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Study objective The incidence of skin and soft tissue infections has increased dramatically during the last decade, in part because of increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Incision and drainage is considered the primary intervention; however, some clinicians prefer ultrasonographically guided needle aspiration because it represents a less invasive alternative. Our hypothesis is that ultrasonographically guided needle aspiration is equivalent to incision and drainage in treating simple skin and soft tissue abscesses. Methods This study was a nonblinded randomized controlled trial. Patients with uncomplicated superficial abscesses were randomized to incision and drainage with packing or ultrasonographically guided needle aspiration. Purulence obtained from the abscess was cultured to identify the causative organism. Bedside ultrasonography was performed pre- and postintervention to confirm the presence or absence of an abscess cavity. Patients were followed up at 48 hours (in person by a clinician) and on day 7 (telephone follow-up by research staff). The primary outcome was a combination of sonographic resolution and clinical resolution of the signs and symptoms of ongoing infection at day 7. The signs and symptoms of ongoing infection include increasing pain, erythema, and the presence of pus. Resolution was assessed with both sonographic resolution (day 0 and day 2) and improvement of clinical symptoms (day 2) and resolution of clinical symptoms (day 7) without further intervention. Results A total of 101 patients were enrolled, 54 incision and drainage and 47 ultrasonographically guided needle aspiration patients. At initial presentation, 60% (95% confidence interval [CI] 45% to 70%) of needle aspirations yielded little or no purulence, despite sonographic visualization of an abscess cavity and sonographic guidance during the procedure. The overall success of ultrasonographically guided needle aspiration was 26% (95% CI 18% to 44%) compared with 80% (95% CI 66% to 89%) success in patients randomized to incision and drainage. The difference between groups was 54% (95% CI 35% to 69%). Overall success of both incision and drainage and ultrasonographically guided needle aspiration was lower in patients with CA-MRSA. Patients with CA-MRSA (n=33) were less likely to receive successful drainage with needle aspiration (8% versus 55%) or incision and drainage (61% versus 89%). The difference for needle aspiration and incision and drainage was 47% (95% CI 15% to 57%) and 28% (95% CI 4% to 45%), respectively. Conclusion Ultrasonographically guided needle aspiration is insufficient therapy for skin abscesses. The presence of CA-MRSA decreases the success of both incision and drainage and ultrasonographically guided needle aspiration.

Ornithine transcarbamylase deficiency (OTCD) is an X-linked inherited disease and the most common inborn error in urea synthesis in human patients. In adult heterozygous patients, OTCD can be responsible for life-threatening hyperammonemic coma. We report the case of a 32-year-old woman admitted to our hospital with seizures after a recent high protein load. Her parents related a history of recurrent episodes of vomiting, meat refusal, lethargy, and convulsions since childhood, and measurement of plasma ammonemia levels was the key to early diagnosis of OTCD. We report the pathophysiologic characteristics, clinical features, clinical course, and differential diagnosis of OTCD and discuss the therapeutic options, including continuous venovenous hemodiafiltration and pharmacologic therapy for reduction of plasma ammonemia levels. A diagnosis of OTCD should be considered in adult nonhepatic patients with hyperammonemic coma, particularly if they have a history of protein avoidance and neurologic symptoms. Early recognition and appropriate treatment are critical to avoid severe brain damage and death.

Study objectives: Empiric antibiotic treatment of urinary tract infection (UTI) in adults is based on the local resistance patterns of common uropathogens. Increasing antibiotic resistance has affected empiric antibiotic choice for UTI. Most antibiotic resistance levels report overall inpatient resistance, and there are limited data on outpatient resistance trends. We describe the effect of age on outpatient resistance patterns to common empiric antibiotics. Methods: This is a multicenter, prospective case series composed of patients with UTI. Participating facilities include 4 emergency departments and 84 outpatient clinics in an urban and suburban environment. All urine samples were collected during a 12-month period from July 2002 through June 2003. Only adult patients with a clean-catch urine containing greater than 100,000 colony-forming units of a uropathogen were included. Uropathogens were tested against levofloxacin, ceftriaxone, trimethoprim/sulfamethoxazole (TMP/SMX), and ampicillin. Resistance data were divided into 5 age groups: 18 to 40, 41 to 50, 51 to 60, 61 to 70, and older than 70 years. Results: Two thousand seven hundred fifty-one total urine cultures met inclusion criteria. The 2 most common uropathogens were Escherichia coli (52% to 76%) and Enterococcus sp (11% to 20%) in all age groups. Older patients were less likely to have a UTI caused by E coli. E coli resistance to ceftriaxone and ampicillin varied little across age (0.2% and 32%, respectively), with the exception of patients older than 70 years, where E coli resistance to ampicillin decreased to 23%. E coli resistance to levofloxacin showed nonlinear relationships to age, with the highest resistance seen in the sixth decade (0.76% to 4.55%). E coli resistance to TMP/SMX decreased with advancing age (14.8% in young adults to 11.5% in adults >70 years). The number of UTIs caused by Enterococcus sp increased with advancing age, with older patients having higher resistance to levofloxacin (5.7% in young adults compared with 33% in adults >70 years). Enterococcus sp resistance to ampicillin varied across age groups, with the highest resistance seen in adults older than 70 years (0.0% to 9.2%). Enterococcus sp was not tested against TMP-SMZ or ceftriaxone. Conclusion: Outpatient uropathogen antibiotic resistance was affected by patient age. Enterococcus sp resistance increased as patient age increased. Empiric antibiotic coverage in the elderly should take into consideration the possibility of higher levels of fluoroquinolone resistance in patients with a Gram-positive UTI.

Study objectives: Numerous patients can present to the emergency department (ED) with flank pain. The diagnostic evaluation of these patients is varied but commonly includes urinalysis and an imaging modality. In this study, we evaluate the safety and utility of emergency ultrasonography for the evaluation of renal colic in patients with flank pain. Methods: This was a consecutive, prospective enrollment of afebrile patients with flank pain presenting to an ED of a tertiary care center. Exclusion criteria included trauma, recent urologic surgery, known current kidney stone, or unstable vital signs. All patients underwent identical evaluations, including urinalysis, bedside emergency ultrasonography, computed tomography (CT) scan, and a follow-up call. Ultrasonographic scans were performed by experienced emergency ultrasonographers who were blinded to the CT scan results. A percentage of the CT scans (n=44) were initially read by a radiology resident and later reread by a radiology attending physician. Final diagnosis was determined at 1-month follow-up after review of all patient records and a patient interview. Sensitivity and specificity of the ultrasonographic and initial CT scans were determined using final CT reading. To evaluate a hypothetical decision tree for the evaluation of flank pain in the ED, data were also analyzed post hoc using a set of predefined assumptions: (1) all patients undergo urinalysis; (2) ultrasonography is performed on patients with hematuria; (3) patients with hematuria and unilateral hydronephrosis (by ultrasonography) are diagnosed with renal colic and discharged; and (4) CT scans were performed on all patients with nondiagnostic urinalysis and ultrasonography. The accuracy of this decision tree was evaluated using the final diagnoses as determined by analysis of data and telephone interview at 1-month follow-up. Results: A total of 82 patients were enrolled from December 2001 to December 2003. The average age was 38.8 years, and 59% were female patients. The overall sensitivity and specificity of the emergency ultrasonography (87% and 78%, respectively) closely matched that of the initial resident-read CT scan (84% and 89%, respectively). An analysis of the flank pain decision tree shows that the combination of a positive urinalysis and ultrasonography (n=39) correctly diagnosed 97% of the patients in the study, whereas CT scan (n=43) diagnosed the remainder. Final diagnoses included renal colic (62%), urinary tract infection (6%), diverticulitis (3.6%), pneumonia (2.4%), flank pain (15%), and other (11%). Conclusion: Patients with multiple diagnoses can present with flank pain. Emergency ultrasonography of the kidney has a sensitivity and specificity similar to that of CT. A flank pain decision tree using limited bedside ultrasonography would result in a reduction of 52% of the CT scans, with no loss of diagnostic sensitivity or specificity.

Study objectives: Acute organophosphate poisoning causes mortality by 2 discrete mechanisms: (1) peripheral cholinergic crisis; and (2) central respiratory depression. It has further been reported that the respiratory depressant diazepam paradoxically attenuates organophosphate-induced central respiratory depression; however, it is not known whether this is specifically caused by diazepam's actions on the γ-aminobutyric acid (GABA) receptor or a nonspecific effect on respiratory drive. We determine whether the respiratory depressant morphine also attenuates organophosphate-induced respiratory depression. Methods: Sprague-Dawley rats (n=34) weighing 200 to 250 g were randomized to receive treatment with nothing (controls), glycopyrrolate 3 mg/kg, diazepam 5 mg/kg, morphine 5 mg/kg, glycopyrrolate+diazepam or glycopyrrolate+morphine, 5 minutes before a single subcutaneous injection of the organophosphate dichlorvos (20 mg/kg). A reviewer blinded to the treatment group observed the animals for signs of peripheral cholinergic crisis (salivation, defecation, urination, and retractions) and respiratory arrest for up to 20 minutes after poisoning. Results: Fasciculations were seen within 3 minutes of dichlorvos injection in all animals, regardless of treatment group. In control animals and those treated solely with diazepam or morphine, fasciculations were followed by signs of severe peripheral cholinergic crisis and respiratory arrest within 6 minutes of poisoning. Rapid respiratory arrest (within 8 minutes of poisoning) also occurred in all animals treated with glycopyrrolate alone; however, it was not preceded by signs of peripheral cholinergic distress. Fifty percent of the animals treated with diazepam+glycopyrrolate survived to the 20-minute endpoint of the study ( P ≤.05 by χ 2 analysis), suggesting that this combination treatment attenuated both the peripheral and central nervous system manifestations of the poisoning. The beneficial effects of combination treatment with a peripheral anticholinergic+a respiratory depressant were not seen in the cohort receiving morphine+glycopyrrolate (100% mortality by 8 minutes). Conclusion: These findings suggest that diazepam attenuates central respiratory depression by a GABA-dependent mechanism not related to its respiratory depressive effects.