Andrew D. Zechnich

Second-generation antihistamines : A comparative review

Second-generation histamine H1 receptor antagonists (antihistamines) have been developed to reduce or eliminate the sedation and anticholinergic adverse effects that occur with older H1 receptor antagonists. This article evaluates second-generation antihistamines, including acrivastine, astemizole, azelastine, cetirizine, ebastine, fexofenadine, ketotifen, loratadine, mizolastine and terfenadine, for significant features that affect choice.In addition to their primary mechanism of antagonising histamine at the H1 receptor, these agents may act on other mediators of the allergic reaction. However, the clinical significance of activity beyond that mediated by histamine H1 receptor antagonism has yet to be demonstrated.Most of the agents reviewed are metabolised by the liver to active metabolites that play a significant role in their effect. Conditions that result in accumulation of astemizole, ebastine and terfenadine may prolong the QT interval and result in torsade de pointes. The remaining agents reviewed do not appear to have this risk. For allergic rhinitis, all agents are effective and the choice should be based on other factors. For urticaria, cetirizine and mizolastine demonstrate superior suppression of wheal and flare at the dosages recommended by the manufacturer.For atopic dermatitis, as adjunctive therapy to reduce pruritus, cetirizine, ketotifen and loratadine demonstrate efficacy. Although current evidence does not suggest a primary role for these agents in the management of asthma, it does support their use for asthmatic patients when there is coexisting allergic rhinitis, dermatitis or urticaria.

Influence of a statewide trauma system on pediatric hospitalization and outcome

BACKGROUND During the years 1987-1991, a statewide trauma system was implemented in Oregon (Ore) but not in Washington (Wash). Incidence of hospitalization, frequency of death and risk-adjusted odds of death for injured children (< 19 years) in the two adjacent states were compared for two time periods (1985-1987 and 1991-1993). METHODS State populations of injured children (International Classification of Diseases, 9th Revision-Clinical Modification, code 800-959) were identified through a Hospital Discharge Index. Hospitals in counties with a population density < 50 persons/square mile were designated rural. Incidence rates are events/10,000 pediatric population per year. RESULTS The pediatric population increased in both states (Ore: 687,000-758,000; Wash: 1,159,000-1,336,000). Incidence of hospitalization for all injured children in entire states declined (Ore: 66.5-38.5; Wash: 54-33); also in rural hospitals (Ore: 67.5-32; Wash: 48 to 31). Seriously injured children (score on the Injury Severity Scale > 15) had a lower incidence in 1991-1993 of admission to rural hospitals (Ore: 2.98; Wash: 2.82) compared with incidence for entire states (Ore: 4.61; Wash: 4.62); in 1985-1987 the incidence was not different. Furthermore risk adjusted odds of death for seriously injured children was significantly lower in Oregon than in Washington in the later time period. CONCLUSION Both states show a similar temporal trend toward a declining frequency of death for children hospitalized with injuries. Injury prevention strategies appear to have reduced the number of serious injuries in both states. However, seriously injured children demonstrated a reduced risk of death in Oregon, consistent with benefit from a statewide trauma system.

Pharmacological reversal of abnormal glucose regulation, BCAA utilization, and muscle catabolism in sepsis by dichloroacetate.

Sepsis has been shown to decrease skeletal muscle glucose oxidation by inhibiting the pyruvate dehydrogenase activity (PDHa) and to increase proteolysis and use of branched-chain amino acids (BCAA). The effects of dichloroacetate (DCA), which reverses PDHa inhibition, were studied in skeletal muscle from a septic (S) rat model of intra-abdominal abscess (E. coli + B. fragilis) and compared to control (C) and sterile inflammatory abscess (I) animals. In one set of S, I, and C animals, DCA (1 mmol/kg) was injected intraperitoneally at 0, 30, and 60 min. Septic, but not I, rats had a twofold increase in skeletal muscle lactate concentrations over C, but no changes in pyruvate. After DCA, both lactate and pyruvate were reduced (p less than 0.001) to same level in S, I, and C. Skeletal muscle alanine was increased in S compared to I or C, but after DCA was reduced threefold in C, S, and I (p less than 0.001) suggesting that alanine synthesis may be impaired due to decreased pyruvate availability. Like alanine, skeletal muscle BCAA were increased in S compared to C, but not altered in I. Following DCA, BCAA levels in muscle from S were reduced (p less than 0.001) to values seen in C or I. Muscle phenylalanine content was significantly elevated in S (p less than 0.05) compared to C or I, but was reduced (p less than 0.05) after DCA in S but not in C or I. Decreased muscle phenylalanine associated with lowered BCAA suggests DCA may decrease septic muscle protein catabolism and/or enhance protein synthesis. Coupled with an increased PDHa and reduced lactate levels, this suggests that DCA may reverse the excess muscle catabolism and BCAA dependence of sepsis by increasing glucose and lactate oxidation and may be a useful therapeutic modality.

Use of an electronic emergency department information system as a data source for respiratory syndrome surveillance

SECTION I: SYNDROMIC SURVEILLANCE USING EMERGENCY DEPARTMENT DATA Syndromic Surveillance for Bioterrorism: a System for Rapid Detection of Influenzalike Illness and Bioterrorism-Related Outbreaks B. Miller, H. Kassenborg, W. Dunsmuir, J. Nordin, J. Griffith, M. Hadidi, G. Amundson, and R. Danila Minnesota Department of Health, Minneapolis, Minnesota, University of New South Wales, Sydney, Australia, HealthPartners Medical Group, Minneapolis, Minnesota The prodrome of several potential bioterrorism diseases will likely present as influenzalike illness. In a bioterrorism event, the window of opportunity for initiating effective postexposure prophylaxis is short. Real-time, syndrome-based surveillance mechanisms are needed. HealthPartners Medical Group (HPMG) delivers primary care to 240,000 persons in the Minneapolis/St. Paul metropolitan area in Minnesota. Patient encounter data, including International Classification of Diseases, 9th Revision (ICD-9) codes are entered rapidly into their database. Nonidentifying demographic and ICD-9 data are sent to the Minnesota Department of Health (MDH) after posting to an HPMG database. Data are automatically extracted daily and sent to a secure MDH server. Data are appended to 3 years of HPMG ICD-9 count data and analyzed using an outbreak detection algorithm designed specifically by MDH for bioterrorism surveillance. The algorithm normalizes the data using a regression model adjusted for day of the week, season, holidays, and autocorrelation. Cumulative sum (CUSUM) analysis of the predictive residuals is used to detect unexpected ICD-9 count increases. The detection system triggers an “alarm” if the daily ICD-9 count exceeds a threshold. The HPMG ICD-9 data set was independently validated by comparison with historical metropolitan area influenza and pneumonia deaths. The regression model adequately controlled for ICD-9 variability associated with weekend counts and seasonal influenzalike illness fluctuations. The system detected an influenza A outbreak that began in December 2000. When the system was “spiked” with data from a 1979 inhalation anthrax outbreak, it rapidly triggered an alarm. Detection of a bioterrorism event is possible, and real-time syndromic surveillance is achievable using existing data sets. This system was developed quickly and inexpensively. Use of an Electronic Emergency Department Information System as a Data Source for Respiratory Syndrome Surveillance John M. Townes, Melvin A. Kohn, Karen L. Southwick, Christopher A. Bangs, Andrew D. Zechnich, J. A. Magnuson, and Jonathan Jui Oregon Health and Science University, Oregon Department of Human Services Office of Disease Prevention and Epidemiology Emergency department (ED) syndromic surveillance may provide early warning of outbreaks due to bioterrorism or natural phenomena. We explored adapting an electronic ED information system (EmSTAT) for use as a data source for respiratory syndrome surveillance. After examining the flow of data in the system, we selected a subset of data elements

Rural Hospital Transfer Patterns before and after Implementation of a Statewide Trauma System

OBJECTIVE To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system. METHODS A pre- vs post-system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open-tibia) were reviewed for a 3-year period before statewide trauma system implementation and 3 years after hospital trauma designation. RESULTS Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open-tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in >1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level-4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level-4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level-4 EDs were significantly more likely to be transferred to Level-2 facilities (66% vs 82%, p = 0.030), while patients at Level-3 facilities were significantly more likely to be transferred to Level-1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level-4 hospitals, while transfers from Level-3 facilities were dependent on type of injury. CONCLUSION Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.

Advanced life support in the wilderness: 5-year experience of the Reach and Treat Team

Increasing recreation in the wilderness raises questions about the value of providing advanced life support (ALS) care in the backcountry. Since 1989 the Reach and Treat (RAT) team has provided ALS care in the wilderness area that surrounds Mount Hood, Oregon. The purpose of our study was to describe patient demographics, terrain, injuries, and ALS treatment in the wilderness environment. We utilized a retrospective, observational analysis of RAT missions from 1989 to 1994 based on data sheets maintained by the RAT team, prehospital run sheets, and hospital charts. Of the 114 missions analyzed, the median time of missions was 3 h, 9 min (range, 44 min-76 h) and 20% required technical climbing skills. Of the 74 patients treated, 55 (90%) received ALS care: 8 were intubated, 52 had intravenous lines established, and 24 received morphine for pain. Twenty patients were entered into the local trauma system. The most common injuries were extremity injuries (58), head injuries (18), and hypothermia (15). Mean time from arrival to return to staging area was 95 min. No injuries to RAT team members occurred during these missions, although two minor injuries occurred during training and testing. We found that wilderness-trained paramedics safely provided ALS care in a backcountry environment. This care may improve patient comfort during long extrication and speeds the arrival of potentially life-saving interventions such as advanced airway management.

Telemark skiing injuries: A three-year study

Telemark skiing is an increasingly popular wilderness activity. Little is known, however, about the injuries incurred during modern telemark skiing. To determine the incidence and types of these injuries we carried out a prospective analysis of injured telemarkers over three ski seasons from November 1994 through May 1997 at the Mount Hood Meadows ski area medical clinic in Oregon. Injured telemark skiers presenting to the clinic were asked to fill out a one-page survey, and a diagnosis was provided by the clinic physician or nurse. During the 1995-1996 and 1996-1997 ski seasons, skiers were counted at the ski lifts to determine the proportion of telemark skiers, alpine skiers, and snowboarders using the lifts. Using these proportions and the total ticket sales for the year, the number of downhill skiers, snowboarders, and telemarkers over the season were estimated, and injury rates were calculated. During the three ski seasons, 33 injuries were identified in 28 injured telemarkers. Of the study participants, 75% (21) were male. The average age was 33.1 years. Self-described intermediate and advanced telemarkers accounted for 74% of the injured. In 96% of the injuries, the skier was performing a telemark turn. Powder snow or heavy, wet snow conditions were reported most often. Lower-extremity injuries were most common, accounting for 42.5% (14) of the total. Seven of the lower-extremity injuries were ankle injuries, and four were knee injuries. Upper-extremity injuries comprised 24.2% (8) and head and facial injuries 21.2% (7) of the total. The least number of injuries occurred in the spine, 12.1% (4). Release plates were used by 8 of 28 skiers and only released in two instances. Telemark skiers comprised 0.9% of skiers counted at the lifts during the 1995-1996 season and 1.8% in 1996-1997. Injury rates/1000 skier days in 1995-1996 were 3.3 (95% CI: 3.27, 3.35) for downhill skiers, 4.1 (95% CI: 3.32, 5.22) for telemark skiers, and 6.8 (95% CI: 6.54, 7.00) for snowboarders. Injury rates/1000 skier days in 1996-1997 were 3.1 (95% CI: 3.05, 3.15) for downhill skiers, 1.7 (95% CI: 1.44, 2.11) for telemark skiers, and 5.6 (95% CI: 5.39, 5.78) for snowboarders. We conclude that telemark skiers comprise only a small proportion of skiers at a lift-served area. Lower-extremity injuries were most common, followed by upper-extremity and head and facial injuries. Injury rates for telemarkers are comparable to those for alpine skiers.

SUICIDAL PATIENTS IN THE ED: ETHICAL ISSUES

Emergency physicians frequently are expected to evaluate and develop treatment plans for potentially suicidal patients. The struggle to prevent someone from self-injury while respecting their personal autonomy is frequently present in the ED, as physicians must decide whether to intervene with a patient who does not seek treatment. The implications of this struggle are discussed in the article.

Elimination of Over-the-Counter Medication Coverage in the Oregon Medicaid Population: The Impact on Program Costs and Drug Use

OBJECTIVES To reduce program costs, the Oregon Medicaid program eliminated reimbursement for over-the-counter (OTC) medications. Considering that physicians might substitute more expensive prescription-only products for eliminated OTC therapy, this investigation evaluates the policys impact on medication costs. METHODS This retrospective investigation examines pharmacy claims for adult Medicaid eligible recipients between March 1992 and February 1994 using an interrupted time-series analysis. The policys impact on program costs and on the number of submitted claims was evaluated separately for prescription-only and total prescribing in nine therapeutic categories. RESULTS In the preintervention period, OTC products comprised 36% (213,516 of 592,672) of drug claims and 9% (

Trauma system impact on admission site: a comparison of two states.

1.36 million of