It was a tense scene at the Huntsville Hospital in Alabama on November 20 following the death of three teenagers who were killed when a school bus tumbled off an interstate onto the street below. Anxious family members rushed to the hospital cafeteria seeking information about their children as news of the crash spread, reported The Huntsville Times. A fourth teen has since died from injuries sustained in the crash.

Some family members collapsed after receiving news about their children who were on the school bus. Hospital officials said the situation was compounded by the inability of hospital staff to identify some of the more severely injured students who were unable to talk and had no identification on them, reported the Associated Press.

At Crestwood Medical Center, which treated nine victims, the scene was quieter, the newspaper said. Family members were directed to a conference room where they waited to visit their children. Several local clergy members were on hand to comfort them.

A 37-year-old hospital pharmacy manager at Shands-Jacksonville Medical Center in Florida died November 20 after she was shot multiple times following a confrontation with a patient in the hospital pharmacy, according to news reports.

The woman who shot the pharmacist was quickly arrested outside the hospital and charged with murder. She admitted to the shooting, reported the Associated Press. A relative told the Florida Times-Union newspaper that the shooter suffered from mental health problems.

Fifteen to 20 people were in the pharmacy when the shooting happened about 9 a.m. The pharmacy manager, who was shot in the head, tried to assist the shooter after she had a disagreement with another pharmacist, the newspaper reported. The pregnant wife and mother of two had worked in the hospital pharmacy since 2002. The hospital brought in grief counselors for staff and planned to review its security measures.

Question from a colleague:  What do you do about a chronic alcoholic who probably always has at least a .15 alcohol level in him/her and who, after being transported to the ER, because of a fall down a flight of stairs and who has an alcohol level of .38 and who is clinically stable and is mentally “with it”, wants to leave AMA?

1)  Let him leave AMA because, despite his alcohol level, he really is mentally sharp since he is always drunk and he is perfectly able to make his own decisions or

2)  Threaten to hog-tie him into submission until his alcohol level drops below 0.08 (assuming you have adequate personnel to fight with him) or

3)  Simply call the police to jail him for disorderly conduct and thereby keep him somewhat safe or

4)  Try to find a family member to stay with him while you have him sign out AMA.

Personally, I prefer options 2 or 3.  Despite the fact he is always drunk and appears to be mentally sound, I can’t trust his judgement nor am I 100% confident he is physically OK.  I also can’t trust relatives or friends to be clinically astute or caring.

PS: I write this knowing that maybe only one person might read this and want to contribute an idea.

It just occurred to me while working in the ER tonight that it’s easy for a patient or a family member to video us with their cell phone while we are examining the patient.  Depending upon our inherent personality, the level of our stress, or just the side of the bed that we got up on, it’s possible that we could be very embarassed by our actions if we were taped for the whole world to see. 

What to do about it?  I guess one thing is to be kinder and gentler.  Obviously, the errant “winds of war” will always do their damndest to scuttle that sentiment. 

Another option is to be cognizant of cell phones in people’s hands and if it looks suspicious, ask them to desist so as not to create “a HIPAA violation.”  They can always use the phone in the room.

Drug manufacturer Roche and US regulators are warning that influenza patients treated with oseltamivir (Tamiflu) may have an increased risk of self-injury and delirium. “People with the flu, particularly children, may be at increased risk of self-injury and confusion shortly after taking Tamiflu and should be closely monitored for signs of unusual behavior,” says a warning that Roche has added to its official product information. Oseltamivir is used both to prevent and to treat flu and is regarded as the best available drug for dealing with a potential pandemic strain of flu. The US and many other countries are stockpiling it because of the pandemic threat. 
 
The warning follows an FDA review of 103 reports of neuropsychiatric adverse events associated with oseltamivir use between Aug 29, 2005, and Jul 6, 2006, of which 95 came from Japan. That compares with 126 such adverse events reported between 1999 and Aug 2005. About two thirds of the problems were in children and youth younger than 17 years. The adverse events included 3 fatal falls. Most of the events (60/103) were described as delirium with disturbed behavior. Other problems included suicidal events, panic attacks, delusions, convulsions, depressed consciousness, and loss of consciousness. 
 
FDA and Roche both say the contribution of the drug to the adverse events is not known. FDA says influenza by itself can lead to neuropsychiatric disorders, but many of the problems reported (e.g. suicide attempts), were not typical of those associated with flu alone. Citing factors that seem to implicate oseltamivir in the events, FDA said most of the problems occurred within a day after the start of treatment, and in many cases the physician suspected the drug was the cause. In addition, many of the patients recovered quickly after they stopped taking oseltamivir. “It is still unclear whether these neuropsychiatric events are drug-related only, disease manifestations alone, or a combination” of the two, the report states. 
 
The analysis notes that oseltamivir is used much more widely in Japan, with 24.5 million prescriptions from 2001 - 2005, than in the US, with 6.5 million prescriptions in the same period. In Japan the product information already includes a warning about possible psychoneurological problems. The FDA report expresses concern that if oseltamivir use in the US increases to the levels seen in Japan, the number of adverse events will increase as well. “Therefore, it would be prudent to update the U.S. labeling to be similar in scope with the current Japanese labeling,” it says. The Japanese origin of most of the adverse event reports might suggest that the problems are related to genetic characteristics common in Japan. But given the much greater use of the drug in Japan and the possibility of different surveillance practices there, the lack of cases reported in the US doesn’t constitute good evidence for that hypothesis, it states. (CIDRAP 11/14/06 http://www.cidrap.umn.edu/ ) aged loan stockfederal loan agencyagent california loan signingnew york agreement form loan constructionloan agricultural operatingaircraft only loans interestam payments loan southamerica bank loan auto paymentbank america loan departmentamerican online loan auto lender

Adults may have a slightly higher risk for hospitalization with Guillain-Barré syndrome (GBS) within a few weeks after influenza vaccination than at other times, though their overall risk of the disorder remains very low, Canadian researchers reported. Researchers from the University of Toronto, who published their findings in the Nov 13 issue of Archives of Internal Medicine, studied residents of Ontario, where everyone older than 6 months can receive a free annual flu shot. GBS causes weakness or tingling that can worsen to paralysis. The syndrome affects roughly 1 in 100,000 people each year. Some previous studies have linked flu vaccination with a slightly increased risk of GBS, but uncertainty remains about the association. 
 
The researchers performed 2 analyses. In the first, they identified all hospitalizations for GBS among Ontario residents aged 18 and older from Apr 1993 - Mar 2004. Then they identified which patients received flu shots and compared their risk for hospitalization for GBS for two time intervals: 2 to 7 weeks and 20 to 43 weeks after vaccination. In a second analysis, the researchers examined the number of hospitalizations for GBS in Ontario 1991 - 2004 and compared the number of cases before and after the universal flu immunization program began in 2000. 
 
The results of the first analysis revealed there were 1,601 hospitalizations for GBS between 1993 - 2004, 269 of which occurred within 43 weeks after the patient received a vaccine, presumably for influenza, in Oct or Nov. Patients were 1.45 times as likely to be hospitalized for GBS from 2 - 7 weeks after vaccination as they were between 20 - 43 weeks after vaccination. In the second analysis, the authors identified 2,173 hospitalizations for GBS between 1991 - 2004 and found no significant difference between hospitalization rates before and after the universal immunization program took effect. The authors say the results should be interpreted carefully. “The increase in relative risk we observed corresponds to a very low absolute risk for Guillain-Barré syndrome, given the low baseline incidence of the disease (approximately 1 in 100,000 population),” they write. “Furthermore, the lack of association on a population level is consistent with the assumption that the influenza vaccine is one of many potential causes of GBS.” They also note that the US Institute of Medicine in 2003 reviewed studies from the preceding 26 years and concluded there was inadequate evidence to either confirm or reject a link between flu immunization and GBS. 
 
A recent study of the safety of the influenza vaccine in thousands of children aged 6 to 23 months found only 2 instances of GBS, and neither of the patients was diagnosed with the condition within a few weeks after vaccination. However, the researchers say that people who receive flu shots should be advised of the possible risk for GBS and that active surveillance should be included in any mass vaccination program for pandemic flu. Julie Gerberding, director of the US CDC, said the study is consistent with other research findings that have shown people who get the flu vaccine have a negligible risk of developing GBS. She said the study has not prompted the CDC to change its recommendations about flu vaccination, and added that the health risks related to flu far outweigh any risk of developing GBS from the vaccine. 
 
Reference: Juurlink DN, Stukel TA, Kwong J, et al. Guillain-Barré syndrome after influenza vaccination in adults: a population-based study. Arch Intern Med 2006;166(20):2217-21. To read the abstract, go to: 
http://archinte.ama-assn.org/cgi/content/abstract/166/20/2217 (CIDRAP 11/14/06 http://www.cidrap.umn.edu/ ) loans ace pay dayacs schopol loansloan action and mortgageto a loan calendar bill add2bfha al 2bloanssmall alabama loans businessalaska credit personal loan with badloans home albuquerque Map

Acute Bronchitis
Richard P. Wenzel, M.D., and Alpha A. Fowler, III, M.D.
NEJM

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.
A 40-year-old man with no underlying lung disease has a 7-day history of mild shortness of breath with exertion, as well as cough that is now productive of purulent sputum. He reports no paroxysms of cough and no contact with ill persons in his community. He does not appear to be in distress. His temperature is 37°C, his pulse 84 beats per minute, and his respiratory rate 17 breaths per minute. On auscultation of the lungs, no rales are heard; scattered wheezes are heard in the lung bases. How should he be evaluated and treated?
The Clinical Problem
Acute bronchitis is a clinical term implying a self-limited inflammation of the large airways of the lung that is characterized by cough without pneumonia. The disorder affects approximately 5% of adults annually,^1,2 with a higher incidence observed during the winter and fall than in the summer and spring. In the United States, acute bronchitis is the ninth most common illness among outpatients, as reported by physicians.³
Viruses are usually considered the cause of acute bronchitis but have been isolated in a minority of patients.^1,4 Those isolated in acute bronchitis (from the most to the least common in large series) include influenza A and B viruses, parainfluenza virus, respiratory syncytial virus, coronavirus, adenovirus, and rhinovirus. Human metapneumovirus has been identified as a causative agent.^5,6,7 A recent French study involving adults who had been vaccinated against influenza showed a viral cause in 37% of 164 cases of acute bronchitis, of which 21% were rhinovirus.⁴ Thus, the yield of specific pathogens varies according to several factors, including the presence or absence of an epidemic, the season of the year, and the influenza vaccination status of the population.
Bacterial species commonly implicated in community-acquired pneumonias are isolated from the sputum in a minority of patients with acute bronchitis.¹ However, the role of these species in the disease or its attendant symptoms remains unclear, because bronchial biopsies have not shown bacterial invasion. In some cases, atypical bacteria are important causes, including Bordetella pertussis, Chlamydophila (Chlamydia) pneumoniae, and Mycoplasma pneumoniae.¹ Some data have suggested that B. pertussis may underlie 13 to 32% of cases of cough lasting 6 days or longer, although in a recent prospective study, B. pertussis comprised only 1% of cases of acute bronchitis.⁸
Pathobiology
Acute bronchitis is thought to reflect an inflammatory response to infections of the epithelium of the bronchi. Epithelial-cell desquamation and denuding of the airway to the level of the basement membrane in association with the presence of a lymphocytic cellular infiltrate have been demonstrated after influenza A tracheobronchitis⁹; microscopical examination has shown thickening of the bronchial and tracheal mucosa corresponding to the inflamed areas. Such pathological findings are consistent with reports of proximal lower airway inflammation confined to the bronchi, as detected by positron-emission tomography with ¹⁸F-fluorodeoxyglucose as a tracer, in the setting of acute bronchitis.¹⁰
However, there are wide variations in the anatomical distribution of many pathogens that cause acute bronchitis. In a study involving volunteers exposed to rhinovirus infections, for example, virus was detected in specimens of induced sputum obtained from all the subjects, in approximately one third of bronchial biopsy specimens, in almost a quarter of bronchoalveolar lavage specimens, and in more than a third of bronchial brushing specimens.¹¹ Such data indicating viral infection of the lower airways may help to explain the relationship observed between rhinovirus infection (and other presumed upper respiratory viral infections) and exacerbation of asthma.¹² Thus, although its name suggests only large-airway disease, acute bronchitis may be accompanied by an array of symptoms, depending on the degree of viral involvement of the large and small airways.
Natural History
During the first few days of infection, the symptoms of mild upper respiratory infections cannot be distinguished from those of acute bronchitis. However, with acute bronchitis, coughing persists for more than 5 days, and during this protracted period the results of pulmonary function testing may become abnormal. Forty percent of patients have significant reductions in the forced expiratory volume in 1 second (i.e., a value below 80% of the predicted value)¹³ or bronchial hyperreactivity, as measured by bronchial provocation,¹⁴ with improvement during the following 5 to 6 weeks.
Cough after acute bronchitis typically persists for 10 to 20 days but occasionally may last for 4 or more weeks. In a recent report on a clinical trial of the efficacy of an acellular pertussis vaccine involving 2781 healthy adults, the median duration of cough from acute bronchitis due to all causes was 18 days (mean, 24).⁸ In addition, approximately 50% of patients with acute bronchitis report the production of purulent sputum. In otherwise healthy patients, purulent sputum usually indicates the presence of sloughed tracheobronchial epithelium and inflammatory cells, and its positive predictive value for the presence of alveolar disease is low (approximately 10%).¹⁵
A study of the quality of life of patients with upper respiratory tract infections, some of whom had received a diagnosis of acute bronchitis, showed significant decrements in seven subscales of the Medical Outcomes Study 36-item Short-Form General Health Survey, including vitality and social functioning,¹⁶ but such decrements are presumed to be transient. Data on short- or long-term outcomes are limited, but one study indicated that within a month after the initial visit, up to 20% of patients had reconsulted their physicians because of persistent or recurrent symptoms.¹ The effect of an episode of acute bronchitis on a patient’s subsequent lung health is uncertain. In one study, 34% of patients with acute bronchitis received a new diagnosis of chronic bronchitis or asthma at 3 years of follow-up.¹⁷ In another study, mild bronchial asthma was diagnosed on the basis of spirometry or bronchial provocation in 65% of patients with recurrent episodes of acute bronchitis.¹⁸ However, these studies lacked control groups, and it is unclear whether acute bronchitis led directly to the chronic condition or whether the chronic disorder or the propensity for its development was present at the time of the inflammation of the large airway.
Strategies and Evidence
Diagnosis
Acute bronchitis should be differentiated from acute inflammation of the small airways — asthma or bronchiolitis — which typically presents as progressive cough accompanied by wheezing, tachypnea, respiratory distress, and hypoxemia. It should also be distinguished from bronchiectasis,¹⁹ a distinct phenomenon associated with permanent dilatation of bronchi and chronic cough. The diagnosis of chronic bronchitis is reserved for patients who have cough and sputum production on most days of the month for at least 3 months of the year during 2 consecutive years.²⁰ The acute exacerbation of chronic bronchitis, identified by the worsening air flow and symptoms in such patients, is not discussed here.
A careful history taking, including reports of contact with ill people, and physical examination may suggest a specific cause (Table 1). A common presentation of pertussis is cough of 2 to 3 weeks’ duration in an adolescent or young adult; fever is less common in pertussis than in viral bronchitis.^18,26 However, in the absence of an epidemic, the positive predictive value of young age, prolonged cough, or the absence of fever is low for pertussis. During an epidemic of influenza, the finding of both cough and fever was reported to have a positive predictive value of 79% for this condition.²⁷

Diagnostic Testing
At the bedside, cough in the absence of fever, tachycardia, and tachypnea suggests bronchitis, rather than pneumonia. In fact, the presence of normal vital signs and the absence of rales and egophony on chest examination minimize the likelihood of pneumonia to the point at which further diagnostic testing is usually unnecessary.²⁸ An exception, however, is cough in elderly patients; pneumonia in elderly patients is often characterized by an absence of distinctive signs and symptoms. Among patients 75 years of age or older who had community-acquired pneumonia, only 30% had a temperature above 38°C, and only 37% had a heart rate of more than 100 beats per minute.²⁹
Rapid diagnostic tests exist for several pathogens currently linked to acute bronchitis. However, not all the rapid tests are widely available, and their routine use is not cost-effective in an outpatient setting. Rapid tests should be used primarily when the suspected organism is treatable, the infection is known to be circulating in the community, and the patient has suggestive symptoms or signs (e.g., testing for influenza during influenza season in patients with cough and fever) (Table 1). Multiplex polymerase-chain-reaction (PCR) testing of nasopharyngeal swabs or aspirates is being developed to diagnose infections resulting from B. pertussis, M. pneumoniae, or C. pneumoniae with clinically useful sensitivity and specificity, as compared with culture or monoplex PCR.³⁰
Treatment
            Antimicrobial Therapy
Antimicrobial agents are not recommended in most cases of acute bronchitis. Systematic analyses of clinical trials have suggested that antibiotics may reduce the duration of symptoms, but at best modestly. Specifically, a meta-analysis of eight trials involving patients with acute bronchitis suggested that symptoms were reduced by a fraction a day with the use of erythromycin, doxycycline, or trimethoprim–sulfamethoxazole. The results were statistically significant but clinically trivial.³¹ Results of a randomized, double-blind trial comparing a 5-day course of azithromycin in 112 patients with vitamin C in 108 patients (total dose of each agent, 1.5 g), published after the meta-analysis had been completed, showed no difference between groups in the health-related quality of life at 7 days (the primary outcome) or in the proportion of patients who returned to work, school, or usual activities at home on day 3 or 7.³²
A Cochrane Review of nine randomized, controlled trials of antibiotic agents (including three trials not included in the previous review³¹) also showed a significant but minor reduction in the duration of cough (0.6 day).³³ There was a nonsignificant reduction in the number of days of feeling ill and a nonsignificant increase in adverse events attributed to antibiotics (relative risk of adverse events, 1.22; 95% confidence interval, 0.94 to 1.58).
Antimicrobial therapy may be more beneficial when a treatable pathogen is identified than when a treatable pathogen is not identified. For example, anti-influenza agents (including oseltamivir and zanamivir) decrease the duration of symptoms by approximately 1 day and result in an earlier return to normal activity (by 0.5 day) among patients with infections caused by susceptible viruses. Prompt antibiotic treatment of patients with pertussis is indicated to limit transmission, but (with the possible exception of therapy initiated during the first week of symptoms) there are no compelling data to support the prospect that cough will be less severe or less prolonged with antibiotic therapy. Similarly, although several classes of antibiotics have in vitro activity against M. pneumoniae and C. pneumoniae, it is unclear whether antibiotic treatment of bronchitis linked to these organisms influences outcomes. Table 1 includes suggested antimicrobial therapy for cases in which such therapy is considered.
            Other Therapy
The few randomized, placebo-controlled trials that have examined the effect of ₂-agonists administered orally or by aerosol for cough associated with acute bronchitis have involved small numbers of patients and have had mixed results.^34,35,36 In these studies, among patients without preexisting lung disease, daily cough scores and the likelihood of persistent cough after 7 days did not differ significantly between the active treatment and placebo groups. However, in one trial, a subgroup of patients with evidence of airflow limitation had significantly lower scores for symptoms on day 2 after treatment with ₂-agonists.³⁴ A recent Cochrane Review of five trials involving 418 adults showed that even among patients with airflow obstruction, the potential benefit of ₂-agonists is not well supported and should be balanced against the adverse effects of treatment.³⁷ In practice, a brief trial (7 days) of inhaled or oral corticosteroids may be reasonable for troublesome cough (i.e., cough persisting for more than 20 days), but there are no clinical trial data to support this approach. Data from clinical trials are also not available to support the use of mucolytic or antitussive agents.
Areas of Uncertainty
Distinguishing the minority of cases of acute bronchitis due to a treatable cause from those due to currently nontreatable viruses is often challenging. Recently, the measurement of serum levels of procalcitonin, which is typically elevated in bacterial infections, has been proposed as a means of identifying patients in whom treatment with antibiotics is warranted. In one clinical trial, low levels of procalcitonin (<0.1 µg per liter) were used to discriminate safely between patients with cough or dyspnea who did not require antibiotic therapy, such as those with acute bronchitis,³⁸ and patients who did require such therapy. However, more data are needed to validate the usefulness of the procalcitonin test for discriminating between patients with bronchitis and those with pneumonia.
Although clinicians might argue that the pressure of time influences the prescribing of antibiotics, the data do not support this contention. A recent study involving almost 4000 adults with upper respiratory tract infections showed that the mean duration of an office visit was 14.2 minutes when antibiotics were prescribed, as compared with 15.2 minutes when no prescription for antibiotics was given.³⁹
Previous studies involving volunteers exposed to rhinovirus showed that nonsteroidal drugs alone or in combination with antihistamines reduced the severity of symptoms, including cough.⁴⁰ However, the effects of either drug alone or their combination in naturally occurring acute bronchitis have not been evaluated. Results of a single randomized trial involving 486 adults with acute bronchitis suggested a clinical benefit of an extract of the roots of Pelargonium sidoides, but the data require confirmation.⁴¹
Guidelines
According to the 2001 guidelines of the American College of Physicians for the treatment of uncomplicated acute bronchitis, antibiotic treatment is “not recommended, regardless of duration of cough.”⁴² According to the 2006 guidelines of the American College of Chest Physicians (ACCP) for treating acute bronchitis, routine treatment with antibiotics is not justified, antitussive agents are only occasionally useful, and there is no routine role for inhaled bronchodilators or mucolytic agents.⁴³ However, these guidelines note that subgroups of patients with chronic airflow obstruction at baseline or wheezing at the onset of illness do have a benefit from ₂-agonists. Inhaled anticholinergic agents are not recommended. These guidelines have been criticized on the grounds that many of the recommendations were based “more on opinion than on evidence.”⁴⁴
Both the ACCP guidelines and guidelines of the Centers for Disease Control and Prevention (CDC) recommend macrolides as first-line therapy for pertussis.^25,43 For infection with influenza A virus, in January 2006 the CDC recommended therapy with either oseltamivir or zanamivir,²¹ noting that the circulating H3N2 strains of influenza A virus were almost uniformly resistant to both first-generation drugs (amantadine and rimantadine).
Summary and Recommendations
The patient described in the vignette most likely has a viral infection causing uncomplicated acute bronchitis. On the basis of data from clinical trials, antibacterial agents are not recommended. Chest radiography is not indicated, given the absence of signs of pneumonia on physical examination. In the absence of an influenza outbreak in the community, no rapid testing for viral causes should be ordered, and no antiviral therapy should be prescribed; influenza is especially unlikely in a patient who is afebrile. In the absence of a history of contact with a person with suspected pertussis (or a person with a history of persistent cough), this diagnosis is unlikely. If paroxysms of cough developed later or if whooping or post-tussive vomiting occurred, testing for pertussis would be reasonable. The patient should be advised that the cough may persist for an additional 10 to 21 days and that infrequently, it persists longer. For his wheezing and shortness of breath with activity, clinical experience suggests that a ₂-agonist such as albuterol may provide relief, although data from clinical trials are inconsistent. On the basis of clinical experience, the patient might be offered short-term use of codeine or hydrocodone-containing preparations or inhaled corticosteroids if the cough is persistent, although data from trials to support their use are lacking.
Dr. Wenzel reports receiving consulting fees from Pfizer and Replidyne and research support from Pfizer. No other potential conflict of interest relevant to this article was reported.

Source Information
From the Department of Internal Medicine, Virginia Commonwealth University, Richmond.
Address reprint requests to Dr. Wenzel at the Department of Internal Medicine, Virginia Commonwealth University, 1101 E. Broad St., P.O. Box 980663, Richmond, VA 23298, or at rwenzel@mcvh-vcu.edu .
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35. Littenberg B, Wheeler M, Smith DS. A randomized controlled trial of oral albuterol in acute cough. J Fam Pract 1996;42:49-53. [ISI][Medline]
    

36. Hueston WJ. Albuterol delivered by metered-dose inhaler to treat acute bronchitis. J Fam Pract 1994;39:437-440. [ISI][Medline]
    

37. Smucny J, Flynn C, Becker L, Glazier R. Beta2-agonists for acute bronchitis. Cochrane Database Syst Rev 2004;1:CD001726-CD001726. [Medline]
    

38. Christ-Crain M, Jaccard-Stolz D, Bingisser R, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet 2004;363:600-607. [CrossRef][ISI][Medline]
    

39. Linder JA, Singer DE, Stafford RS. Association between antibiotic prescribing and visit duration in adults with upper respiratory tract infections. Clin Ther 2003;25:2419-2430. [CrossRef][ISI][Medline]
    

40. Gwaltney JM Jr, Druce HM. Efficacy of brompheniramine maleate for the treatment of rhinovirus colds. Clin Infect Dis 1997;25:1188-1194. [ISI][Medline]
    

41. Matthys H, Eisebitt R, Seith B, Heger M. Efficacy and safety of an extract of Pelargonium sidoides (EPs 7630) in adults with acute bronchitis: a randomised, double-blind, placebo-controlled trial. Phytomedicine 2003;10:Suppl 4:7-17. [CrossRef][ISI][Medline]
    

42. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001;134:521-529. [Abstract/Full Text]
    

43. Braman SS. Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. Chest 2006;129:Suppl:95S-103S. [Abstract/Full Text]
    

44. Cough guidelines choke on evidence. Lancet 2006;367:276-276. [Medline]

Abstract:

The appropriate dose of succinylcholine (SCH) in morbidly obese patients is unknown. We studied 45 morbidly obese (body mass index >40 kg/m²) adults scheduled for gastric bypass surgery. The response to ulnar nerve stimulation of the adductor pollicis muscle at the wrist was recorded using the TOF-Watch SX® acceleromyograph. In a randomized double-blind fashion, patients were assigned to one of three study groups. In Group I, patients received SCH 1 mg/kg ideal body weight, in Group II 1 mg/kg lean body weight, and in Group III 1 mg/kg total body weight. After SCH administration, endotracheal intubating conditions were scored. The recovery from neuromuscular block was recorded for 20 min. There was no difference in the onset time of maximum neuromuscular blockade among groups, but maximum block was significantly less in Group I. The recovery intervals were significantly shorter in Groups I and II. In one third of the patients in Group I, intubating conditions were rated poor, whereas no patient in Group III had poor intubating conditions. Our study demonstrates that for complete neuromuscular paralysis and predictable laryngoscopy conditions, SCH 1 mg/kg total body weight is recommended.

Harry J. M. Lemmens, MD, PhD, and Jay B. Brodsky, MD

Department of Anesthesia, Stanford University School of Medicine, Stanford, California

Address correspondence and reprint requests to Dr. Jay Brodsky, Department of Anesthesia, H3580, Stanford University Medical Center, Stanford, CA 94305. Address e-mail to jbrodsky@stanford.edu .

Two Australian medical researchers writing in the British Medical Journal have urged doctors to use Google to help diagnose rare illnesses in patients. 

The conclusion is based on research which showed that Google could provide a reasonable degree of accuracy, correctly diagnosing 15 of 26 cases published in the New England Journal of Medicine in 2005. 

“Useful information on even the rarest medical syndromes can now be found and digested within a matter of minutes,” said the article by Hangwi Tang and Jennifer Hwee Kwoon Ng from the Department of Rheumatology at the Princess Alexandra Hospital in Queensland. 

“Our study suggests that, in difficult diagnostic cases, it is often useful to Google for a diagnosis. Search engines such as Google are becoming the latest tools in clinical medicine, and doctors in training need to become proficient in their use.”

Tang and Ng are not suggesting that patients self-diagnose using Google, but claim that the search engine can give a doctor an important edge, quoting anecdotal and statistical evidence.

“Patients may find the search less efficient and be less likely to reach the correct diagnosis,” said the researchers.

“We believe that Google searches by a human expert (a doctor) have a better yield, as Google is exceedingly good at finding documents with co-occurrence of the signs/symptoms used as search terms, and human experts are efficient in selecting relevant documents.”

Use of Google to search for medical conditions by an amateur can yield confusing results, vnunet.com found. Typing ’severe chest pain’ into the advanced search facility results in about 1.6 million hits.

Among the first 10 is Family Doctor, which provides a decision tree that yields 14 different outcomes for severe chest pain, ranging from heart attack (recommended course of action: contact emergency services) to hyperventilation (lie down and relax). 

Also in the first 10 hits, Wrong Diagnosis provides a list of nearly 100 conditions that can cause chest pain, from asbestosis to a bacterial digestive infection known as Whipple’s disease.

Source: vnunet.com

Penetrating neck trauma continues to be a challenging subset of trauma care. This area is loaded with potential high-risk injuries and controversies about the optimal management. The literature favors a more selective approach to these patients, however, the fundamental principles of resuscitation still apply because airway compromise and exsanguination are the greatest immediate life threats. This article reviews the medical literature on the diagnosis and management of these complex injuries.
– The Editor of Trauma Reports
Introduction
The management of penetrating neck trauma presents a significant challenge to emergency personnel. Penetrating injuries to the neck present a challenging diagnostic and therapeutic dilemma because the spectrum of injuries ranges from minor to acutely life threatening. Successful management requires a practical understanding of the anatomy of the neck and the tremendous number of vital structures in close proximity. A thorough diagnostic and management strategy must be implemented in the emergency department (ED) to avoid missing potentially devastating injuries. Optimal strategy remains controversial, and there remains substantial institutional variation.
Epidemiology
Although there has been a decrease of penetrating neck injury in the United States in the past years, it remains a significant public health concern.¹ This is due to the epidemic numbers of firearm-related injuries from interpersonal violence that still occur, particularly in highly populated urban areas. Most injuries are secondary to stabbings or gunshot wounds. Penetrating neck trauma accounts for 5%-10 % of all traumatic injuries in some urban trauma centers.^2-4 Most penetrating injuries to the neck involve zone II, which extends from the cricoid cartilage to the angle of the mandible. As with most penetrating trauma mechanisms, males are affected more commonly than females by approximately fourfold.² Mortality from penetrating neck trauma ranges from 2% to 10%.^2,3
In the neck, vascular structures are the important anatomical structure most often injured.² Venous injuries occur more often than arterial injuries. The common carotid artery is the most common arterial injury, with the subclavian artery being the next most commonly injured.² Laryngotracheal and esophageal injuries occur almost equally with esophageal injuries being less common.^2,5
Historical Perspective
Historical accounts of penetrating neck injury date to antiquity. One of the first works involves an esophageal injury from a stab wound 5000 years ago.⁶ Ambrose Pare described the first repair of a cervical vascular injury.⁷ Both the common carotid artery and internal jugular vein were lacerated and subsequently ligated. The battlefield gave rise to many accounts and advances in diagnosis and management of penetrating neck trauma. During the Civil War, penetrating neck trauma management focused primarily on observation. Mortality rates were approximately 15%.⁸ World War I management also focused primarily on observation, although exploration and ligation became more prevalent. Mortality rates remained essentially unchanged. By World War II through the Vietnam conflict, mandatory exploration with vascular repair was the accepted practice.⁹ Although this strategy missed very few injuries, it resulted in numerous negative surgical explorations. Today’s modern diagnostic capabilities have given rise to new management strategies, some of which focus on nonoperative management following diagnostic testing or observation alone.
Etiology
The etiology of penetrating neck injuries can be divided into three categories: gunshots, stabbings, and miscellaneous. Each category has different predisposing factors and injury patterns. Gunshot wounds and other high-velocity injuries generally produce greater damage and thus are more likely to require surgical exploration. Injuries from gunshots and stabbings most often have a clear etiology, and their epidemiological patterns vary according to causal factors (e.g., crime rates, hunting accidents, military activity). Concomitant injury patterns obviously must be diagnosed and managed. The miscellaneous category represents a broad spectrum of injury by various other penetrating objects — from automobile glass secondary to car collisions to impalement from airborne objects. Associated injury patterns can be as broad and unpredictable as the mechanism of injury itself.
The pediatric patient with penetrating neck trauma represents a unique management challenge. This type of injury is uncommon in the pediatric population, but the potential injuries and complications can be devastating.¹⁰ Literature on diagnosis and management regarding the pediatric patient is also scant. One study demonstrated motor vehicle collisions to be the most common mechanism of injury at 32.2%. Gunshot wounds and animal bites followed at 22.8% and 12.9%, respectively.¹⁰ A specific mechanism of concern is penetrating neck injuries from air-guns because physicians and other personnel may mistakenly consider BB gun injuries as somewhat trivial. Significant injuries have been reported, including an expanding spinal hematoma.¹¹ Mortality rates were similar to the adult population. Zone II injuries were most common, a fact also seen in the adult studies.¹⁰ Associated injury patterns remain very broad, depending upon the mechanism of trauma and whether the injury is isolated or associated with multiple injuries.
Pathophysiology
The pathophysiology of penetrating injury is relatively straightforward. Traditionally, gunshot wounds are divided into low-velocity weapons (< 1000 ft/sec) and high-velocity weapons (>2500 ft/sec).^12,13 Low-velocity weapons, which includes most handguns, tend to cause direct vascular injury. High-velocity weapons (e.g., hunting rifles and assault rifles) cause cavitation or disruption of tissue well removed from the tract. Types of direct vascular injury include intimal flap (most common), (Figure 1) transection, laceration, puncture, arteriovenous fistula, and pseudoaneurysm (Figure 2).¹² Types of indirect vascular trauma include spasm, external compression, mural contusion, and thrombosis.¹² Although the ballistics may be relatively straight forward, the path of the bullet may be difficult to predict.
The injuries from stab wounds are directly related to the characteristics of the weapon used, although the path and depth of penetration are often difficult to predict. Apparently minor wounds may be associated with significant underlying injuries.
Anatomy
The anatomy of the neck is complex. There are many important structures in proximity to each other. Traditionally, the neck is divided into three zones for the management of penetrating trauma. (See Table 1 and Figure 3.) Zone I extends from the sternal notch to the cricoid cartilage. Injuries to zone I have the highest mortality due to associated injuries to intrathoracic structures (Figure 4).² Zone II lies between the cricoid cartilage and the angle of the mandible. Zone II injuries are the most common. Zone III consists of the upper neck above the angle of the mandible to the base of the skull. Surgical exposure is difficult in zones I and III.
 
 
Another classification separates the neck into triangles. The sternocleidomastoid muscle is the anatomical landmark that divides the neck into anterior and posterior triangles.¹³ The anterior triangle lies between the anterior midline of the neck, the inferior aspect of the angle, and the anterior border of the sternocleidomastoid. The posterior triangle is bordered by the posterior aspect of the sternocleidomastoid, the middle third of the clavicle, and the anterior aspect of the trapezius. Injuries to the posterior triangle have a lower incidence of significant injuries than those to the anterior triangle.¹⁴
The fascial and muscle planes of the neck are extremely important in the evaluation of penetrating injuries. The platysma is a thin, broad muscle that originates from the deep fascia that covers the upper chest and inserts on the inferior aspect of the mandible.¹³ It is covered anteriorly by the superficial fascia and by the deep fascia posteriorly. Any violation of this muscle defines penetrating neck trauma and mandates surgical consultation. The deep fascial layers may help contain a hematoma. These fascial layers also may provide a route for spread of infection in case of injury, especially the pretracheal fascia, which connects to the anterior pericardium.^2,4
Clinical Features of Penetrating Neck Trauma
Isolated penetrating neck injuries are uncommon. Penetrating neck injuries occur most often in the setting of multiple trauma.⁴ The presentation may range from relatively asymptomatic to dramatic and acutely life-threatening depending upon the structures involved. To avoid missing subtle findings, the search for injuries must be systematic. The history and physical examination should be directed to the areas of potential injury including vascular, laryngotracheal, esophageal, and neurological injuries.¹⁵
Vascular injuries occur in approximately 25% of patients with penetrating neck injuries.^15-17 Exsanguination is the most common cause of immediate death after a vascular injury.¹⁷ Morbidity and mortality also result from hematomas compromising the airway, direct vascular injury with subsequent occlusion, and bullet embolization.¹⁷ Mortality from these injuries ranges from 5% to 50%.^2,4,13,15 The clinical features of a vascular injury may be quite obvious, such as pulsatile bleeding or an expanding hematoma. These signs, believed to demonstrate a definite vascular injury, are referred to as “hard signs”.^2,13 (See Table 2.) Vascular injuries also may present with subtle neurologic or pulse deficits, therefore, a rapid yet vigilant exam is necessary. Late complications include traumatic aneurysm and arteriovenous fistula.⁵
Laryngotracheal injuries complicate 10% of penetrating neck injuries.^15,17 With penetrating trauma, these injuries are rarely occult.³ The most common signs and symptoms include dyspnea, stridor, dysphonia, hemoptysis, laryngeal tenderness, subcutaneous emphysema, and air bubbling from the wound.^2,3,13,15 (See Table 3.) Any of the above findings mandate laryngoscopy.

Esophageal injury occurs less frequently than vascular or laryngotracheal injuries due to the relatively protected location of the esophagus.¹⁷ Some authors have noted dyspnea, hemoptysis, and air-bubbling through wounds as “hard signs” of aerodigestive tract injuries.¹⁸ Most esophageal injuries are associated with laryngotracheal injuries due to its location.⁵ Signs and symptoms of esophageal injury include dysphagia, oropharyngeal hemorrhage, nasogastric tube bleeding, subcutaneous emphysema, and resistance to movement of the neck. As with laryngotracheal injuries, crepitance is a strong indicator of esophageal injury.^2,3,4,17-19 (See Table 4.) Despite these signs, esophageal injuries are the most commonly missed injuries in the neck.^17,20 A delay in the diagnosis of these injuries increases mortality.¹³ An early diagnosis is required to prevent the development of mediastinitis due to para-esophageal contamination.

Injuries to the nervous system include direct spinal cord injury, cranial nerve injury, peripheral nerve injury, and deficits in the central nervous system. Approximately 10% of patients with penetrating neck trauma will have an associated spinal cord or brachial plexus injury.¹³ The clinical presentation will depend upon the involved structure and the extent of the injury. In a recent study, almost 10% of asymptomatic patients with gunshot wounds to the trunk, head, or neck had spinal injuries.²¹ This percentage is much higher than had been reported in previous studies, and its results have been challenged.^22,23 In Connell’s study, no spinal injuries were found among nonintoxicated patients with a normal neurological examination who had penetrating trauma.²² Also, the presence of a peripheral nerve injury should alert the evaluating personnel to the possibility of an associated arterial injury because most nerves are located close to large arteries.⁵
To read the rest of this article, please visit AHC Online.
References
1. Thompson EC, Porter JM, Fernandez LG. Pentrating neck trauma: An overview in management. J Oral Maxillofac Surg 2002;60:918-923.
2. Duchynski RM. Neck injury. In: Ferrera PC, Colucciello SA, Marx JA, et al , eds. The Management of Trauma: An Emergency Medicine Approach. Philadelphia:Mosby 2001:218-231.
3. Baron BJ. Penetrating and blunt neck trauma. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th Ed. New York:McGraw-Hill 2004:1590-1595.
4. Schaider J, Bailitz J. Neck trauma: Don’t put your neck on the line. Emerg Med Pract 1993;5(7).
5. Craducci B, Lowe RA, Dalsey W. Penetrating neck trauma: consensus and controversies. Ann Emerg Med 1986;15:208-215.
6. Breasted JH. The Edwin Smith Surgical Papyrus. Chicago, IL: University of Chicago Press; 1930.
7. Key G. The Apologie and Treatise of Ambroise Pare Containing the Voyages Made into Divers Places with Many Writings Upon Surgery. London, UK: Falcon Education Book;1957.
8. Otis GA. Medical and Surgical History of the War of Rebellion, Part 3, Vol 2: Surgical History. Washington, DC: U.S. Government Printing Office;1983.
9. Fogelman MJ, Stewart RD. Penetrating wounds of the neck. Am J Surg 1956; 91:581-93.
10. Abujamra L, Joseph MM. Penetrating neck injuries in children: A retrospective review. Pediatr Emerg Care 2003;19:308-313.
11. Keller JE, Hindman JW, Kidd JN, et al. Air-gun injuries: Initial evaluation and resultant morbidity. Amer Surg 2004;70(6):484-490.
12. Frykberg ER, Schinco MA. Peripheral vascular injury. In: Moore EE, Feliciano DV, Mattox KL, eds. Trauma. 5th Ed. New York: McGraw-Hill 2004:969-1003.
13. Britt LD, Peyser MB. Penetrating and blunt neck trauma. In:Moore EE, Feliciano DV, Mattox KL, eds. Trauma. 5th Ed. New York: McGraw-Hill 2004:445-458.
14. Siegrist B, Steeb G. Penetrating neck injuries. South Med J 2000; 93:567-570.
15. Kendall JL, Anglin D, Demetriades D. Penetrating neck trauma. Emerg Med Clin North Amer 1998;16:85-105.
16. Asensio JA, Valenzianio CP, Falcone RE, Grosh JD. Management of penetrating neck iInjuries: The controversy surrounding zone II injuries. Surg Clin North Am 1991;71:267-296.
17. Newton K. Neck trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th Ed. Philadelphia: Mosby 2002:370-380.
18. Vassiliu P, Baker J, Henderson S, Alo K, Velmahos G, Demetriades D. Aerodigestive injuries of the neck. Amer Surg 2001;67:75-79.
19. Weigelt JA, Thal ER, Snyder WH, et al. Diagnosis of penetrating cervical esophageal injuries. Am J Surg 1987;154:619-622.
20. Demetriades D, Asensio JA, Valmahos G, Thai E. Complex problems in penetrating neck trauma. Surg Clin North Am 1996;76:661-683.
21. Klein Y, Cohn SM, Soffer D, et al. Spine injuries are common among asymptomatic patients after gunshot wounds. J Trauma 2005;58:833-836.
22. Connell RA, Graham CA, Munro PT. Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury 2003;34:912-914.
23. Rhee P, Martin M, Pleurad D, et al. Letter to editor. J Trauma 2005; 59:1033-1034.

Source: Trauma Reports, 11/06

Medscape: October 31, 2006 (Boston, MA) — Noninvasive assessment of coronary artery disease by coronary 64-slice multidetector computed tomography (MDCT) can be used for ruling out ACS in subjects presenting with chest pain to the emergency department and may be useful for improving early triage, a new study suggests. 

The study, published online in Circulation on October 30, 2006, was conducted by a team led by Dr Udo Hoffman (Massachusetts General Hospital, Boston, MA). They explain that accurate triage of patients presenting with acute chest pain to the emergency department remains difficult because chest-pain history, a single set of biochemical markers for myocardial necrosis, and the initial 12-lead ECG, alone or in combination, cannot identify a group of patients who can be safely discharged without further diagnostic testing. As a consequence, more than 60% of patients with chest pain who are admitted to the hospital turn out not to have ACS. In addition, the rate of missed diagnosis of ACS remains unacceptably high (2% to 8%).

They point out that as coronary artery disease is the major underlying cause of ACS, a noninvasive method that quickly and accurately excludes the presence of CAD could substantially improve the ability to triage patients with chest pain and that MDCT could be the answer. This scan requires patients to be injected intravenously with a contrast agent and to hold their breath during the 15-second exam.

CT results matched eventual clinical diagnosis  

In the current study, patients presenting with chest pain to the emergency department underwent MDCT for the assessment of coronary atherosclerotic plaque and significant coronary artery stenosis. An expert panel, blinded to the CT data, determined the presence or absence of ACS on the basis of all data accrued during the index hospitalization and five-month follow-up. Among 103 patients, only 14 patients were found to have ACS. The MDCT results correlated well with other methods of diagnosis. Both the absence of significant coronary artery stenosis and nonsignificant coronary atherosclerotic plaque on the CT scan accurately predicted the absence of ACS, with a negative predictive value of 100%. Multivariate logistic regression analyses demonstrated that adding the extent of plaque from a MDCT scan significantly improved the initial models containing only traditional risk factors or clinical estimates of the probability of ACS.

Hoffman commented to heartwire that this is the first study that has “very rigorously” looked at the role of MDCT in a cardiology clinical application. “MDCT is an emerging technology and is not used routinely yet, but it is probably used most in patients with stable angina to help decide whether to send them to angiography. We may do about 10 a day, and many private practices will offer this, but there is a reimbursement issue at the moment as it is not an established diagnostic modality yet,” he explained.

“Great potential” 

But Hoffman believes that MDCT has great potential as a diagnostic aid in chest-pain patients presenting in the emergency room. “At present, just acting on the traditional risk factors and tests conducted in the emergency department, it can still be difficult to differentiate those patients with an ACS from those whose chest pain is not cardiac related. Many patients are admitted to the hospital for stress tests and angiography, but fewer than 40% of patients admitted after initially normal blood tests and ECG turn out to have symptoms related to heart disease. But if we add the CT information to those tests conducted in the emergency department, things become a lot clearer,” he said.

Hoffman believes MDCT will be used to exclude ACS rather than to confirm it. “I am not suggesting that MDCT be used at present to decide whether patients need a stent or not— it’s not ready for that yet—but it probably does have a role in helping to decide who needs to be sent to angiography and who can be sent home. MDCT does not give the level of knowledge necessary to know whether a stent is required—you need angiography for that—but it can tell you whether there is significant stenosis or not. The beauty of MDCT is that it is much easier to perform than angiography. It takes less time, requires less physician time, it is less invasive, has fewer complications, and is much less expensive. It’s not going to replace angiography but it may enable fewer patients to be sent to angiography by ruling out ACS beforehand,” he told heartwire.

Hoffman said that it would probably not be needed for all patients presenting with chest pain, as those who are thought to be very likely to be having an ACS are referred straight to angiography anyway and those who have a very low likelihood of having an ACS are also quite easy to identify and so doing MDCT in these patients would probably not be cost-effective. But there is a large group of patients in the middle in whom doctors are not sure what is going on, and it is these patients in whom MDCT would be useful. “The challenge now is to make emergency department doctors familiar with this new technology,” he added.

Larger trial planned  

Hoffman hopes to have data on around 400 patients by early next year. “Although the current study lays the groundwork for using MDCT and identifies the patients who may benefit most, we need observational studies and randomized clinical trials to determine whether this technology improves the ability to quickly assess patients with chest pain and whether its use results in fewer hospitalizations and invasive tests,” he said. He is planning a larger multicenter trial to start later next year that will randomize 1800 to 2000 chest-pain patients to either MDCT or not, with physicians using the test results in their decision-making.

A large trial of MDCT is also under way in stable-angina patients, the Prospective Investigation Of Coronary Artery Disease (PIOCAD), in which 1000 patients with stable disease will receive a CT and a cath, and the cost-effectiveness of each of these modalities will be compared.

1. Hoffmann U, Nagurney JT, Moselewski F, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 2006; DOI: 10.1161/CIRCULATIONAHA.106.634808. Available at: http://circ.ahajournals.org.

An attempted shooting by an Ob-Gyn physician at Saint Peter’s University Hospital in New Brunswick, NJ, has refocused attention on hospital security, reported the Home News Tribune.

A fourth-year resident at the hospital reportedly tried to fire a handgun at an emergency room security guard, the newspaper said. That report came a month after an 86-year-old patient was sexually assaulted in her room at the hospital, an incident that prompted a review of hospital security throughout the region.

The 29-year-old obstetrician-gynecologist had been on leave from the hospital when she reportedly tried to enter the emergency room with a loaded .25-caliber semi-automatic, according to news reports. She was stopped by a security guard in the vestibule of the emergency room because she did not have identification. Officials said she then took out the handgun, aimed it at the guard, and pulled the trigger several times but the gun jammed.

Objective of the recent study (reference below): To quantify the prevalence and outcomes (i.e. mortality) of non-traumatic hypotensive ED patients who are admitted into the hospital.

Design: A single-center prospective cohort analysis.

Population: 4,790 non-traumatized patients who were >17 years of age and who were admitted into the hospital from the ED.

Interventions: Patients were enrolled throughout a one year period. They were divided into two groups: 1) those exposed to hypotension in the ED and 2) those not exposed. Patient presentations, vital signs, therapeutics, and ultimate outcomes were studied. The principal outcome measure was in-hospital mortality. Secondary outcome measures includ