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Background Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare mosaic disorder of Gαs activation. Fibroblast Growth Factor 23 (FGF23)-mediated hypophosphatemia is a feature of FD/MAS that has been associated with poor skeletal outcomes. Standard therapy includes oral phosphorus and vitamin D analogs; however, treatment is limited by potential adverse renal and gastrointestinal effects. Burosumab is a monoclonal antibody to FGF23 approved to treat patients with X-linked hypophosphatemia and tumor-induced osteomalacia. There is currently no safety or efficacy data to support burosumab use in patients with FD/MAS. Case description A 7-year-old boy with severe FD/MAS presented with persistent hypophosphatemia and skeletal complications despite conventional treatment with oral phosphate and calcitriol. He was started on burosumab and achieved sustained normalization of serum phosphorus and marked improvement in alkaline phosphatase levels. This was accompanied by an encouraging clinical response, including decreased bone pain, improved muscle strength, and improved ambulation. No adverse effects of burosumab therapy were observed. Conclusions This is the first reported case of burosumab treatment in a patient with FD/MAS. The encouraging biochemical and clinical response in this patient highlights the need for future studies to explore the safety and efficacy of burosumab in the FD/MAS pediatric population.

International audience; ObjectifsLa voie robot-assistée a récemment été décrite pour l’implantation du sphincter artificiel urinaire (SAU) chez la femme pour tenter de diminuer la morbidité périopératoire. L’objectif de cette étude était de rapporter les résultats périopératoires et fonctionnelles de la première série multicentrique internationale de sphincter artificiel urinaire robot-assistée.MéthodesToutes les patientes ayant eu une implantation robot-assistée d’un SAU en utilisant une technique standardisée (voie antérieure) entre 2013 et 2020 dans quinze institutions européennes ont été incluses dans une étude rétrospective. L’indication du SAU était une incontinence urinaire d’effort par insuffisance sphinctérienne définie comme la combinaison d’une faible pression de clôture urétrale et un urètre peu mobile/figé. Le principal critère d’évaluation était le résultat fonctionnel classé comme sec (aucune protection), amélioré ou inchangé.RésultatsCent vingt-cinq patientes ont été incluses. Les caractéristiques des patientes sont résumées dans le Tableau 1. Il y a eu 20 complications peropératoires (16 %) : 12 plaies du col vésical et huit plaie vaginales. Dans un cas de plaies multiples du col vésical, l’intervention a été interrompue mais elle a été poursuivie dans tous les autres cas. Vingt-deux patientes ont eu une complication postopératoire (17,6 %) mais seulement quatre étaient Clavien ≥ 3 (3,2 %) : trois explantations précoces (2 pour érosion vaginale et une pour infection) et une réintervention pour fistule vésicale. Après un suivi moyen de 13 mois, il y a eu 7 explantations (4,1 %) : les 3 précoces rapportées ci-dessus, une pour rétention chronique d’urine et trois pour érosions tardives (2 vaginales et une urétrale). Au dernier suivi, 101 patientes étaient sèches (80,8 %), 11 étaient améliorées (8,8 %) et 13 étaient inchangées (10,4 %).ConclusionCette série est la première série multicentrique internationale évaluant les Résultats de l’implantation du SAU chez la femme par voie robot-assistée selon une technique standardisée. Cette étude confirme les résultats périopératoires et fonctionnels prometteurs rapportés dans les précédentes séries.

Lower urinary tract symptoms are classified in storage symptoms, voiding symptoms, and post-micturition symptoms. Evaluation of lower urinary tract dysfunction aims at: identifying the symptoms and related bother, assessing related pelvic floor dysfunction, and suspecting underlying causes. Primary evaluation in current clinical practice include identification of each symptom according to the current terminology, other urological symptoms, as well as bowel function and sexual function. Bother and impact on quality of life are also evaluated, usually through standardized, validated questionnaires. Clinical examination of the pelvis is mandatory, and complementary evaluation by bladder diary, pad test, uroflowmetry is often proposed, depending on the clinical picture. Indications for further investigations (blood tests, imaging, urodynamics, endoscopy) are guided by the initial clinical assessment.

International audience

Data are lacking on long-term outcomes of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity. The aim of this study was to assess the outcomes of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity after more than 10 years of followup.We retrospectively reviewed the charts of all consecutive neurological patients who had received onabotulinumtoxin A or abobotulinumtoxin A intradetrusor injections for neurogenic detrusor overactivity between January 2002 and November 2007 at a total of 3 academic centers. The primary outcome measure was the 10-year discontinuation rate. Other outcomes of interest were failure, reasons for discontinuation and subsequent treatments of neurogenic detrusor overactivity. Discontinuation-free and failure-free survival was estimated by Kaplan-Meier analyses.A total of 140 patients were included in study. The 10-year discontinuation-free and failure-free survival rates were 49.1% and 73%, respectively. The most common reason for discontinuation was failure in 43.7% of cases, which was primary and secondary in 17.2% and 26.5%, respectively. Secondary failure occurred after a median of 8 injections and a median of 80.1 months from the first injection. Other reasons for discontinuation were patient decision in 28.1% of patients, nonbotulinum toxin A related improvement of urinary incontinence in 14.1%, neurological condition progression in 12.5% and an adverse event in 1.6%. Discontinuation-free survival was significantly poorer in patients with spina bifida than in patients with multiple sclerosis or spinal cord injury (p = 0.02).More than half of the patients with neurogenic detrusor overactivity discontinued intradetrusor botulinum toxin A within the first 10 years after the initial injection. Patients with spina bifida are at high risk for discontinuation.

Traumatic brain injuries (TBI) are common occurrences in childhood, often resulting in long term, life altering consequences. Research into endocrine sequelae following injury has gained attention; however, there are few studies in children. This paper reviews the pathophysiology and current literature documenting risk for endocrine dysfunction in children suffering from TBI. Primary injury following TBI often results in disruption of the hypothalamic-pituitary-adrenal axis and antidiuretic hormone production and release, with implications for both acute management and survival. Secondary injuries, occurring hours to weeks after TBI, result in both temporary and permanent alterations in pituitary function. At five years after moderate to severe TBI, nearly 30% of children suffer from hypopituitarism. Growth hormone deficiency and disturbances in puberty are the most common; however, any part of the hypothalamic-pituitary axis can be affected. In addition, endocrine abnormalities can improve or worsen with time, having a significant impact on children’s quality of life both acutely and chronically. Since primary and secondary injuries from TBI commonly result in transient or permanent hypopituitarism, we conclude that survivors should undergo serial screening for possible endocrine disturbances. High indices of suspicion for life threatening endocrine deficiencies should be maintained during acute care. Additionally, survivors of TBI should undergo endocrine surveillance by 6–12 months after injury, and then yearly, to ensure early detection of deficiencies in hormonal production that can substantially influence growth, puberty and quality of life.

Objectifs Il n’y a pas a l’heure actuelle de consensus sur la technique a employer pour la reparation des fistules vesico-vaginales (voie vaginale vs voie abdominale ; voie transvesicale vs voie extravesicale ; interposition de tissu vs pas d’interposition de tissu). L’objectif de cette video etait de presenter une technique de cure de fistule vesico-vaginale trans-vesicale robot-assistee avec epiplooplastie laparoscopique. Methodes Nous presentons le cas d’une femme de 48 ans consultant pour incontinence urinaire permanente dans les suites d’une hysterectomie par voie abdominale pour fibrome. Son seul autre antecedent medical etait une dystrophie myotonique de Steinert. L’examen clinique et la cystoscopie mettait en evidence une fistule vesico-vaginale infra-centimetrique supra-trigonale, situe au niveau du dome vaginal. Resultats Pour commencer, la fistule est intubee avec une sonde ureterale. La patiente est ensuite positionnee en declive et l’epiploon est mobilise en laparoscopie pour preparer l’epiplooplastie. La patiente est ensuite mise en position de Trendelenburg a 23° et le robot chirurgical Da Vinci est amarree en utilisant les memes trocarts que pour le temps cœlioscopique. Apres une adhesiolyse, la vessie est remplie avec du serum physiologique et une lame est placee dans le vagin pour faciliter la dissection de l’espace inter-vesico-vaginal. La vessie est ensuite ouverte au dome jusqu’a l’orifice fistuleux qui est reseque. L’orifice vaginal est suturee au V-Lock horizontalement et la cystotomie est elle refermee au V-Lock verticalement. Enfin, l’epiplooplastie est interposee entre vessie et vagin et fixee avec un V-Lock. Conclusion La cure de fistule vesico-vaginale trans-vesicale robot-assistee avec epiplooplastie laparoscopique apparait faisable et etait associee dans le cas present a des resultats peri-operatoires et fonctionnels satisfaisants. Des series prospectives, idealement controlees, sont necessaires pour confirmer les benefices potentielles de cette approche compares aux autres techniques precedemment decrites.

Study Objective Evaluate for differences in the management of adolescents with polycystic ovarian syndrome (PCOS) across 3 pediatric specialties. Design Retrospective review of medical records. Setting Academic children’s hospital. Participants 181 adolescents seen between July 2008 and June 2010 by providers in Pediatric Endocrinology (PEndo), Adolescent Medicine (AMed), or Pediatric and Adolescent Gynecology (PGyn) identified via billing data (ICD-9 code for PCOS, 256.4). Interventions None. Main Outcome Measures (1) Percentage of adolescents with a billing diagnosis of PCOS who met diagnostic criteria; (2) Percentage of individuals screened for comorbidities and differences across specialties; (3) Differences in treatment recommendations across specialties; (4) Factors associated with recommendation for metformin and hormonal contraceptives. Results Thirteen percent of PEndo patients did not meet diagnostic criteria for PCOS; 20% of AMed and PGyn patients did not meet criteria. There were significant differences in rates of screening for obesity, insulin resistance, and Type 2 diabetes. There were significant differences in treatment recommendations for lifestyle changes, metformin, and anti-androgen therapy across specialties. Specialty and obesity were significant predictors of metformin recommendation; specifically PEndo predicted metformin recommendation. PGyn and AMed specialties predicted hormonal contraceptive recommendation. Conclusions The variability observed among specialties may be due to differences in training, accounting for a range of comfort with aspects of PCOS. Formulation of consensus guidelines for diagnosis and management of PCOS are needed, along with broad educational efforts. By correctly diagnosing, screening for comorbidities, and managing PCOS appropriately during adolescence, providers may reduce the risk for long-term consequences.

Objectifs La voie robot-assistee a ete recemment decrite comme une option qui pourrait permettre de reduire la morbidite de l’implantation du sphincter artificiel urinaire AMS-800 chez la femme. La plaie du col vesical peroperatoire reste pour autant une complication relativement commune avec cette voie d’abord. L’objectif de cette video etait de decrire les principes de prise en charge d’une plaie du col vesical peroperatoire. Methodes Nous presentons le cas d’une femme de 70 ans aux antecedents de cure de prolapsus prothetique par voie vaginale et de deux bandelettes sous-uretrales TOT avec persistance d’une incontinence urinaire d’effort par insuffisance sphincterienne. Resultats Les etapes cles suivies ici et dans les quelques autres cas de plaie vesicale pour effectuer une reparation efficace et permettre l’implantation du sphincter artificiel en minimisant le risque d’erosion vesicale sont : – reprendre la dissection plus lateralement pour ramener medialement les fibres detrusoriennes laisses sur la paroi vaginale et retrouver le bon plan ; – effectuer un passage autour du col vesical plus distal, vers l’uretre pour pouvoir positionner la manchette aussi loin que possible de la plaie du col vesical ; – terminer ce passage autour du col vesical et mettre en place le mesureur ; – reparer minutieusement la plaie du col vesical en 2 ou 3 plans par des hemisurjets ; – effectuer un test au bleu pour s’assurer que la reparation est etanche. Conclusion Grâce a une vision magnifiee en 3 dimensions et une dexterite augmentee par la technologie Endowrist, la voie d’abord robot-assistee pourrait permettre non seulement de diminuer la frequence des perforations du col vesical mais aussi de faciliter leur detection precoce en peroperatoire et une reparation efficace en suivant les principes exposes dans cette video.

Objectifs Les symptomes de la phase du remplissage sont frequents chez les patients atteints de maladie de Parkinson (MP). La forte prevalence des troubles ano-rectaux associes font de la neuromodulation sacree (NMS) un traitement potientiellement interessant dans cette population, mais il n’existe aucune donnee a ce jour pour le confirmer. L’objectif de ce travail etait d’evaluer les resultats de la NMS chez les patients MP. Methodes Tous les patients atteints de MP ayant eu un test de NMS pour symptomes de la phase du remplissage entre 2008 et 2018 dans six centres universitaires ont ete inclus dans une etude retrospective. Les patients avec un diagnostic de syndrome parkinsonien atypique etaient exclus. Le test effectue etait soit percutane (PNE), soit a l’aide de l’electrode definitive ( staged ). Un boitier interstim 2 etait implante a l’issue de la phase de test chez les patients ayant une amelioration de leurs symptomes > 50 %. Resultats Vingt patients ont ete inclus. Il s’agissait majoritairement d’hommes (60 %) avec un âge median de 74 ans, tous resistants aux anticholinergiques et dont 90 % avaient une hyperactivite detrusorienne au bilan urodynamique pre-NMS. Les tests etaient de type PNE dans 6 cas et staged dans 14 cas. Treize patients (65 %) avaient une amelioration > 50 % de leurs symptomes apres une phase de test d’une duree moyenne de 8,7 jours et ont donc eu l’implantation d’un boitier interstim 2. Aucune complication postoperatoire n’a ete notee que ce soit lors des 20 tests ou des 13 implantations. Apres un suivi median de 20 mois, seul 7 patients conservaient une amelioration > 50 % (efficacite en intention de traiter : 35 %) avec une difference significative en fonction du type de test (PNE = 0 % vs. staged = 50 % ; p = 0,05). Conclusion Cette serie est la premiere a evaluer les resultats de la NMS chez les patients atteints de MP. Les resultats observes semblent inferieurs a ceux rapportes dans les populations idiopathiques et soulignent la necessite d’autres etudes aidant a preciser le role de la NMS dans cette population. Le test percutane (PNE) semble sous-optimal chez les patients atteints de MP.

Study objective Validate a clinical prediction rule prognostic of short-term fatal and inpatient nonfatal outcomes for heart failure patients admitted through the emergency department. Methods We retrospectively studied a random cohort of 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure as defined by primary discharge diagnosis codes. We reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low risk by the prediction rule. Results The prediction rule classified 1,609 (19.2%) of the patients as low risk. Within this subgroup, there were 12 (0.7%; 95% confidence interval [CI] 0.3% to 1.2%) inpatient deaths, 28 (1.7%; 95% CI 1.1% to 2.4%) patients survived to hospital discharge after a serious complication, and 47 (2.9%; 95% CI 2.1% to 3.7%) patients died within 30 days of the index hospitalization. Conclusion This prediction rule identifies a group of admitted heart failure patients at low risk of inpatient mortal and nonmortal complications. Our validation findings suggest the rule could assist physicians in making site-of-care decisions for this patient population and aid in analyzing presenting illness burden in study populations.

International audience; BACKGROUND: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting. OBJECTIVE: To identify the factors associated with the hospitalization of low-risk patients with pneumonia. METHODS: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments. RESULTS: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to outpatient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III. CONCLUSIONS: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contraindications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

Objectives: To derive a prediction rule using data available in the emergency department (ED) to identify a group of patients hospitalized for the treatment of heart failure who are at low risk of death and serious complications. Methods: The authors analyzed data for all 33,533 patients with a primary hospital discharge diagnosis of heart failure in 1999 who were admitted from EDs in Pennsylvania. Candidate predictors were demographic and medical history variables and the most abnormal examination or diagnostic test values measured in the ED (vital signs only) or on the first day of hospitalization. The authors constructed classification trees to identify a subgroup of patients with an observed rate of death or serious medical complications before discharge < 2%; the tree that identified the subgroup with the lowest rate of this outcome and an inpatient mortality rate < 1% was chosen. Results: Within the entire cohort, 4.5% of patients died and 6.8% survived to hospital discharge after experiencing a serious medical complication. The prediction rule used 21 prognostic factors to classify 17.2% of patients as low risk; 19 (0.3%) died and 59 (1.0%) survived to hospital discharge after experiencing a serious medical complication. Conclusions: This clinical prediction rule identified a group of patients hospitalized from the ED for the treatment of heart failure who were at low risk of adverse inpatient outcomes. Model performance needs to be examined in a cohort of patients with an ED diagnosis of heart failure and treated as outpatients or hospitalized.

Community-acquired pneumonia causes more than 4 million episodes of illness each year and has high morbidity, mortality, and total cost of care. Nationwide, nearly 75% of community-acquired pneumonia patients are initially evaluated and treated in hospital-based emergency departments (EDs). Substantial variation exists in illness severity assessment, hospital admission decisions, and performance of recommended processes of care. We designed an ED-based quality improvement trial focused on the initial care of patients with community-acquired pneumonia. We used the Pneumonia Severity Index and level of arterial oxygenation to identify patients at low risk for 30-day mortality and to guide admission decisionmaking. We assessed the performance of recommended "best practices," consisting of assessment of arterial oxygenation, the collection of blood cultures for inpatients, and the timely initiation of appropriate empiric antibiotic therapy for inpatients and outpatients. We conducted a 32-site, cluster-randomized trial in Pennsylvania and Connecticut, comparing the effectiveness and safety of 3 guideline implementation strategies of increasing intensity. The multifaceted implementation plans were carried out in conjunction with each state's quality improvement organization. This article describes the background, objectives, and methodology of this trial to translate evidence-based knowledge on the quality and efficiency of care for community-acquired pneumonia into clinical practice.

Summary Background: Bispectral index (BIS) is a signal processing device that potentially is a pharmacodynamic measure of the effects of anaesthesia on the central nervous system. Methods: In this prospective blinded study, we investigated the pharmacodynamic relationship between BIS, haemodynamic changes during anaesthesia and endtidal nonsteady state concentrations of sevoflurane in 30 children, mean age 3.3 ± 1.1 years, who were undergoing tonsillectomy and adenoidectomy. A standardized anaesthetic technique was used and included induction and maintenance with sevoflurane, nitrous oxide and oxygen. BIS, heart rate, mean arterial pressure (MAP) and endtidal sevoflurane (ETsevo) concentrations were continuously recorded and specifically noted at the time of intubation, placement of Dingman gag, incision of adenoid, adenoid out, incision of tonsil, tonsil one out, tonsil two out, last agent off, first spontaneous movement, first eye opening and extubation. The anaesthetist was blinded to BIS throughout the procedure. Results: Using a Spearman correlation analysis, there was significant negative correlation between BIS and ETsevo concentrations (r=− 0.888, P

Objectives: Existing clinical practice guidelines for ordering prothrombin time (PT) and partial thromboplastin time (PTT) tests in the emergency department (ED) include physician expectation of an invasive procedure as a criterion. This study sought to determine whether this criterion accurately identifies patients who undergo an invasive procedure and whether an amalgam of these guidelines identifies patients at low risk of an adverse medical outcome. Methods: A prospective observational cohort study of adults treated in a university medical center ED between July 1997 and March 1998. Physicians were surveyed at order placement to determine the presence of guideline criteria. Adverse clinical outcomes defined as an International Normalized Ratio [INR] > 1.3 or PTT > 39.9 seconds combined with consequent directed medical therapy were abstracted from ED and the first 24 hours of inpatient medical records. Results: The sensitivity of ED physician expectation of an invasive procedure was 60.0%; therefore, it was excluded from both the PT and PTT guidelines. There were 553 patients with a PT test order; test order indications were absent in 190 (34.4%), of which one (0.5%, 95% CI = 0.1% to 2.9%) had adverse outcomes. There were 547 patients with a PTT test; test order indications were absent in 226 (41.3%), of which three (1.3%, 95% CI = 0.4 to 3.8%) had adverse outcomes. All three were taking warfarin when they presented to the ED. Conclusions: Emergency department physician expectation of an invasive procedure for patients with PT or PTT test orders is an insensitive predictor of patients who undergo such procedures. Clinical practice guidelines that exclude this criterion identify ED patients at the time of ED presentation at low risk for adverse medical outcomes in the ED or shortly after admission.

In this prospective study, we evaluated the bispectral index (BIS) and postoperative recall during the intraoperative wake-up examination in 34 children and adolescents undergoing scoliosis surgery. Each anesthesiologist was blinded to BIS values throughout surgery and the wake-up test. The BIS, mean arterial blood pressure, and heart rate were compared at: before starting the wake-up test, patient movement to command, and after the patient was reanesthetized. The anesthetic technique for Group 1 was small-dose isoflurane, nitrous oxide, fentanyl, and midazolam and for Group 2 was nitrous oxide, fentanyl, and midazolam. Controlled hypotension was used for all cases. At patient movement to command, the patients were told a specific color to remember (teal) and on the second postoperative day were interviewed for explicit recall of the color and other intraoperative events. A total of 37 wake-up tests were performed in 34 patients. There was a significant increase in both groups of BIS (P0.001), mean arterial blood pressure (P0.001), and heart rate (P0.01) at the time of purposeful patient movement followed by a significant decline in BIS after reintroduction of anesthesia (P0.01). No patient recalled intraoperative pain, one patient recalled the wake-up test but not the color, and five patients recalled the specified color. We conclude that BIS may be a useful clinical monitor for predicting patient movement to command during the intraoperative wake-up test, particularly when controlled hypotension is used and hemodynamic responses to emergence of anesthesia are blunted.The relationship between bispectral index (BIS) and purposeful intraoperative patient movement is consistent with previous BIS utility studies. We conclude that BIS may be a useful clinical monitor for predicting patient movement to command during the intraoperative wake-up test, particularly when controlled hypotension is used and hemodynamic responses to emergence of anesthesia are blunted.

[Hsieh M, Auble TE, Yealy DM. Predicting the future: can this patient with acute congestive heart failure be safely discharged from the emergency department? Ann Emerg Med. February 2002;39:181-189.]

UNLABELLED The bispectral index (BIS) correlates with consciousness during adult anesthesia. In this prospective, blinded study of children (n = 24) and infants (n = 25) undergoing elective circumcision, we evaluated BIS and consciousness level during emergence from anesthesia. Anesthesia was maintained with sevoflurane, and a penile nerve block was performed in each patient before surgical stimulation. At the completion of surgery, the sevoflurane was decreased stepwise from 0.9% in increments of 0.2%, and arousal was tested with a uniform auditory stimulus given after a steady state of end-tidal sevoflurane concentration was achieved at each step. The BIS increased significantly as the sevoflurane concentrations decreased in children (0.9%, 62.5 +/- 8.1; 0.7%, 70.8 +/- 7.4; and 0.5%, 74.1 +/- 7.1; P < 0.001 for 0.7% and 0.5% compared with 0.9%), but a similar relationship was not demonstrated in infants. The BIS values at 0.7% and 0.5% sevoflurane were significantly higher in children than infants (P < 0.02 and P < 0.002, respectively). In both children and infants, the BIS increased significantly from pre- to postarousal (children, 73.5 +/- 7 to 83.1 +/- 12, P = 0.01; infants, 67.8 +/- 10 to 85.6 +/- 13.6, P < 0.001). The BIS at which arousal was possible with the stimulus tended to be higher in children than in infants (P = 0.06). IMPLICATIONS In this study comparing the Bispectral index (BIS) in infants and children undergoing circumcision surgery by use of a standardized surgical and anesthetic technique, a significant decrease in BIS was detected in children during a stepwise decrease in end-tidal sevoflurane concentration. A similar relationship was not demonstrated in infants less than 1 yr old. In both children and infants, BIS increased significantly from pre- to postarousal. Additional studies are necessary to determine changes in BIS with maturational changes in the electroencephalogram.

Study objectives To examine the psychometric and cardiac effects of pseudoephedrine at 1 and 3 atmospheres (atm) of pressure (0 and 66 feet of sea water, respectively), and to make recommendations about the agent's safety in the diving environment. Design Double-blind, placebo-controlled, crossover study. Setting Monoplace hyperbaric chamber of a university hospital. Subjects Thirty active divers (mean age 38 yrs). Intervention A bank of seven tests was used to assess cognitive function during four different simulated dive combinations: placebo-1 atm, placebo3 atm, pseudoephedrine-1 atm, and pseudoephedrine-3 atm. Measurements and main results Heart rate and cardiac rhythm were recorded during all dives. Repeated-measures analysis of variance was used to analyze the effects of pseudoephedrine, depth, and drug-depth interaction. No significant, independent effects of pseudoephedrine were seen on any of the seven psychometric test scores (p>0.05), although the drug tended to increase anxiety scores (p=0.092). Depth resulted in a significant increase in anxiety scores (p=0.021) and a significant decrease in verbal fluency test scores (p=0.041); it had no significant effects on the other five psychometric tests (p>0.05). Pseudoephedrine caused a significant increase (p=0.036) in mean heart rate, and depth caused a significant decrease (p=0.013). Neither pseudoephedrine nor depth affected cardiac rhythm. Conclusion Pseudoephedrine does not cause significant alterations in psychometric performance at 3 atm of pressure that might increase the risk of diving. Depth causes significant adverse effects on anxiety levels and semantic memory at 3 atm. Pseudoephedrine and depth have significant but opposite effects on heart rate; although, these effects are unlikely to be clinically significant during diving. It is unlikely that pseudoephedrine adds significant risk to the diver.

Study Objectives. To examine the psychometric and cardiac effects of dimenhydrinate at 1 and 3 atmospheres (atm) of pressure (0 and 66 feet of sea water, respectively), and to make recommendations about the drug's safety in the diving environment. Design. Double-blind, placebo-controlled, crossover study. Setting. Monoplace hyperbaric chamber of a university hospital. Subjects. Thirty active divers (mean age 38 yrs). Interventions. A bank of seven tests was used to assess cognitive function during four different dive combinations: placebo-1 atm, placebo-3 atm, dimenhydrinate-1 atm, and dimenhydrinate-3 atm. Measurements and Main Results. Heart rate and cardiac rhythm were recorded during all dives. Repeated-measures multivariate analysis of variance was used to analyze the effects of dimenhydrinate, depth, and drug-depth interaction. Dimenhydrinate resulted in a significant decrease in scores of mental flexibility (trail-making, part B, p 0.05). It had no effect on mean heart rate (p>0.05), although frequent unifocal ventricular ectopic beats occurred in two subjects after ingestion of the drug. Depth resulted in a significant decrease in verbal memory test scores (p=0.001) and mean heart rate (p

Community-acquired pneumonia (CAP) is a common medical illness with a prognosis that ranges from rapid complete recovery to severe medical complications and death. Approximately 4 million adults are diagnosed with CAP in the United States each year, with more than 600, 000 (15%) hospitalized. 16, 27 An estimated 4 billion dollars is expended annually on patients with CAP, 8, 16 20, 27 with inpatient therapy costing as much as 20 times that of outpatient antimicrobial therapy. There is substantial variability in hospital admission rates for adults with CAP, 25,26 31,36 suggesting that clinicians use inconsistent criteria when making the initial site-of-care decision. Some patients at low risk for a poor outcome may be hospitalized but could be safely treated with an initial course of outpatient therapy. Identification of these patients at the time of presentation could reduce admissions and associated health care costs without compromising patient outcomes. Medical practitioners responsible for the initial site-of-care decision for low-risk patients with CAP consider several clinical and psychosocial factors as very important when selecting the initial site of care. 11 Clinical factors very important in the hospitalization decision include comorbid illness, multilobar infiltrate, poor clinical appearance, and arterial hypoxemia. Conversely, good clinical appearance, normal respiratory status, ability to maintain oral intake, normal mental status, and normal or only mildly abnormal vital signs were very important in the decision to provide outpatient care. Psychosocial factors including patient reliability and adequacy of home support were also rated as very important in the initial site-of-care decision. Evidence suggests that clinicians apply these factors in a manner that tends to overestimate patient risk of short-term mortality. 11 Among patients with an observed 30-day mortality of less than 1%, practitioners estimated that 5% of outpatients and 41% of inpatients had an expected mortality exceeding 5%. Multivariate analysis revealed that patients with a physician-estimated risk of death in excess of 5% were 18 times more likely to be hospitalized. Physicians often overestimate the potential for short-term mortality and consequently opt for more intensive inpatient therapy. The decision to hospitalize patients with CAP and at low risk of mortality may be at odds with patient preferences. Empirical evidence showed that 80% of a group of low-risk patients would have preferred outpatient-based care, and most were willing to pay approximately one week's worth of household income to be assured of this preference. 6 Better risk assessment by clinicians could yield more highly valued care and ultimately reduce the costs associated with hospitalization for CAP. The author's review the current consensus guidelines and clinical prediction rules now available for assessing patient prognosis and selecting an appropriate initial site of care for adults presenting with CAP.

Objective: To determine the feasibility of police officers providing defibrillation with automated external defibrillators (AEDs) and to assess the effectiveness of this strategy in reducing time to defibrillation of victims of out-of-hospital sudden cardiac arrest. Methods: This was a prospective, interventional cohort study with historical controls conducted in 7 suburban communities in which police usually arrived at the scene of medical emergencies before EMS personnel. All adult patients who suffered cardiac arrest before EMS arrival and on whom EMS personnel attempted resuscitation were enrolled. Police officers who were trained to use and equipped with AEDs during the intervention phase were dispatched simultaneously with EMS to medical emergencies. Police were instructed to use the AED immediately on determination of pulselessness. Outcome measures were the difference between control and intervention phases in interval from the time the call was received at dispatch to the time of first defibrillation and in rate of survival to hospital discharge for patients initially in ventricular fibrillation. Results: EMS personnel attempted 183 resuscitations in the control phase and 283 during the intervention; of these, 80 (44%) and 127 (45%), respectively, involved patients with initial ventricular fibrillation rhythms. Mean time to defibrillation decreased from 11.8±4.7 minutes in the control phase to 8.7±3.7 minutes in the intervention phase ( P P =.1). When police arrived before EMS personnel, shock administered by police compared with shock administered by EMS was associated with improved survival (26% [12/46] versus 3% [1/29], P =.01). Logistic regression analysis revealed AED use was an independent predictor of survival to hospital discharge. Conclusion: In 7 suburban communities, police use of AEDs decreased time to defibrillation and was an independent predictor of survival to hospital discharge. [Mosesso VN Jr, Davis EA, Auble TE, Paris PM, Yealy DM: Use of automated external defibrillators by police officers for treatment of out-of-hospital cardiac arrest. Ann Emerg Med August 1998; 32:200-207.]

To determine whether there were differences in tidal volume (Vt), minute volume (MV), average mask leak per breath (ML), gastric insufflation (GI), and peak airway pressure (PAP) when ventilating a nonintubated mannikin with a bag-valve-mask (BV), manually triggered ventilator (MTV), and automated ventilator (AV). The authors' hypothesis was that there would be no differences among the devices for any of these variables.This was a prospective in-vitro experimental model. A convenience sample of 19 emergency medical technicians (EMTs) ventilated a nonintubated mannikin-mechanical test lung model with the BV, MTV (flow rate 40 L/min; pressure relief 55 cm H2O), and AV (800 mL/breath; rate 12). Each subject, blinded to volume and pressure gauges, used each device for 2 minutes at both normal (0.1 cm H2O) and poor (0.04 cm H2O) compliances. Vt, MV, GI, and PAP were measured directly and ML was calculated. A survey was issued to the EMTs who participated in the study. Data were analyzed with repeated-measures ANOVA and the Bonferroni-Dunn multiple comparison test with alpha set at 0.05.At the normal compliance, PAP was higher for the BV than the MTV (p = 0.0001) and AV (p0.0001). MV was also greater with the BV than with the AV (p = 0.001). PAP was also higher at the poor compliance with the BV than with the MTV and AV (p = 0.008 and 0.013, respectively). The BV had a higher GI at this compliance (p0.0001) and a higher ML than the AV (p = 0.002).All three devices delivered similar volumes when used by EMTs, but the BV was associated with higher PAP, ML, and GI.

Portable transport ventilators (TV) and demand valves (DV) may be effective and easy-to-use alternatives to bag-valve (BV) for prehospital ventilation of adults. The purpose of the study was to determine whether such devices maintain arterial blood gases and airway pressures similar to those for BV in a pediatric swine model.This study was a prospective, randomized, crossover design using immature swine (9.6 +/- 0.9 kg) to model ventilation in small children. Anesthetized, intubated, paralyzed, and cannulated animals were ventilated initially on standard mechanical hospital ventilation (HV). They were then assigned in random order to 10-minute intervals of ventilation using BV, TV, low-frequency jet ventilation (JV), and DV. Data were analyzed using repeated-measures ANOVA and Tukey multiple comparisons (alpha = 0.05).The PaO2 exceeded 90 mm Hg for all animal/ventilation combinations. Blood PaCO2 was lower for BV and DV than it was for TV, JV, or HV. In contrast, blood pH was higher for BV and DV than it was for TV, JV, or HV. Peak airway pressure was higher for BV than it was for HV, TV, or JV; it was lower for JV than it was for HV, TV, or BV.This animal model suggests that automated TV and JV may provide more effective ventilation of children than do manual BV or DV devices. Although promising, these findings require application in children under prehospital emergent conditions.

Study objective: We sought to assess the involvement of law enforcement agencies in out-of-hospital emergency medical care and their attitudes toward expanded roles in emergency medical services (EMS) systems. Methods: We mailed a 20-question survey to 800 police chiefs and sheriffs randomly selected from a list of all law enforcement agencies in the United States. The questions focused on the characteristics of each law enforcement agency, its current level of involvement in providing out-of-hospital emergency medical care, and the characteristics of its associated community and local EMS system. The survey concluded with four statements to assess officer attitudes toward an expanded role in EMS-related activities. We used the χ 2 or Fisher exact test to analyze differences in proportions. The α-error rate was set at .05. Results: Seventeen surveys were returned as undeliverable. Of the remaining 783 surveys, we received 602 responses (77%). Five hundred forty-nine (70.1%) of the respondents were the primary law enforcement agencies in their communities; they make up the final sample. The median number of officers per agency was 12 (range, 1 to 2,623), and the median population served was 6,936 (range, 150 to 1,500,000). Responses indicated that 442 (80.7%) agencies responded to one or more specific types of medical emergencies and 263 (50.3%) provided some level of patient care. Law enforcement officers frequently arrived at the scene of medical emergencies before EMS personnel (81.5%), with a roll-time interval of less than 8 minutes (87.2%). Only 14 agencies (2.6%) used automatic external defibrillators. Fifty-three percent agreed with the statement that EMS-related activities would interfere with their law enforcement duties. However, more than 60% of respondents agreed that law enforcement agencies should be involved in providing emergency medical services for life-threatening emergencies, that their officers would be willing to undertake extra medical training, and that EMS-related activities would improve their public images. Conclusion: Many law enforcement agencies are involved to some extent in providing out-of-hospital emergency medical care, and most of the agencies we surveyed would support additional medical training and new or expanded roles for themselves in EMS systems. Alonso-Serra HM, Delbridge TR, Auble TE, Mosesso VN, Davis EA: Law enforcement agencies and out-of-hospital emergency care. Ann Emerg Med April 1997; 29:497-503.]

There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation.From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate ofor = 30 or a temperature ofor = 40 degrees C), and abnormal laboratory findings (such as a pH7.35, a blood urea nitrogen concentrationor = 30 mg per deciliter [11 mmol per liter] or a sodium concentration130 mmol per liter) at presentation.There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients.The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.

Over the last three years, the Holifield accelerator system has been reconfigured into a first-generation radioactive ion beam facility, the HRIBF, a national user facility for RIB research. The construction and reconfiguration have been completed and the equipment commissioning and beam development phases have started. The progress to date, the present status, and future plans will be given. The special problems connected with the production and acceleration of RIBs will be discussed.

Objectifs La perte secondaire d’efficacite d’un sphincter urinaire artificiel amene a rechercher une dysfonction mecanique ou un facteur tissulaire. En cas d’absence d’erosion uretrale, une repressurisation peut etre proposee dans l’objectif de retrouver la continence par une meilleure coaptation en regard de la paroi uretrale. Le but de cette etude etait d’evaluer les resultats de la repressurisation de sphincter artificiel chez l’homme. Methodes Etude retrospective a ete menee dans un centre universitaire de reference. Tous les patients ayant eu une repressurisation de sphincter artificiel AMS800™ entre 2005 et 2015 avec ou sans changement de ballon ont ete inclus. Les donnees etudiees etaient : les indications operatoires, les modalites de repressurisation, les complications et les donnees d’efficacite (pad-test de 24 heures et port de protection). Le succes etait defini par un pad-test Resultats Trente-quatre patients ont ete inclus ( Tableau 1 ). Tous les patients ont ete implantes avec un dispositif AMS800™ avec ballonnet 61–70cmH20, avec placement initial de la manchette en periurethral ( n = 19) ou intracaverneux ( n = 15). Le delai median de repressurisation etait de 40 mois [5–154]. Une simple repressurisation (gonflage de 2 a 5 mL sous controle de pression uretrale retrograde) a ete effectuee dans 14 cas et un changement de ballon (71–80cmH20) dans 20 cas. Le taux de succes etait de 35 %. Dix-sept patients (50 %) ont necessite une reprise chirurgicale pour erosion, atrophie uretrale, migration de ballon, fuite au niveau du ballon ou de la manchette, ou infection ( Tableau 2 ). Conclusion La repressurisation sphincterienne est une solution de recours en cas de deficit de pression de cloture de la manchette mais comporte un risque d’erosion uretrale qui fait discuter en alternative un repositionnement de manchette en zone non atrophiee.

See related editorial, "Effectiveness of Basic Life Support Defibrillation." Study objective: Although some studies demonstrate otherwise, we hypothesized that metaanalysis would demonstrate a reduction in the relative risk of mortality when basic life support (BLS) providers can defibrillate out-of-hospital cardiac arrest patients. Design: Metaanalysis of studies meeting the following criteria: single-tier or two-tier emergency medical service (EMS) system, survival to hospital discharge for patients in ventricular fibrillation, and manual and/or automatic external defibrillators. The aerror rate was .05. Results: Seven trials qualified for metaanalysis. Across all trials, the risk of mortality for BLS care with defibrillation versus that without was .915 (P =.0003). Separate subset analyses of single-tier and two-tier EMS systems demonstrated similar results. Conclusion: BLS defibrillation can reduce the relative risk of death for out-of-hospital cardiac arrest victims in ventricular fibrillation. Weaknesses in individual study designs and regional clustering limit the strength of this metaanalysis and conclusion. [Auble TE, Menegazzi JJ, Paris PM: Effect of out-of-hospital defibrillation by basic life support providers on cardiac arrest mortality: A metaanalysis. Ann Emerg Med May 1995;25:642-648.]

Clinicians currently order imaging studies for most patients with blunt head or neck trauma if there is even a remote possibility of cervical-spine injury, in order to avoid missing a potentially disabling fracture, dislocation, or ligamentous injury. The result of this practice is that 96 percent or more of cervical-spine radiographs reveal no clinically important injuries.1,2 A decision rule, or clinical prediction rule, that could reliably identify patients with trauma who are at very low risk for cervical anatomical disruption could help reduce unnecessary radiographic testing, improve efficiency, and decrease health care expenditures that accompany testing. In this issue . . .

Several management strategies for radiographic evaluation of head-injury patients have been developed, most are based on retrospective analysis. The study attempted to prospectively evaluate the previously published Masters' criteria defining low-, medium-, and high-yield patients. A community hospital emergency department with a low prevalence of serious head injury was studied, and 1,000 consecutive patients 2 years of age presenting with historical or physical evidence of blunt head trauma were asked to participate; 967 consented. The patients were categorized by staff emergency physicians as low-, moderate-, and high-yield for intracranial injury on the basis of their initial history and physical examination. These categories guided imaging decisions in accordance with the guidelines of Masters. The patients were evaluated 6 weeks later by multiple questionnaire and/or telephone calls to determine whether or not undiagnosed head injuries had been missed. The 967 patients initially evaluated were classified according to their risk of intracranial injury as follows: 886 at low risk, 78 at moderate risk and 3 at high risk. Complete follow-up data were available for 895 of these patients (93%). Of the 895, 71 patients (7.9%) did report receiving follow-up medical care for their head injury; none had evidence of missed intracranial injury requiring intervention. Therefore, it can be inferred with a 95% confidence interval that 0.4% or less of patients who were diagnosed as not having intracranial injuries requiring intervention may actually have such injuries. The application of Masters' management strategy in low-risk populations permits clinicians to safely reduce the number of radiographs ordered for patients with head injury.

To test the hypothesis that two-thumb chest compression generates higher arterial and coronary perfusion pressures than the current American Heart Association-approved two-finger method.Randomized, crossover experimental trial.Animal laboratory experiment with seven swine of either sex weighing 9.4 kg (SD, 0.8 kg), representing infants less than 1 year old.Animals were sedated with IM ketamine/xylazine, intubated with a 6.0 Hi-Lo endotracheal tube, anesthetized with alpha-chloralose, and paralyzed with pancuronium. ECG was monitored continuously. Left femoral arterial and Swan-Ganz catheters were placed. Cardiac arrest was induced with an IV bolus of KCl and verified by ECG and pressure tracings. Five American Heart Association-certified basic rescuers were randomly assigned to perform external chest compressions for one minute by either the currently recommended two-finger method or the two-thumb and thorax-squeeze method. After all five completed their first trial, rescuers crossed over to the other method for a second minute of compressions. Ventilation was performed with a bag-valve device, and no drugs were given during CPR. After three complete cycles, the fourth through sixth cycles of compressions were recorded. Every compression was analyzed for arterial systolic, diastolic, mean, and coronary perfusion pressures. One thousand fifty compressions were analyzed with repeated-measures analysis of variance and Scheffé multiple comparisons.Systolic blood pressure, diastolic blood pressure, mean arterial pressure, and coronary perfusion pressure were all significantly higher (P.001) with the two-thumb thoracic squeeze technique: systolic blood pressure, 59.4 versus 41.6 mm Hg; diastolic blood pressure, 21.8 versus 18.5 mm Hg; mean arterial pressure, 34.2 versus 26.1 mm Hg; and coronary perfusion pressure, 15.1 versus 12.2 mm Hg.The two-thumb method of chest compression generates significantly higher arterial and coronary perfusion pressures than the two-finger method in this infant model of cardiac arrest.

Background:Asimpleprognosticmodelcouldhelpidentifypatientswithpulmonaryembolismwhoareatlowrisk of death and are candidates for outpatient treatment. Methods: We randomly allocated 15531 retrospectively identified inpatients who had a discharge diagnosis of pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our rule to predict 30-day mortality using classification tree analysis and patient data routinely available at initial examination as potential predictor variables. We used data from a European prospective study to externally validate the rule among 221 inpatients with pulmonary embolism. We determined mortality and nonfatal adverse medical outcomes across derivation and validation samples. Results:Our final model consisted of 10 patient factors (age 70 years; history of cancer, heart failure, chronic lung disease, chronic renal disease, and cerebrovascular disease; and clinical variables of pulse rate 110 beats/ min, systolic blood pressure100 mm Hg, altered mental status, and arterial oxygen saturation 90%). Patientswithnoneofthesefactorsweredefinedaslowrisk. The30-daymortalityratesforlow-riskpatientswere0.6%, 1.5%, and 0% in the derivation, internal validation, and externalvalidationsamples,respectively.Theratesofnonfataladversemedicaloutcomeswerelessthan1%among low-risk patients across all study samples. Conclusions:Thissimplepredictionruleaccuratelyidentifies patients with pulmonary embolism who are at low risk of short-term mortality and other adverse medical outcomes. Prospective validation of this rule is important before its implementation as a decision aid for outpatient treatment. Arch Intern Med. 2006;166:169-175

An objective and simple prognostic model for patients with pulmonary embolism could be helpful in guiding initial intensity of treatment.To develop a clinical prediction rule that accurately classifies patients with pulmonary embolism into categories of increasing risk of mortality and other adverse medical outcomes.We randomly allocated 15,531 inpatient discharges with pulmonary embolism from 186 Pennsylvania hospitals to derivation (67%) and internal validation (33%) samples. We derived our prediction rule using logistic regression with 30-day mortality as the primary outcome, and patient demographic and clinical data routinely available at presentation as potential predictor variables. We externally validated the rule in 221 inpatients with pulmonary embolism from Switzerland and France.We compared mortality and nonfatal adverse medical outcomes across the derivation and two validation samples.The prediction rule is based on 11 simple patient characteristics that were independently associated with mortality and stratifies patients with pulmonary embolism into five severity classes, with 30-day mortality rates of 0-1.6% in class I, 1.7-3.5% in class II, 3.2-7.1% in class III, 4.0-11.4% in class IV, and 10.0-24.5% in class V across the derivation and validation samples. Inpatient death and nonfatal complications wereor= 1.1% among patients in class I andor= 1.9% among patients in class II.Our rule accurately classifies patients with pulmonary embolism into classes of increasing risk of mortality and other adverse medical outcomes. Further validation of the rule is important before its implementation as a decision aid to guide the initial management of patients with pulmonary embolism.

We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores.We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata. We compared the discriminatory power (area under the receiver operating characteristic curve) of these rules to predict mortality and their accuracy based on sensitivity, specificity, predictive values, and likelihood ratios.The Pneumonia Severity Index (risk classes I-III) classified a greater proportion of patients as low risk (68% [2152/3181]) than either a CURB score1 (51% [1635/3181]) or a CURB-65 score2 (61% [1952/3181]). Low-risk patients identified based on the Pneumonia Severity Index had a slightly lower mortality (1.4% [31/2152]) than patients classified as low-risk based on the CURB (1.7% [28/1635]) or the CURB-65 (1.7% [33/1952]). The area under the receiver operating characteristic curve was higher for the Pneumonia Severity Index (0.81) than for either the CURB (0.73) or CURB-65 (0.76) scores (P0.001, for each pairwise comparison). At comparable cut-points, the Pneumonia Severity Index had a higher sensitivity and a somewhat higher negative predictive value for mortality than either CURB score.The more complex Pneumonia Severity Index has a higher discriminatory power for short-term mortality, defines a greater proportion of patients at low risk, and is slightly more accurate in identifying patients at low risk than either CURB score.

OBJECTIVE: To assess the agreement between prospectively and retrospectively determined variables comprising the Pneumonia Severity Index (PSI), assignment to PSI risk class, and designation as low risk, based on these two methods of data collection. STUDY DESIGN AND SETTING: We analyzed data from a randomized trial of patients with community-acquired pneumonia managed in 32 hospital emergency departments (EDs). For all enrolled patients, the 20 PSI variables were collected prospectively by ED providers and retrospectively by medical record abstractors. We examined the agreement for each of the 20 PSI variables, assignment to the five PSI risk classes, and classification of patients as low (classes I-III) vs. high (classes IV and V) risk. Agreement was measured using total percent agreement and the kappa statistic. RESULTS: Among the 3,220 enrolled patients, percent agreement was >90% for 18 of the 20 variables comprising the PSI, with most unweighted kappa's being >0.6. Agreement was substantial for assignment to PSI risk class (percent agreement: 92.7%; weighted kappa: 0.79) and for classification as low vs. high risk (percent agreement: 88.5%; unweighted kappa: 0.74). CONCLUSION: There was substantial agreement between retrospective and prospective assignment to PSI risk class, classification as low vs. high risk, and the determination of most individual variables that constitute the PSI.

Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations.This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate. EMS managers and paramedics attended an orientation program, and then developed and implemented recruitment strategies. Adult volunteer subjects who met Centers for Disease Control and Prevention criteria for influenza vaccination were enrolled. Paramedics obtained informed consent, determined subject eligibility, administered the vaccine, and observed each subject for 10 minutes. Paramedics, EMS managers, and subjects completed surveys; EMS managers reported costs and resource utilization. Data were analyzed descriptively.Ninety paramedics from 15 EMS agencies in three counties participated. Subjects were recruited by print and broadcast media and enrolled at 73 events held at retail establishments, community events, EMS stations, churches, senior citizen complexes, and private residences. Of the 2,075 adults immunized, 1,014 (49%) did not receive influenza vaccination in the previous year. Seven hundred five (34%) reported that they probably would not have been vaccinated elsewhere. Fixed cost for each immunization was $3.42. The EMS managers estimated their variable costs to range from zero dollars (volunteer agencies with all donated expenses) to $15.31 per immunization. No adverse events were reported. Subjects, paramedics, and EMS managers indicated a high level of satisfaction with the project.The MEDICVAX Project demonstrated the feasibility of EMS agencies to safely provide influenza immunizations. The project reached some adults who likely would not have been immunized.

UNLABELLED: The pharmacokinetic variables of ropivacaine were characterized after epidural bolus injection in pediatric patients. The subjects, 7 infants (aged 3-11 mo) and 11 young children (aged 12-48 mo), received 1.7 mg/kg of ropivacaine via a lumbar epidural catheter. Total plasma concentrations of ropivacaine measured over 24 h were assayed by high-pressure liquid chromatography, and pharmacokinetic modeling was performed by Nonlinear Mixed Effects Modeling analysis. The median peak venous plasma concentrations (C(max)) in infants and young children were 610 microg/L (interquartile range [IQR], 550-725 microg/L) and 640 microg/L (IQR, 540-750 microg/L), respectively. The median times to maximum plasma ropivacaine concentration (T(max)) were 60 min (IQR, 60-120 min) in infants and 60 min (IQR, 30-90 min) in young children. There were no statistical differences between median values of C(max) and T(max) between infants and young children. The calculated clearance (CL) in infants was 4.26 mL x min(-1) x kg(-1) (9% coefficient of variation), and in young children it was 6.15 mL x min(-1) x kg(-1) (11% coefficient of variation). The CL for infants was significantly less than the CL for young children (P < 0.01). The volume of distribution was estimated to be 2370 mL/kg (9% coefficient of variation) for both young children and infants. No systemic toxicity was observed in either group. IMPLICATIONS: This study revealed that the pharmacokinetic variables of lumbar epidural bolus ropivacaine in pediatric patients aged 3 to 48 mo are similar to those of adults, except that drug clearance was less in infants compared with older children.

Objective: Previous experiments in the authors swine lab have shown that cardiopulmonary resuscitation (CPR) using two-thumb chest compression with a thoracic squeeze (TT) produces higher blood and perfusion pressures when compared with the American Heart Association (AHA)-recommended two-finger (TF) technique. Previous studies were of short duration (1-2 minutes). The hypothesis was that TT would be superior to TF during prolonged CPR in an infant model. Methods: This was a prospective, randomized crossover experiment in a laboratory setting. Twenty-one AHA-certified rescuers performed basic CPR for two 10-minute periods, one with TT and the other with TF. Trials were separated by 2-14 days, and the order was randomly assigned. The experimental circuit consisted of a modified manikin with a fixed-volume arterial system attached to a neonatal monitor via an arterial pressure transducer. The arterial circuit was composed of a 50-mL bag of normal saline solution (air removed) attached to the manikin chest plate and connected to the transducer with a 20-gauge intravenous catheter and tubing. Rescuers were blinded to the arterial pressure tracing. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded in mm Hg, and pulse pressures (PPs) were calculated. Data were analyzed with two-way repeated-measures analysis of variance. Sphericity assumed modeling, with Greenhouse-Geisser and Huynh-Feldt adjustments, was applied. Results: Marginal means for TT SBP (68.9), DBP (17.6), MAP (35.3), and PP (51.4) were higher than for TF SBP (44.8), DBP (12.5), MAP (23.3), and PP (32.2). All four pressures were significantly different between the two techniques (p ≤ 0.001). Conclusion: In this infant CPR model, TT chest compression produced higher MAP, SBP, DBP, and PP when compared with TF chest compression during a clinically relevant duration of prolonged CPR.

Study objective This study aimed to establish whether the outpatient management of patients presenting with an asthma exacerbation to the emergency department (ED) was in compliance with the 1992 guidelines of the “International Consensus Report on the Diagnosis and Management of Asthma.” Design Prospective, observational study using a researcher-administered questionnaire. Setting University tertiary referral ED. Patients Convenience sample of asthmatics (aged 18 to 54 years) presenting for asthma treatment between July 1, 1997, and June 30, 1998. Results Eighty-five asthmatic patients were enrolled. Of these, 34 patients (40%) smoked, 53 patients (62%) were undertreated with medication when compared to the consensus guidelines, and 74 patients (87%) had no written “plan of action.” During an asthma attack, 9 patients (11%) did not use a bronchodilator as first-line action and 76 patients (89%) did not commence or increase the use of an inhaled steroid. Forty-nine patients (58%) did not know that bronchospasm occurred in asthma, and 53 patients (62%) did not know that bronchial swelling occurred. Twenty-six patients (31%) thought short-acting bronchodilator drugs were asthma preventers. Sixty-two patients (73%) could not adequately define peak expiratory flow (PF), 41 patients (48%) did not own a PF meter, and only 8 patients (9%) determined their PF daily. Fifty-three patients (62%) were reviewed by a physician once a year or less, and 18 patients (21%) noted family and friends as their only source of asthma education. Conclusions The outpatient management of most asthma patients presenting to the ED did not comply with the consensus guidelines, and asthma knowledge was poor.

Study objective: Two separate clinical decision rules, one developed in Ottawa and the other in Pittsburgh, for the use of radiography in acute knee injuries have been previously validated and published. In this study, the rules were prospectively validated and compared in a new set of patients. Methods: A prospective, blinded, multicenter trial was conducted in the emergency departments of three urban teaching hospitals. A convenience sample of 934 patients with knee pain requiring radiographs was enrolled. A standardized data form was completed for each patient, comprising the 10 clinical variables included in the two rules. Standard knee radiographs were then taken in each patient. The rules were interpreted by the primary investigator on the basis of the data sheet and the final radiologist radiograph reading. Results: In the 745 patients in whom the Pittsburgh rules could be applied there were 91 fractures (12.2%). The use of the Pittsburgh rule missed one fracture, yielding a sensitivity of 99% (95% confidence interval [CI], 94% to 100%); the specificity was 60% (95% CI, 56% to 64%). The Ottawa inclusion criteria were met by 750 patients, with 87 fractures (11.6%). The Ottawa rule missed three fractures, for a sensitivity of 97% (95% CI, 90% to 99%); specificity was 27% (95% CI, 23% to 30%). Conclusion: Prospective validation and comparison found the Pittsburgh rule for knee radiographs to be more specific without loss of sensitivity compared with the Ottawa rule. [Seaberg DC, Yealy DM, Lukens T, Auble T, Mathias S: Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries. Ann Emerg Med July 1998; 32:8-13.]

Objective: To determine the effect of an inhaled 50% nitrous oxide/50% oxygen mixture on measures of observed anxiety in children during laceration repair. Methods: A prospective, randomized, placebo-controlled, double-blind comparison of an inhaled 50% nitrous oxide/50% oxygen mixture (treatment group) with 100% oxygen (control group) during repair of lacerations was performed. The study population was a convenience sample of children aged 2–7 years in an urban pediatric ED. The primary outcome variable was the change in scores before and during laceration repair with a 10-point modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) assessment. The secondary outcome variable was a 4-point anxiety scale measured before and during the procedure. Results: Thirty patients were entered into the study. Seventeen children inhaled the 50% nitrous oxide/oxygen mixture and 13 inhaled 100% oxygen during laceration repair. There was no statistically significant difference in initial CHEOPS and anxiety scores between the 2 groups (p = 0.687 and 0.809, respectively). The median CHEOPS scores in the treatment group decreased by 5 points, while those of the control patients increased by 3 (p < 0.001). The median anxiety scores in the treatment population decreased by 1 point, with an increase of 1 for the control patients (p < 0.001). Conclusion: Administration of a 50% nitrous oxide/50% oxygen mixture to children during their laceration repair resulted in a significant decrease in measures of anxiety when compared with inhalation of 100% oxygen.