Muller et al report that S-100B had a specificity of 12.2% and a
sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker
for CCT triage may improve patient screening and decrease the number of
CCT scans performed. However, if we were to roll a 6-sided die and call
the number 6 negative and the numbers 1 to 5 positive we would expect to
have a test with similar parameters: 83.3% sensitivity (i.e. positiv...
Muller et al report that S-100B had a specificity of 12.2% and a
sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker
for CCT triage may improve patient screening and decrease the number of
CCT scans performed. However, if we were to roll a 6-sided die and call
the number 6 negative and the numbers 1 to 5 positive we would expect to
have a test with similar parameters: 83.3% sensitivity (i.e. positive 5/6
times in those with the disease) and 16.6% specificity (i.e. negative 1/6
times in those without the disease). This illustrates how adopting a low
threshold for positivity can produce and apparently high sensitivity at
the expense of specificity for an essentially worthless test (like rolling
a die). Reporting likelihood ratios overcomes this problem. The likelihood
ratios for a positive and negative test based on the estimates of
sensitivity and specificity reported by Muller are 0.98 and 1.11
respectively.
In fact, the performance of S-100B may not be quite as bad as their
reported estimates suggest. Based on the data reported in Table 2 the
sensitivity is indeed 86.4% (19/22) but the specificity is actually 31.8%
(67/211), giving positive and negative likelihood ratios of 1.27 and 0.43
respectively. This is still not much help for decision-making but probably
better than rolling a die.
Ischemia modified albumin (IMA) has recently been proposed for the
early detection of myocardial ischemia without infarction [1]. We read
with interest the article of Ming-Hui Lin, who evaluated this marker as an
early negative predictor of acute coronary syndrome (ACS) in different
time to presentation groups and different cardiac risk groups [2]. The
authors asserted that IMA is a relatively new test, performed on diffe...
Ischemia modified albumin (IMA) has recently been proposed for the
early detection of myocardial ischemia without infarction [1]. We read
with interest the article of Ming-Hui Lin, who evaluated this marker as an
early negative predictor of acute coronary syndrome (ACS) in different
time to presentation groups and different cardiac risk groups [2]. The
authors asserted that IMA is a relatively new test, performed on different
instruments and with no universal standardisation, so that different
laboratories are likely to produce different test results. This is however
only partially true. In a previous study we have comprehensively addressed
this issue, highlighting that the diagnostic performances of IMA are
influenced by some analytical drawbacks. In particular, there is a
significant inverse association between IMA and serum albumin, so that the
"raw" IMA serum values in patients with extremely low or high serum
albumin levels (i.e., <20 or >55 g/L) may be unreliable and lacking
in clinically informative value. To overcome this limitation, we have
thereby proposed the use of a corrective formula, as follows: [(individual
serum albumin concentration/median albumin concentration of the
population) x IMA value] [3]. The major advantage of this equation is the
normalization of test results for the concentration of serum albumin in
the samples. We have also demonstrated that this approach is effective to
(i) substantially reduce the otherwise heterogeneous distribution of
values in heath and disease while maintaining the median IMA concentration
substantially unchanged, and (ii) overcome the bias arising from various
methods and instrumentation, thus contributing to harmonize results among
different laboratories and techniques. Although we agree that IMA might
not be a reliable negative predictor for ACS using the manufacturer cut-off, it might be advisable to re-evaluate the results of Ming-Hui Lin
normalizing results for serum albumin by using our corrective formula.
The Corresponding Author has the right to grant on behalf of all
authors and does grant on behalf of all authors, an exclusive licence (or
non exclusive for government employees) on a worldwide basis to the BMJ
Publishing Group Ltd and its Licensees to permit this article (if
accepted) to be published in EMJ editions and any other BMJPGL products
to exploit all subsidiary rights, as set out in our
licence(http://group.bmj.com/products/journals/instructions-for-
authors/licence-forms)."
Competing Interest: None to declare.
References.
1. Lippi G, Montagnana M, Salvagno GL, Guidi GC. Potential value for new
diagnostic markers in the early recognition of acute coronary syndromes.
CJEM 2006;8:27-31.
2. Lin RM, Fatovich DM, Grasko JM, Vasikaran SD. Ischaemia modified
albumin cannot be used for rapid exclusion of acute coronary syndrome.
Emerg Med J. 2010;27:668-71
3. Lippi G, Montagnana M, Salvagno GL, Guidi GC. Standardization of
ischemia-modified albumin testing: adjustment for serum albumin. Clin Chem
Lab Med 2007;45:261-2.
This paper stated prevalence of Tension Pneumothorax which is
misleading and up to 20 times higher than that which might be seen by the
standard pre-hospital care practitioner. Further analysis of the two
references used for this statement is given and it can be seen that their
results should not be extrapolated to the general pre-hospital environment
without qualification.
This paper stated prevalence of Tension Pneumothorax which is
misleading and up to 20 times higher than that which might be seen by the
standard pre-hospital care practitioner. Further analysis of the two
references used for this statement is given and it can be seen that their
results should not be extrapolated to the general pre-hospital environment
without qualification.
Coats described tension pneumothorax in up to 5.4% of patients, 64%
of whom were ventilated. They were also a major trauma sub-group.
McPherson looked retrospectively at US soldier fatalities in Vietnam
- when there was no pre-hospital chest decompression. His abstract and
discussion however, mis-represent the figures stated in his results and
the study has methodological floors. Accepting these floors though, he
observed that fatal tension pneumothorax may have occurred in up to:
0.3% of American casualties (26/7801)
3.9% of casualties who died and had signs of a chest wound (26/663)
Despite its floors McPherson’s paper may be more applicable to the
average pre-hospital clinician as it looks purely at awake patients.
However, the external validity of both these papers (which look at
high risk groups) to pre-hospital clinicians seeing a predominance of
blunt trauma, awake patients should be questioned.
The inference that should be taken away by the reader is that "fatal
tension pneumothorax is very unlikely to occur in more than 0.3% of awake
patients encountered in pre-hospital care" Even this is probably too high,
but may go some way to stemming the tide of iatrogenic, needle induced
pneumothorax.
References
1. McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma 2006;60:573–8.[Medline]
2. Coats TJ, Wilson AW, Xeropotamous N. Pre-hospital management of patients with severe thoracic injury. Injury 1995;2:581–5.[CrossRef]
Our previous study reported in your journal in 2012 found that 7.5%
of the transvaginal sonography (TVS) probe samples were human
papillomavirus (HPV) DNA positive in our Emergency Department, when a
barrier was applied along with low level disinfection using a quaternary
ammonia based agent. (1)
M'Zali et al also demonstrated that TVS probes remained substantially
contaminated by HPV, C. trachomatis, mycoplasma...
Our previous study reported in your journal in 2012 found that 7.5%
of the transvaginal sonography (TVS) probe samples were human
papillomavirus (HPV) DNA positive in our Emergency Department, when a
barrier was applied along with low level disinfection using a quaternary
ammonia based agent. (1)
M'Zali et al also demonstrated that TVS probes remained substantially
contaminated by HPV, C. trachomatis, mycoplasmas, Gram-positive and Gram-
negative bacteria with low level disinfection. (2)
According to the Centres for Disease Control and Prevention (CDC)
guidelines, transvaginal probes, as they have direct contact with mucosal
membranes, should be processed using a high level disinfection method. (3)
However, many suitable agents can potentially damage the transducer and
reduce its life span. Since the discovery of substantial HPV contamination
in 2011, our department has adopted high level disinfection techniques
using the Tristel TRIO wipes system [Tristel Solutions Ltd, U.K.], which
is a chlorine dioxide based agent specially designed for endocavity
ultrasound probes as well as certain endoscopes.
After implementation of the new disinfection method for 1 year, we
performed another surveillance sampling of the TVS probe. A total of 50
samples were collected daily over 50 consecutive days between March and
May 2013. All samples were HPV DNA negative by PCR performed as previously
described. (1)
Our latest results provide encouraging evidence that barrier methods
together with high level disinfection can successfully reduce HPV
contamination of the TVS probe. The associated increase in cost is
worthwhile to ensure a low risk of contamination.
Reference:
1. Ma ST, Yeung AC, Chan PK, Graham CA. Transvaginal ultrasound probe
contamination by the human papillomavirus in the emergency department.
Emerg Med J. 2013 Jun;30(6):472-5.
2. M'Zali F, Bounizra C, Leroy S, Mekki Y, Quentin-Noury C, Kann M.
Persistence of microbial contamination on transvaginal ultrasound probes
despite low-level disinfection procedure. PLoS One. 2014 Apr
2;9(4):e93368.
RE: Coats, Timothy J.: Future research in emergency medicine:
explanation or pragmatism? Large or small? Simple or complex? Emerg Med J.
2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future
research in emergency medicine: explanation or pragmatism? Large or small?
Simple or complex.
Coats highlights the potential role of emergency medicine in
conducting large pragmatic t...
RE: Coats, Timothy J.: Future research in emergency medicine:
explanation or pragmatism? Large or small? Simple or complex? Emerg Med J.
2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future
research in emergency medicine: explanation or pragmatism? Large or small?
Simple or complex.
Coats highlights the potential role of emergency medicine in
conducting large pragmatic trials and the shortcomings of the more
traditional complex randomized controlled trials. He correctly points out
that traditional phase III trials are difficult to run, extremely
expensive, and restricted by highly competitive funding mechanisms. While
many of the points made in the article are valid, the premise that
emergency medicine researchers are not capable, or competitive in an arena
of rigorously conducted clinical trials is disconcerting and inaccurate.
Emergency physicians can compete, create niches, and succeed! The trial
design is irrelevant.
Over the last 10 years, the number of emergency physicians conducting
high quality RCTs has risen steadily1,2. These include both industry-
sponsored and federally funded trials. As the specialty matures, it is
only logical that emergency medicine expands its research footprint and
relevance.
The concept that traditional clinical trials or research are
restricted only to specialties that have narrowed their scope to a
particular disease state, organ system, technical skill, or type of
research is unsound. Emergency Medicine's uniqueness is that there are
diverse interests and a broad base of expertise. Science in general, and
clinical trials is particular, is a TEAM sport. The emergency physician
is ideally poised to take the reins of the RCT team, since emergency
medicine holds the key to the door (literally) and is the entry point for
many diseases and conditions into the system. Indeed, emergency medicine's
recent success in high-quality research has garnered substantial attention
at NIH. Just in the past 3 years, a number of requests for proposals
(RFPs) are targeted at emergency medicine researchers3. The Neurological
Emergencies Treatment Trials (NETT) network4,5 is constructed primarily of
emergency physicians as principal investigators. The NETT is being
heralded as one of the most successful acute trials networks in the
history of the NIH, and it has proven that emergency physicians not only
can run complicated RCT's, but that they excel at it. Fortunately for
other specialties, emergency medicine is collaborative by nature and seeks
out the participation and expertise of its colleagues. Non-EM researchers
now actively engage emergency physicians in acute trials because they
realize EM's critical role (e.g. Stroke Hyperglycemia Insulin Network
Effort (SHINE) Trial, Albumin in Acute Ischemic Stroke (ALIAS) Trial6).
Despite the specialty's relative young age and limited research
infrastructure, EM researchers are leading the pack in many fields of
research including traumatic brain injury, stroke, status epilepticus,
asthma and others. The ProTECT III trial is one of the highest funded
NINDS clinical trial ever awarded for TBI research, and the PI is an
emergency physician. The RAMPART study was multimillion-dollar clinical
trial for status epilepticus that recruited patients so fast and
efficiently that, even with an expanded sample size, it was completed 2
years ahead of schedule...and the PI was an EM researcher7. There are
numerous other examples. Clinical specialization based on a particular
organ system does not inherently confer any unique talents or exclusive
skills. Emergency medicine can compete with good science, training, and a
passion to succeed.
The type of trial design that one chooses depends on the question to
be answered. The distinction between efficacy and effectiveness is
clearly an important one (treatments may be efficacious, but when employed
to the broader population are not effective), but there are many reasons
for why this may occur; not all are encompassed in the term
generalizability. The small sample size in RCTs is more a function of
poor trial design than a fundamental flaw in any particular trial
methodology.
Even though the apparent underlying intent of Coates' article is to
justify large simple trials, the argument is lost on the contention that
emergency medicine is not competitive in disease-based sciences and
therefore should become "known" for a particular methodology. There is no
doubt that substantial inequalities in funding with our non-EM colleagues
exist8 and numerous challenges abound for EM researchers. But, emergency
medicine is making significant strides as the specialty matures.
Furthermore, trial design does not trump good science. Both types of
trials have merit, and emergency physicians can be great at and compete
for both!
REFERENCES
1. Rosenzweig JS, Van Deusen SK, Okpara O, Datillo PA, Briggs WM,
Birkhahn RH. Authorship, collaboration, and predictors of extramural
funding in the emergency medicine literature. Am J Emerg Med. Jan
2008;26(1):5-9.
2. Birkhahn RH, Van Deusen SK, Okpara OI, Datillo PA, Briggs WM, Gaeta TJ.
Funding and publishing trends of original research by emergency medicine
investigators over the past decade. Acad Emerg Med. Jan 2006;13(1):95-101.
3. Funding Opportunities. 2011;
http://search2.google.cit.nih.gov/search?q=Emergency+Medicine&Search.x=22&Search.y=1&site=GRANTS_ALL&client=GRANTS_ALL_frontend&proxystylesheet=GRANTS_ALL_frontend&output=xml_no_dtd&filter=0&getfields=*,
2012.
4. Hill MD, Martin RH, Palesch YY, et al. The Albumin in Acute Stroke Part
1 Trial: an exploratory efficacy analysis. Stroke; a journal of cerebral
circulation. Jun 2011;42(6):1621-1625.
5. Silbergleit R. Response to Food and Drug Administration draft guidance
statement on research into the treatment of life-threatening emergency
conditions using exception from informed consent: testimony of the
neurological emergencies treatment trials. Acad Emerg Med. Apr
2007;14(4):e63-68.
6. Ginsberg MD, Hill MD, Palesch YY, Ryckborst KJ, Tamariz D. The ALIAS
Pilot Trial: a dose-escalation and safety study of albumin therapy for
acute ischemic stroke--I: Physiological responses and safety results.
Stroke. Vol 372006:2100-2106.
7. Silbergleit R, Lowenstein D, Durkalski V, Conwit R. RAMPART (Rapid
Anticonvulsant Medication Prior to Arrival Trial): a double-blind
randomized clinical trial of the efficacy of intramuscular midazolam
versus intravenous lorazepam in the prehospital treatment of status
epilepticus by paramedics. Epilepsia. Oct 2011;52 Suppl 8:45-47.
8. Bessman SC, Agada NO, Ding R, Chiang W, Bernstein SL, McCarthy ML.
Comparing National Institutes of Health funding of emergency medicine to
four medical specialties. Acad Emerg Med. Sep 2011;18(9):1001-1004.
Acknowledgements: The author thanks the members of the editorial
board of Academic Emergency Medicine who participated in an email
discussion of the source paper; particularly Drs. David Cone, Jill Baren,
Clifton Callaway, Don Yealy, Christopher Moore, Lowell Gerson, Michelle
Biros, and Gary Gaddis.
ingested Non-opaque foreign bodies can be detected with ask the
patient to drink a contrast media mixed with honey . honey is thick
material that increase the foreign body contamination with contrast .
contamination of the foreign body with honey and contrast result in
increase of their radio-density even with no-metallic and vegetable
foreign bodies . honey has a high HU on CT examination m...
ingested Non-opaque foreign bodies can be detected with ask the
patient to drink a contrast media mixed with honey . honey is thick
material that increase the foreign body contamination with contrast .
contamination of the foreign body with honey and contrast result in
increase of their radio-density even with no-metallic and vegetable
foreign bodies . honey has a high HU on CT examination may be above
300HU and can be used alone in delineation of fistulae or the tracks of
deep penetrating wounds . its intrinsic properties as antibacterial and
microbial action make its usage is save . in blunt abdominal trauma with
rapid preparation honey can solve the problem of rapid preparation if it
is dunked with 20 %concentration diluted by water .this will give an
excellent filling of the stomach and small intestine and hence any leakage
or intra-peritoneal free fluid can be seen
We are incredibly glad to hear that Dr. Sherren has taken an interest
in our research (1). I concur with his position on this matter. I believe
that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac
arrest patients will be solved through near future technologies such as
extracorporeal membrane oxygenators. However, if we divide cardiac arrests
broadly into in-hospital and out-of-hospital, or on-site arrests...
We are incredibly glad to hear that Dr. Sherren has taken an interest
in our research (1). I concur with his position on this matter. I believe
that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac
arrest patients will be solved through near future technologies such as
extracorporeal membrane oxygenators. However, if we divide cardiac arrests
broadly into in-hospital and out-of-hospital, or on-site arrests, we must
admit that, even in the future, on-site treatment will largely rely upon
CPR administered by other persons who are on-hand. Therefore, it is
necessary that resuscitation research on the often overlooked ergonomic
aspects of CPR be revitalized and brought to greater focus. The starting
point for an ergonomic approach to CRP research will have to begin with
the effectiveness of chest compressions. Already, in the 2005 guidelines,
the importance of chest compression was emphasized (2). Within such
emphasis, our research group is especially interested in the influence the
relative body positions of the patient in need of CPR and the rescuer have
on the quality of CPR administered. Previous research in this area
indicates that it is most effective to administer CPR from a kneeling
position (CPRKP) on a patient who is on the floor (3). If this is true,
there is a need to identify what factors cause CPR administered from a
standing position (CPRSP) on a patient who lies on the bed to be less
effective. Research such as this must look at the rescuer's changes in
body positioning, as well as other factors, from an ergonomics perspective
in order to be most effective. Under the assumption that making the
conditions of performing CPRSP more similar to those of CPRKP would reduce
the loss of effectiveness associated with CPRSP, our research team
postulated the following hypotheses: 1) that if the bed on which the
patient lies were to be lowered to the height of the rescuer's knees
during CPRSP, the rescuer would be able to perform CPR in basically the
same position as with CPRKP and 2) that rather than placing the patient on
a mattress and then a backboard, removing the mattress altogether will
improve the conditions of administering CPR. The current study that we are
presenting is the first of several studies being conducted regarding these
hypotheses. We feel that Dr. Sherren's suggestion of having the rescuer
perform CPR while kneeling on the bed itself (CPRKOB) is also a valid
hypothetical solution to solving the problem of loss of effectiveness
associated with performing CPR on patients in beds. However, this too must
undergo rigorous performance studies. While there are cases in which
CPRKOB has been performed in clinical settings, most clinical beds are not
very strong, and thus a level of instability is often a factor in such
cases. This is especially true of smaller emergency-room gurneys. Indeed,
it may be true that the simplest solution to preventing the loss of
effectiveness in CPR performed on patients in beds is to remove the beds
altogether. However, procedures such as endotracheal intubation and
vascular access, as well as various monitors attached to a patient may
make the act of removing a patient from a bed in order to perform CPR
unrealistic; extensive performance studies would have to be performed in
order to make any sort of a persuasive argument for such a procedure. As
Dr. Sherren has pointed out, mannequin-based performance studies have not
beed recognized as very important because they lack things as chest recoil
and thoracic pump effects - therefore, making them less desirable than
animal and clinical trials. However, considering that CPR is a procedure
directly performed by persons, performance studies will give us the best
evidence for the creation of guidelines for effective CPR. Again, we thank
Dr. Sherren for his attention to our research and give him our regards.
References
1. PB Sherren. Effects of bed height on the performance of chest
compressions - Clinical application of results. Emerg Med J 2010;eLetter
2. International Liaison Committee on Resuscitation. International
consensus on cardiopulmonary resuscitation and emergency cardiovascular
care science with treatment recommendations. Part 2. Adult basic life
support. Resuscitation 2005;67:187-201.
3. Perkins GD, Benny R, Giles S, Gao F, Tweed MJ. Do different
mattresses affect the quality of cardiopulmonary resuscitation? Intensive
Care Med 2003;29:2330-5.
The article by Higginson made me think about our specialty and
whether we have got a missing link. However, it reminded me to look at the
Way Ahead document produce by the UK College of Emergency Medicine in
2008. Surely this provides an excellent service concept for our specialty?
The document provides clear guidance as to what our core and extended
services should be and how we should consider delivering them. I wonder...
The article by Higginson made me think about our specialty and
whether we have got a missing link. However, it reminded me to look at the
Way Ahead document produce by the UK College of Emergency Medicine in
2008. Surely this provides an excellent service concept for our specialty?
The document provides clear guidance as to what our core and extended
services should be and how we should consider delivering them. I wonder
whether the author had read this....maybe he should.
We read with interest the case report by Abeysinghe and colleagues
reporting hyperinsulinaemic euglycaemic therapy (HIET) in the treatment of
a patient presenting with persistent hypotension following an overdose of
the lipophilic calcium channel blocker diltiazem.[1]
Diltiazem is extremely lipophilic with a log P value of 4.53 (a
measure of lipid solubility). Thus we consider that it would have been
amenable t...
We read with interest the case report by Abeysinghe and colleagues
reporting hyperinsulinaemic euglycaemic therapy (HIET) in the treatment of
a patient presenting with persistent hypotension following an overdose of
the lipophilic calcium channel blocker diltiazem.[1]
Diltiazem is extremely lipophilic with a log P value of 4.53 (a
measure of lipid solubility). Thus we consider that it would have been
amenable to treatment with intravenous lipid emulsion (ILE). This new and
emerging addition to the treatment arsenal of lipophilic drug overdoses is
supported by a rapidly expanding body of experimental work and clinical
cases. The effectiveness of ILE in reversing local anaesthetic induced
cardiovascular collapse has been unequivocally demonstrated in animal
studies, and recent attention has turned to non-local anaesthetic
applications.[2] The role of ILE has extended to include suppression of
the toxic effects of verapamil and recently the first case report
describing a successful outcome with the use of ILE combined with HIET for
the treatment of diltiazem overdose has been published.[3]
Abeysinghe and colleagues astutely noted that in calcium channel
blocker overdose 'myocardial extraction of free fatty acids is decreased
despite maintained plasma levels'. ILE is believed to have several
beneficial effects with enhancement of myocardial fatty acid transport
appearing to be one of the ways in which physiological and metabolic
integrity might be restored. Secondly, ILE binds lipophilic drugs within
an expanded intravascular lipid phase (the 'lipid sink' effect), thereby
reducing the amount of drug available to exert its toxic effects. Finally,
ILE may act via a direct inotropic action by increasing cardiac
intracellular calcium concentration.[2] With evidence for the
effectiveness of ILE in lipophilic drug overdoses increasing we believe it
may become a standard intervention in the treatment of calcium channel
blocker overdose either as monotherapy or possibly alongside HIET.
Dr Theophilus Luke Samuels
Dr David R Uncles
Dr Johann W Willers
Dr Aikaterini Papadopoulou
References
1 Abeysinghe N, Aston J, Polouse S. Diltiazem overdose: a role for
high-dose insulin. Emerg Med J 2010;27:802-3.
2 Cave G, Harvey M. Intravenous Lipid Emulsion as Antidote Beyond
Local Anaesthetic Toxicity: A Systematic Review. Acad Emerg Med
2009;16:815-24.
3 Montiel V, Gougnard T, Hantson P. Diltiazem poisoning treated with
hyperinsulinemic euglycemia therapy and intravenous lipid emulsion. Eur J
Emerg Med Published Online First: 17 November 2010. doi:
10.1097/MEJ.0b013e32834130ab.
As a paediatrician I have learnt that auscultation often adds little
to my assessment of children with possible pneumonia. If the patient
(adult or child) has other clinical features of pneumonia e.g hypoxia,
pleuritic pain, tachypnoea, then a chest radiograph will probably be
requested anyway.
Interestingly the British Thoracic Society guidelines on Community
Aquired Pneumonia in Adult...
As a paediatrician I have learnt that auscultation often adds little
to my assessment of children with possible pneumonia. If the patient
(adult or child) has other clinical features of pneumonia e.g hypoxia,
pleuritic pain, tachypnoea, then a chest radiograph will probably be
requested anyway.
Interestingly the British Thoracic Society guidelines on Community
Aquired Pneumonia in Adults (Thorax 2001;56 (suppl IV)) state that a chest
radiograph is not indicated for the majority of patients diagnosed with
pneumonia in the community but also state that "diagnosing pneumonia
clinically without a chest radiograph is inaccurate".
So do you perform a chest radiograph or do you give antibiotics -
whether they have crepitations or not?
Muller et al report that S-100B had a specificity of 12.2% and a sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker for CCT triage may improve patient screening and decrease the number of CCT scans performed. However, if we were to roll a 6-sided die and call the number 6 negative and the numbers 1 to 5 positive we would expect to have a test with similar parameters: 83.3% sensitivity (i.e. positiv...
Ischemia modified albumin (IMA) has recently been proposed for the early detection of myocardial ischemia without infarction [1]. We read with interest the article of Ming-Hui Lin, who evaluated this marker as an early negative predictor of acute coronary syndrome (ACS) in different time to presentation groups and different cardiac risk groups [2]. The authors asserted that IMA is a relatively new test, performed on diffe...
Dear Editor,
This paper stated prevalence of Tension Pneumothorax which is misleading and up to 20 times higher than that which might be seen by the standard pre-hospital care practitioner. Further analysis of the two references used for this statement is given and it can be seen that their results should not be extrapolated to the general pre-hospital environment without qualification.
Coats describe...
Our previous study reported in your journal in 2012 found that 7.5% of the transvaginal sonography (TVS) probe samples were human papillomavirus (HPV) DNA positive in our Emergency Department, when a barrier was applied along with low level disinfection using a quaternary ammonia based agent. (1)
M'Zali et al also demonstrated that TVS probes remained substantially contaminated by HPV, C. trachomatis, mycoplasma...
RE: Coats, Timothy J.: Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex? Emerg Med J. 2011 Dec;28(12):1004-7.
Emergency Medicine Can! Response to Coats, Timothy J.: Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex.
Coats highlights the potential role of emergency medicine in conducting large pragmatic t...
Dear Editor
ingested Non-opaque foreign bodies can be detected with ask the patient to drink a contrast media mixed with honey . honey is thick material that increase the foreign body contamination with contrast . contamination of the foreign body with honey and contrast result in increase of their radio-density even with no-metallic and vegetable foreign bodies . honey has a high HU on CT examination m...
We are incredibly glad to hear that Dr. Sherren has taken an interest in our research (1). I concur with his position on this matter. I believe that cardiopulmonary resuscitation (CPR) issues in in-hospital cardiac arrest patients will be solved through near future technologies such as extracorporeal membrane oxygenators. However, if we divide cardiac arrests broadly into in-hospital and out-of-hospital, or on-site arrests...
The article by Higginson made me think about our specialty and whether we have got a missing link. However, it reminded me to look at the Way Ahead document produce by the UK College of Emergency Medicine in 2008. Surely this provides an excellent service concept for our specialty? The document provides clear guidance as to what our core and extended services should be and how we should consider delivering them. I wonder...
We read with interest the case report by Abeysinghe and colleagues reporting hyperinsulinaemic euglycaemic therapy (HIET) in the treatment of a patient presenting with persistent hypotension following an overdose of the lipophilic calcium channel blocker diltiazem.[1]
Diltiazem is extremely lipophilic with a log P value of 4.53 (a measure of lipid solubility). Thus we consider that it would have been amenable t...
Dear Editor,
As a paediatrician I have learnt that auscultation often adds little to my assessment of children with possible pneumonia. If the patient (adult or child) has other clinical features of pneumonia e.g hypoxia, pleuritic pain, tachypnoea, then a chest radiograph will probably be requested anyway.
Interestingly the British Thoracic Society guidelines on Community Aquired Pneumonia in Adult...
Pages