sium sulfate does not provide a meaningful improvement in pulmonary function testing when used in addition to standard therapy in patients with moderate to severe asthma exacerbation who do not require intubation. [Eric L. Legome, MD] Editor’s Comment: Magnesium was of no benefit to patients in this study. It is interesting that all patients received aminophylline, another drug of no benefit to acute asthma patients.
0 A COMPARISON OF ALBUTEROL ADMINISTERED BY METER DOSE INHALER (AND HOLDING CHAMBER) OR WET NEBULIZER IN ACUTE ASTHMA. Colacone A, Afilalo M, Wolkove N, et al. Chest. 1993;104:835-41. The dose-response relationship between albuterol administered by meter dose inhalation (MDI) with a spacer and by wet nebulizer (WN) in the treatment of acute asthma is compared in this double-blind placebo-controlled study. The maximum responses to treatment and comparative doses required to achieve similar response were also evaluated. The authors randomized 85 consecutive adult patients presenting to an emergency department with an asthma exacerbation, and an initial forced expiratory volume over 1 minute (FEVi) < 70% of predicted, to receive either four puffs of placebo from an MD1 and 2.5 mg albuterol by WN or four puffs albuterol by MD1 and holding chamber (0.4 mg) and 2.5 ml saline by WN. Some patients also received IV aminophylline and/or steroids requiring further stratification of the treatment groups. Exclusion criteria included complicating medical illness, pregnancy, or previous administration of inhaled or IV P-agonists in the emergency department. Treatments were administered every 30 min, and fixed vital capacity (FVC) and FEV, were measured 20 min after treatment. Dyspnea and hand tremor were also evaluated. The two groups were well matched at baseline in severity of initial presentation (FEVi, percent predicted, was 36 f 12 in the MD1 group and 35 f 16 in the WN group). There were no significant differences between study groups in both multivariate and univariate analysis of response to treatment. After three doses, 90% of MD1 patients and 83% of WN patients had achieved maximal bronchodilation, as indicated by spirometric measurement. The authors emphasize that these results apply strictly to a dose ratio of 6.09 to 1 in favor of MD1 (0.4 mg in MD1 versus 2.5 mg in WN). They suggest that altering this drug dose ratio favors the form of administration concordantly in other studies that have found dif[Mark Carvalho, MD] ferences in response. Editor’s Comment: The severity of asthma exacerbation was moderate in both treatment groups and typical of most emergency department presentations. More severe cases may have inadvertently been selected out because those patients could not cooperate with spirometric testing or received immediate therapy prior to enrollment and evaluation.
El ACCURACY OF CLINICAL KNEE EXAMINATION DOCUMENTED BY ARTHROSCOPY. A PROSPECTIVE STUDY. Oberlander MA, Shalvoy RM, Hughston JC. J Sports Med. 1993;21(6):773-7. This prospective study was done to determine the accuracy of a clinical examination for diagnosing intra-articular knee injuries by comparison of the preoperative diagnosis with postarthroscopy findings. A 6-month prospective study of patients with knee injuries was undertaken with 290 patients, 6 of which had bilateral knee involvements. Preoperative evaluation includes a history and physical examination with standard knee radiographs. Forty-four of the patients underwent supplemental studies that included magnetic resonance imaging or arthrograms. All 290 of the patients had subsequent arthroscopic exam. In the 290 patients studied, 296 knee exams were performed. The correct diagnosis was made in 56% of these examinations whereas an incomplete diagnosis was made in 31070,and an incorrect diagnosis was made in 13%. Of the specific type of lesions noted, there was 90% accuracy in diagnosing medial tears as opposed to a 95% accuracy of lateral ligament injuries. Anterior cruciate ligament tears were diagnosed with 93% accuracy, while the diagnosis of chondral fracture was accurate in 87% of cases. Chronic injuries, those of more than 6 weeks, were more likely to be misdiagnosed than acute injuries. The authors found that the likelihood of correctly diagnosing all injuries by physical examination was extremely low: 30% successfulin the study. [Christopher Schirmer, MD] Editor’s Comment: The timing of these knee examinations with respect to the time of injury is not documented. Physical examination of the knee is less accurate in the acute setting.
0 TUBE THORACOSTOMY FOR OCCULT PNEUMOTHORAX: A PROSPECTIVE RANDOMIZED STUDY OF ITS USE. Enderson BL, Abdalla B, Frame SB. Trauma. 1993;35(5):726-9. This prospective, randomized study evaluated the need for tube thoracostomy in the event of an occult pneumothorax (a pneumothorax that was not detected on a routine chest radiograph). Trauma patients determined to have a pneumothorax on abdominal computed tomography scanning were randomized to either the tube thoracostomy or the observed group. Those patients who received tube thoracostomies had no major complications, while 8 of 21 patients without a chest tube had progression of their pneumothoraces during positive pressure ventilation, and 3 of these developed tension pneumothoraces. In conclusion, those patients receiving positive pressure ventilation with occult pneumothoraces should undergo tube thoracostomy. [Bold R. Hood, MD] Editor’s Comment: This is a small study, but the recommendation seemsreasonable.