Background. Most lacerations and surgical incisions are closed with sutures or staples. Octylcyanoacrylate tissue adhesive (OCA) was recently approved for use in the United States. We compared the ...cosmetic appearance of lacerations and incisions repaired with OCA versus standard wound closure methods (SWC). Methods. A multicenter randomized clinical trial including patients with simple lacerations or surgical incisions was conducted at 10 clinical sites. Patients were randomly assigned to treatment with OCA or SWC. Follow-up was performed at 1 week and at 3 months to determine infection rates and cosmetic outcome. Results. Eight hundred fourteen patients with 924 wounds (383 traumatic lacerations, 235 excisions of skin lesions or scar revisions, 208 minimally invasive surgeries, and 98 general surgical procedures) were enrolled. Groups were similar in baseline characteristics. Wound closure with OCA was faster than with SWC (2.9 vs 5.2 minutes, P <.001). At 1 week infection rates were similar (OCA, 2.1% vs SWC, 0.7%; P =.09) and fewer OCA wounds were erythematous (18% vs 36%, P <.001). There were no differences in wound dehiscence rates (OCA, 1.6% vs SWC, 0.9%; P =.35). At 3 months there was no difference in the percent of wounds with optimal appearance (OCA, 82% vs SWC, 83%; P =.67). Conclusions. Repair of traumatic lacerations and surgical incisions with OCA is faster than with SWC, and cosmetic outcome is similar at 3 months. (Surgery 2002;131:270-6.)
OBJECTIVE: Cytoarchitectonic changes in the anterior cingulate cortex, hippocampus, subiculum, entorhinal cortex, amygdala, mammillary bodies, and septum were reported in a postmortem study of ...autism. Previously, the authors found smaller cingulate volume and decreased metabolism of the cingulate in seven autistic patients. In this study, they measured the volume and glucose metabolism of the amygdala, hippocampus, and cingulate gyrus in an expanded group of 17 patients with autism spectrum disorders (autism N=10 or Asperger's disorder N=7) and 17 age- and sex-matched healthy volunteers. METHOD: Subjects performed a serial verbal learning test during 18F-deoxyglucose uptake. The amygdala, hippocampus, and cingulate gyrus were outlined on magnetic resonance imaging scans, volumes of the structures were applied to matching coregistered positron emission tomography scans, and three-dimensional significance probability mapping was performed. RESULTS: Significant metabolic reductions in both the anterior and posterior cingulate gyri were visualized in the patients with autism spectrum disorders. Both Asperger's and autism patients had relative glucose hypometabolism in the anterior and posterior cingulate as confirmed by analysis of variance; regional differences were also found with three-dimensional significance probability mapping. No group differences were found in either the metabolism or the volume of the amygdala or the hippocampus. However, patients with autism spectrum disorders showed reduced volume of the right anterior cingulate gyrus, specifically in Brodmann's area 24′. CONCLUSIONS: Compared with age- and sex-matched healthy volunteers, patients with autism spectrum disorders showed significantly decreased metabolism in both the anterior and posterior cingulate gyri.
Autism spectrum disorders are characterized by core deficits in social interaction and speech/communication skills, repetitive behaviors, and restricted interests. Other abnormalities include ...seizures, electroencephalographic (EEG) abnormalities, affective instability, impulsivity, and aggression. Divalproex sodium is indicated as both an anticonvulsant in epilepsy and a mood stabilizer in bipolar illness and thus might be useful for these complicating symptoms in autism.
A retrospective pilot study was conducted to determine whether divalproex sodium was effective in treating core dimensions and associated features of autism. Fourteen patients who met DSM-IV criteria for autism, Asperger's disorder, or pervasive developmental disorder not otherwise specified, both with and without a history of seizure disorders or EEG abnormalities, were openly treated with divalproex sodium. Improvement was assessed via the Clinical Global Impressions-Improvement scale.
Of 14 patients who completed a trial of divalproex sodium, 10 (71%) were rated as having sustained response to treatment. The mean dose of divalproex sodium was 768 mg/day (range, 125-2500 mg/day), and it was generally well tolerated. Improvement was noted in core symptoms of autism and associated features of affective instability, impulsivity, and aggression.
Divalproex sodium may be beneficial to patients with autism spectrum disorders, particularly those with associated features of affective instability, impulsivity, and aggression as well as those with a history of EEG abnormalities or seizures. Of note, all patients with an abnormal EEG and/or seizure history were rated as responders. However, these findings must be interpreted with caution, given the open retrospective nature of the study. Controlled trials are needed to replicate these preliminary findings.
Emergency departments are a major entry point for the initial management of acute heart failure (AHF) patients throughout the world. The initial diagnosis, management and disposition – the decision ...to admit or discharge – of AHF patients in the emergency department has significant downstream implications. Misdiagnosis, under or overtreatment, or inappropriate admission may place patients at increased risk for adverse events, and add costs to the healthcare system. Despite the critical importance of initial management, data are sparse regarding the impact of early AHF treatment delivered in the emergency department compared to inpatient or chronic heart failure management. Unfortunately, outcomes remain poor, with nearly a third of patients dying or re-hospitalised within 3 months post-discharge. In the absence of robust research evidence, consensus is an important source of guidance for AHF care. Thus, we convened an international group of practising emergency physicians, cardiologists and advanced practice nurses with the following goals to improve outcomes for AHF patients who present to the emergency department or other acute care setting through: (a) a better understanding of the pathophysiology, presentation and management of the initial phase of AHF care; (b) improving initial management by addressing knowledge gaps between best practices and current practice through education and research; and (c) to establish a framework for future emergency department-based international education and research.
Abstract Objective We sought to determine the impact of 3 validated scales of physician risk behavior on imaging use in emergency department (ED) patients with abdominal pain. Methods We performed a ...prospective cohort study of nonpregnant ED patients with acute, nontraumatic abdominal pain and then administered 3 instruments (a risk-taking subscale of the Jackson Personality Index, the stress from uncertainty scale, and a malpractice fear scale) to attending physicians who had evaluated these patients and made decisions regarding abdominal imaging. Outcomes were the use of abdominal pelvic computed tomography (CT) and any imaging use (CT, ultrasound, or abdominal plain film). Hierarchical logistic regression was used to determine the effect of risk scales on abdominal imaging use. Results Of 838 patients with acute abdominal pain, 487 (58%) received imaging studies; 395 (47%) received an CT, 111 (13%) ultrasound, and 122 (15%) an abdominal plain film. Both CT and any imaging use were lower among the physicians who were least risk-averse as measured by the risk-taking subscale (highest quartiles vs 3 lower quartiles). In adjusted analysis, probability of CT in the least risk-averse group was 35% (95% confidence interval CI, 28%-44%) compared to 50% (95% CI, 45%-54%) among more risk-averse physicians, and the probability of any imaging was 53% (95% CI, 44%-61%) compared to 64% (95% CI, 61%-68%). Malpractice fear and stress due to uncertainty were not predictive of imaging use. Conclusion Self-reported physician risk-taking behavior predicts the use of imaging in ED patients with abdominal pain, whereas malpractice fear and stress due to uncertainty do not.
...on a regular and recurring basis the entire spectrum of ultrasound-interpreting physicians must go through a new learning curve to accommodate the changes in the data quality. In the case of ...echocardiography, recent improvements in near-field resolution with transthoracic echocardiographic imaging have been accompanied by an increase in clinical uncertainty regarding the right ventricular anterior wall, which was previously difficult to see in such detail. Because right ventricular dysplasia is a risk for arrhythmias and sudden cardiac death, uncertainty about what comprises "normal" right ventricular anatomy may lead to additional testing and clinical concerns for the provider and patient.
Obesity is a major problem of modern societies that sometimes, but not necessarily, is associated with binge-eating disorder (BED), a relatively new disorder characterized by binge eating without ...purging. The purpose of this article is to review the rationale for the potential use of pharmacological treatments in BED, and the potential use of the recently proposed compounds. Therefore, a careful medline of published articles from 1980 to December 2010 was carried out using the following keywords: BED and treatment, topiramate, zonisamide, sibutramine, venlafaxine, duloxetine, ghrelin, opiate blockers. Single case reports, observational studies, opinion articles, and studies concerning adults with syndromes resulting in BED (i.e., night eating syndrome) were also reviewed. All examined papers would indicate that the pharmacological treatment of BED is still heterogenous and poorly established, mainly for the lack of controlled studies in large samples of patients. In any case, the data on serotonin and norepinephrine reuptake inhibitors and on novel anticonvulsants seem quite promising in terms of efficacy and tolerability. In addition, the preliminary findings on the possibility of modulating appetite through the interference with the ghrelin system suggest new and intriguing ways of intervention in BED.
Pre-adult onset of major depressive disorder (MDD) may predict a more severe phenotype of depression. As data from naturalistic psychiatric specialty care settings are scarce, we examined phenotypic ...differences between pre-adult and adult onset MDD in a large sample of consecutive out-patients.
Altogether, 1552 out-patients, mean age 39.2 ± 11.6 years, were diagnosed with current MDD on the Mini-International Neuropsychiatric Interview Plus diagnostic interview as part of the usual diagnostic procedure. A total of 1105 patients (71.2%) had complete data on all variables of interest. Pre-adult onset of MDD was defined as having experienced the signs and symptoms of a first major depressive episode before the age of 18 years. Patients were stratified according to the age at interview (20-40/40-65 years). Correlates of pre-adult onset were analysed using logistic regression models adjusted for age, age squared and gender.
Univariate analyses showed that pre-adult onset of MDD had a distinct set of demographic (e.g. less frequently living alone) and clinical correlates (more co-morbid DSM-IV - Text Revision diagnoses, more social phobia, more suicidality). In the multivariate model, we found an independent association only for a history of suicide attempts odds ratio (OR) 3.15, 95% confidence intervals (CI) 1.97-5.05 and current suicidal thoughts (OR 1.81, 95% CI 1.26-2.60) in patients with pre-adult versus adult onset MDD.
Pre-adult onset of MDD is associated with more suicidality than adult onset MDD. Age of onset of depression is an easy to ascertain characteristic that may help clinicians in weighing suicide risk.
This study was designed to assess the diagnostic performance of B-type natriuretic peptide (BNP) in the diagnosis of acute congestive heart failure (CHF) in patients with permanent/paroxysmal atrial ...fibrillation (AF) presenting with acute dyspnea.
It is unknown to what extent AF affects the diagnostic performance of BNP in patients presenting with acute dyspnea.
We studied 1,431 patients drawn from a cohort of patients (n = 1,586) with acute dyspnea who had BNP levels measured on arrival. Patients were prospectively classified according to the presence or absence of permanent/paroxysmal AF.
In total, 292 patients had permanent/paroxysmal AF. In patients without HF, permanent/paroxysmal AF was associated with significantly higher BNP levels (p = 0.001). Conversely, in patients with HF, BNP levels did not differ significantly between patients with and without AF (p = 0.533). A BNP cutoff value of 100 pg/ml had a specificity of 40% and 79% for the diagnosis of acute HF in patients with and without AF, respectively. The areas under the receiver-operating characteristic curves were 0.84 (95% confidence interval 0.78 to 0.89) and 0.91 (95% confidence interval 0.89 to 0.93) for patients with and without AF, respectively.
In patients without, but not in those with HF, the presence of AF is associated with higher circulating BNP levels, suggesting that a higher diagnostic threshold should be used in patients with AF.
Laceration Management Hollander, Judd E; Singer, Adam J
Annals of emergency medicine,
09/1999, Letnik:
34, Številka:
3
Journal Article
Recenzirano
Odprti dostop
In 1996, almost 11 million lacerations were treated in emergency departments throughout the United States. Although most lacerations heal without sequelae regardless of management, mismanagement may ...result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality. The goals of wound management are simple: avoid infection and achieve a functional and aesthetically pleasing scar. Recent US Food and Drug Administration approval of tissue adhesives has significantly expanded clinicians’ wound closure options and improved patient care. We review the general principles of wound care and expand on the use of tissue adhesives for laceration repair. Hollander JE, Singer AJ: Laceration management.
Ann Emerg Med September 1999;34:356-367.
PDF
