two contiguous leads, T wave inversion or both) were included. Blood samples for tn-T levels were taken at 12, 24, 48, and 120 h. During the 5-month follow up, there were 120 MIS (12.3%), 43 cardiac deaths (4.4%), and 6 deaths from other causes not specified (0.6%); 358 patients (36.7%) had a bypass procedure or angioplasty and 397 (41.8%) had a new hospital admission. The risk of subsequent cardiac events increased gradually with increasing maximal levels of tn-T obtained in the initial 24 h. At low levels of tn-T (<0.06 bg/L), 4.3% of patients had cardiac events. At the next higher level of 0.06-0.18 pg/L, 10.5% of patients had events and at levels over 0.18 pg/L of tn-T, and 16.1% of patients had cardiac events. Based on these findings, the authors concluded patients could be separated into low-, intermediate-, or high-risk groups depending on their 24-h tn-T levels. [ Aviva Jacoby]
women with uncomplicated cervical infections. Decision analysis in which the health outcomes, costs, and cost effectiveness of two-provider-administered treatment strategies for uncomplicated cervical chlamydial infections were compared: ( 1) initial treatment with doxycycline, 100 mg for 7 days and (2) initial therapy with azithromycin, 1 g orally given as a single dose. The azithromycin incurred fewer major and minor complications and was less expensive overall than the doxycycline strategy despite a higher initial cost for the antibiotic. In univariate sensitivity analysis, the azithromycin prevented more major complications but was more expensive when the doxycycline effectiveness was greater than 0.93. The authors state that the azithromycin is more cost effective than the doxycycline strategy for women with uncomplicated cervical chlamydial infections. [Paulo Berger, MD]
Editor’s comment: If validated, this test may influence management and screening after the initial cardiac event.
Editor’s comment: This is an appropriate strategy, although some settings may have more difficulty with the higher initial cost.
0 DIAGONAL EARLOBE CREASES AND PROGNOSIS IN PATIENTS WITH SUSPECTED CORONARY ARTERY DISEASE. WJ Elliott, LH Powell. Am J Med. 1996; 100:205-l 1. The authors of this study sought to establish a relationship betweenearlobecreases(ELC) and cardiac eventsin a prospective, blinded study of 264 high-risk patients followed for 10 years.This associationhasbeensuggestedin a previous autopsy series. An ELC is defined as a visible creasefrom the tragus to the posterior pinna, extending at least one-third of that distance.The primary outcomemeasurewas time to cardiac event: coronary artery bypass graft (CABG), myocardial infarction (MI), or cardiac death, and follow up was nearly 100%. The number of ELCs was significantly associatedwith lO-year cardiac-event-free survival. Ten-year cardiac-free survival was noted in 43.5% of patients without ELCs versus 33% and 17.5% of patients with unilateral or bilateral ELCs, respectively. After adjustmentfor known cardiac risk factors, including age, the relative risk for a cardiac event with a unilateral ELC (vs. no ELC) was 1.33 and for bilateral ELCs, 1.77.The authors concluded that the diagonal ELC is an independent predictor of future cardiac events in patients suspectedof having coronary artery disease.They further noted that the relationship is graded, with increasedrisk associatedwith the greater number of earlobe creases. [Greg w. hnpe, MD] Editor’s comment:As silly as this study sounds,this theory has been thrown around by cardiologists for years. Although they did a nice job on study design and follow up, the conclusions need to be validated. Cl DOXYCYCLINE COMPARED WITH AZITHROMYCIN FOR TREATING WOMEN WITH GENITAL CHLAMYDIA TRACHOMATIS INFECTIONS: AN INCREMENTAL COST EFFECTIVENESS ANALYSIS. Magid D, Douglas JM, Schwartz JS. Ann Inter Med. 1996; 124:389-98. The authors compared the economic consequences of doxycycline therapy with those of azithromycin therapy for
0 THE EFFICACY OF NEBULIZED BUDESONIDE IN DEXAMETHASONE-TREATED OUTPATIENTS WITH CROUP. Klassen TP, Watters LK, Feldman ME, et al. Pediatrics. 1996;97:463-6 The use of glucocorticoid therapy in the outpatient therapy of croup is being studied intensively. The authors of this study examined the use of an inhaled synthetic glucocorticoid, budesonide. Children 3 months to 5 years of age with a syndrome consisting of hoarseness, inspiratory stridor, barking cough, and a croup score of 3 or more after at least 15 min of mist therapy were included in the study. All patients received 0.6 mg/kg of oral dexamethasone and were randomly assigned to receive 4 mL (2 mg) of budesonide solution or 4 mL of saline solution via a nebulizer ; 25 patients were entered into each arm of the study. The outcome measured was the proportion of patients in each group who had at least a 2-point change in their croup score during the 4 h after treatment. The study was double blinded, randomized, and placebo controlled. Twenty-one of 25 patients treated with budesonide had at least a %-point improvement in their croup score; 14 of 25 patients in the placebo group had at least a 2-point improvement in their croup score. This difference reached statistical significance. The use of inhaled budesonide improved the croup score in these patients despite the concomitant use of oral dexamethasone. [James L. Larson, MD] Editor’s comment: If this therapy also improves outcome by reducing admission or revisit rates, then it may be useful. 0 INHALATION OF SINGLE VERSUS MULTIPLE METERED DOSE BRONCHODILATOR ACTUATIONS FROM RESERVOIR DEVICES. Rau JL, Restrep0 RD, Deshpande V. Chest. 1996; 109:969-74. Metered dose inhaler (MDI) administration of bronchodilators have been shown to be as effective as the use of
The Journal of Emergency Medicine
nebulized administration. The use of MDIs in the emergency department can save money and staff time when compared with nebulized medications. Correct use of MDIs by patients at home can decrease the need for emergency department visits. Proper use of the MD1 is critical to achieve the maximal effectiveness of the medications. The investigators in this study compared two different regimens for the MD1 administration of albuterol. The authors used an in vitro lung model to determine the amount of albuterol medication delivered from three different MD1 reservoir systems (spacer). The systems tested were the Monagham Aerochamber, Diemolding aerosol cloud enhancer, and Schering InspirEase. The amount of albuterol delivered was measured in each reservoir system under three different conditions. First, one dose was administered into each chamber, extracted by the artificial lung, and repeated one more time. Next, two and then three doses were delivered into each chamber and extracted by the artificial lung, and the total amount of albuterol delivered was measured. The authors found that under their experimental conditions more albuterol was delivered per activation by using a single activation at a time in all spacer systems. Using three activations at one time did not deliver significantly more medication than two activations at one time. In this experimental model, more efficient delivery of medication occurred when one activation was inhaled at a time. [James L. Larson, MD] Editor’s comment: In this case, more is not necessarily better.
0 PATIENT CHARACTERISTICS AFFECTING ATTENDANCE AT GENERAL OUTPATIENT CLINICS. McClure RJ, Newell SJ, Edwards S. Arch Dis Child. 1996;74: 121-S. The authors attempted to identify the characteristics of pediatric patients who missed scheduled outpatient clinic appointments. Data were gathered in a prospective manner over a 6-month period on 359 children scheduled for an outpatient clinic appointment. Children were divided into an attender group and a non-attender group. When a child attended the first scheduled clinic appointment, an adult care giver was asked to complete a survey. A health visitor attempted to visit the home of all the non-attenders and have an adult care giver fill out the samesurvey. The questionnaire included basic medical information, family perception of degree of illness, socioeconomic status, logistical information, experiences of and satisfaction with the appointment. Seventy-four percent (262) of the questionnaires were satisfactorily completed and returned; 195 from the attender group and 94 from the non-attender group. Lower socioeconomic status. poorer household, unmarried parents, longer journey to clinic, more appointments per year, poor past attendance, and appointment date sent to the patient by mail were all associated with a higher non-attendance rate. Interestingly, the adult care givers of the non-attenders rated their child’s illness as more severe than did the adult care givers of the attenders. The authors conclude that more emphasis
must be placed on assuring that clinic appointments are kept. and, furthermore, discharging a patient from clinic due to non-attendance does a great disservice to the patient and the 1Kelly Gray-Evrom, MD] patient’s family.
0 CASE-CONTROL STUDY OF HIV SEROCONVERSION IN HEALTH-CARE WORKERiF; AFTER PERCUTANEOUS EXPOSURE TO HIV-INFECTED BLOOD-FRANCE, UNITED KINGDOM, AND UNITED STATES, JANUARY 1988-AIvJGUST 1994. MMWR. 1995;44(50):929-33. The overall risk of human immunodeficiency virus (HIV ) infection after percutaneous exposure to HiV-infected blood is reported to be 0.3%. In a case-control study from three countries, the Centers for Disease Control (CDC ) attempted to assessfactors that might increase the risk of transmission. Cases had a documented seroconversion after exposure, whereas controls remained seronegative. There were ?I cases and 679 controls reported. Ninety-four percent of the casesinvolved needle sticks, which is similar to 91% of the controls. Seventy-four percent of both cases and controls were exposed after zidovudine (ZDV) prophylaxis became common. When entered into regression analysis, several factors were found to be significantly associatedwith transmission. These factors included a deep injury, visible blood on the penetrating instrument, exposure from an instrument that had been in an artery or vein, and terminal illness in the patient source of infection. In addition, caseswere less likely to have used ZDV prophylaxis than were controls. Due to the small risk of seroconvertion in any exposure to HIV. a placebo controlled study of ZDV is unlikely to be done. The CDC recommends that exposed individuals be informed 01 the risk of HIV seroconversion after exposure and the limited knowledge concerning the value and toxicity of ZDV prophylaxis. If, after that, prophylaxis is chosen, it should be begun promptly. [Edmund A. Walton, illi)] Editor’s comment: This seems reasonable, and the employee should be informed of those factors with an increased risk of transmission.
q VARIATION IN THE MANAGEMENT OF DEEP VEIN THROMBOSIS: DIPLICATIONS FOR THE POTENTIAL IMPACT OF A CRITICAL PATHWAY. Schoenenberger RA, Pearson SD, Goldhaber SZ, et al. Am J Med. 1996; 100:278-82. This study points out that, although the management of uncomplicated deep vein thrombosis (DVT) is straightforward, the inhospital management is far from standardized and full of variation. The authors of this retrospective chart review attempted to develop a clinical guideline for the inhospital managementof DVT and then compared the guideline with the clinical course of patients discharged with the diagnosis of DVT. The goals set by the guideline were devel-. oped by a multidisciplinary team to improve the quality and