65 years. Although immunization recommendations have been made for this age group, the efficacy of this intervention has not been well documented. We sought to determine the difference in tetanus antibody levels after the administration of one tetanus toxoid immunization to geriatric patients without adequate titers. METHODS: Thirty-five patients older than 65 years at a large urban comprehensive care geriatric center who were documented to have inadequate tetanus antibody titers were each given one tetanus toxoid immunization. Repeat titers were obtained at least 2 months after the immunization with the use of enzyme-linked immunosorbent assay (Bindazyme kit; the Binding Site Corporation, Birmingham, England). We considered tetanus antibody levels greater than .17 IU/mL protective. RESULTS: The mean age was 79.4 years; 30 of 35 (86%) were female. Repeat tetanus antibody titers were obtained an average of 123 days (range, 63 to 204 days) after immunization with tetanus toxoid. The mean preimmunization antibody titer was .1 IU/mL (range, .04 to .16 IU/mL). After immunization, antibody titers increased a mean of .61 IU/mL (range, -.01 to 2.23 IU/mL; 95% confidence interval, .35 to .87 IU/mL). Thirty of the 35 patients who received a single injection of tetanus toxoid (86%) developed protective titers. We found no relationship between seroconversion and age, sex, or medical history; nor did we find a relationship between antibody level and time elapsed since immunization when repeat titers were obtained. CONCLUSION: Administration of one tetanus toxoid injection affords protective immunity in many geriatric patients.
Seroprevalence of tetanus antibodies among adults older than 65 years.
STUDY OBJECTIVE: To define the extent of immunity against tetanus among patients older than 65 years of age by measuring antitetanus antibody levels. METHODS: A convenience sample of 129 patients from an urban comprehensive care geriatric center was studied. Serum was obtained and enzyme-linked immunosorbent assay (ELISA) testing performed. Twenty health care providers, aged 25 to 40 years, were tested for comparison. RESULTS: In 64 (50%) of 129 study patients, antitetanus antibody levels did not reach protective levels. Fifty-four (59%) of 92 women and 10 (27%) of 37 men did not have adequate titers. All 20 health care workers had protective titers. CONCLUSION: Elderly patients are substantially less likely than young individuals to have adequate immunity against tetanus. Emergency physicians must take this into consideration when evaluating tetanus immunization status in injured elderly patients.
Displaced acetabular fractures: long-term follow-up.
From 1980 to 1987, 136 patients with displaced acetabular fractures were reviewed to compare the long-term results of operative versus nonoperative treatment. Of 90 patients followed up to 8 years (mean, 4 years, 9 months), 54 were treated operatively and 36 nonoperatively. Experience in pelvic trauma surgery was of significance both in choice of treatment and success in achieving optimum results. Assessment by a new acetabular fracture score showed that anatomic or near-anatomic restoration of the joint led to 86% excellent or good results compared with 30% good results for fractures remaining moderately or severely displaced.
Secondary flexor tendon reconstruction.
Staged flexor tendon reconstruction using silicone rods is a technique that can be successfully used to salvage severely injured digits. Refinements in the technique have led to the development of an active tendon prosthesis which is under clinical investigation. Attention to technical details and a well-supervised rehabilitation program are necessary to obtain satisfactory results.
Slipped femoral capital epiphysis occurring during growth hormone therapy. Report of a case.
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Flexion distraction fractures of the thoracolumbar spine.
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Compression fixation of peritrochanteric fractures and early weight bearing.
Forty-two patients with peritrochanteric fractures of the femur were treated by open reduction and internal fixation with a 95 degree A-Ocompression plate. In 30 of 42 patients (71%) resumption of weight-bearing was achieved by 4 weeks from the time of surgery. Compressive fixation devices have biomechanical advantages over other types of standard nail-plates.