Douglas J. Federman

Subcutaneous Sumatriptan for Treatment of Acute Migraine in Patients Admitted to the Emergency Department: A Multicenter Study

STUDY OBJECTIVE To assess the efficacy of SC sumatriptan injection versus placebo in the treatment of acute migraine in ED patients and that of open-label 100 mg sumatriptan PO tablets for recurrent migraine. DESIGN Randomized, double-blind, placebo-controlled, multi-center trial. SETTING Twelve EDs in the United States. PARTICIPANTS Adult patients presenting to the ED from September 1992 through April 1993 with a diagnosis of migraine as determined by International Headache Society criteria. Patients were randomized to receive 6 mg sumatriptan SC or placebo. Patients were monitored for improvement in headache severity using a four-point scale and for time to meaningful relief using a stopwatch. The time to discharge from the ED was recorded. An open-label 100 mg sumatriptan PO tablet was given to all patients on discharge from the ED for use at home if the headache recurred within 24 hours. RESULTS One hundred thirty-six patients were enrolled. Seventy-five percent of patients treated with sumatriptan achieved meaningful relief compared with 35% treated with placebo (P < .001). The median time to meaningful relief was 34 minutes in the group that received sumatriptan. Seventy percent of patients in the sumatriptan group versus 35% in the placebo group reported mild or no pain at discharge (P < .001). Migraine-associated symptoms such as nausea, photophobia, and phonophobia were significantly reduced in the sumatriptan group (P < .005). The median time to discharge from the ED was shorter for the sumatriptan group than for the placebo group (60 versus 96 minutes, respectively; P = .001). At baseline, 15% of patients in the sumatriptan group and 19% of patients in the placebo group reported mild or no clinical disability. At the time of discharge, patients with mild or no disability increased to 75% in the sumatriptan group compared with 44% in the placebo group (P = .001). Fifty-seven of 92 patients (62%) with mild or no pain at discharge took open-label oral sumatriptan for headache recurrence, and 37 (65%) experienced meaningful relief within 2 hours. Median time to meaningful relief after oral sumatriptan was 65 minutes. CONCLUSION Sumatriptan (6 mg SC) is effective in treating acute migraine in the ED. Oral sumatriptan (100 mg) is effective in treating headache recurrence within 24 hours.

Computer-assisted determination of protein concentrations from dye-binding and bicinchoninic acid protein assays performed in microtiter plates.

The bicinchoninic acid protein assay was scaled down to operate in the wells of microtiter plates. The total volume of the assay was reduced to 210 microliters and required only 10 microliters of sample per assay. The assay can be rapidly performed and then read with a plate reader. The analysis of the data was performed with a microcomputer interfaced with the reader. A computer program was developed to analyze the data from the bicinchoninic acid assay as well as the dye-binding assay at either the high or low protein concentration ranges. Based upon the absorbance values of the standards, the program computed a linear regression formula which was then used to calculate the concentrations of the sample proteins. A series of assays performed using bovine serum albumin, alpha-chymotrypsin and gamma globulin demonstrated that the scaled down bicinchoninic acid assay produced linear absorption versus concentration data with average correlation coefficients between 0.9967 and 0.9940 at the high and low concentration ranges respectively. The protein-to-protein variation and proper selection of either protein assay based upon the presence of interfering materials was considered.

Routine prolactin measurement is not necessary in the initial evaluation of male impotence

The authors determined the prevalence of hyperprolactinemia in impotent men in a community setting and assessed the cost of case detection with routine estimation of serum prolactin. They recruited 299 consecutive patients with impotence and determined the hormonal levels (prolactin, luteinizing hormone, follicle-stimulating hormone, and testosterone). Pituitary gland imaging was done when the prolactin level was elevated. Simultaneous prolactin and testosterone levels were available for 212 patients. Three patients (1.4% ) had elevated prolactin levels but none had pituitary tumor. Two of these had low testosterone levels. Overall, 51 patients (24.1%) had low testosterone levels. Cost of selective prolactin estimation in patients with low testosterone levels resulted in a net saving of

Modified Barium Swallow Does Not Affect How Often PEGs Are Placed After Stroke

2,574 per case detected. The authors conclude that the prevalence of hyperprolactinemia in impotence is low. Routine measurement of prolactin levels in impotence is not indicated. Selective determination in patients with low testosterone reduces the cost of diagnostic evaluation.

Can a Clinical Score Aid In Early Diagnosis and Treatment of Various Stroke Syndromes

Dysphagia frequently follows stroke, but often resolves quickly. Percutaneous endoscopic gastrostomy (PEG) or other feeding tubes are placed to improve nutrition and hydration, and reduce the risk of aspiration pneumonitis. We evaluated the impact of modified barium swallow in determining PEG placements and the influence of specific swallowing abnormalities on PEG placement. The abnormalities assessed were presence of pharyngeal stasis and/or visualization of posterior pharyngeal transfer problems and aspiration of liquid or solids. A total of 302 patients with stroke were admitted to our hospital between 1989 and 1993, but only those with hemorrhagic or nonhemorrhagic stroke by computed tomographic (CT) scans or magnetic resonance imaging (MRI) or autopsy were included in our study. Patients with transient ischemic attacks (TIAs), central nervous system tumors, and traumas were excluded. Barium swallow studies were performed on 69 (23%) of patients; 49 (71%) were abnormal, based on aspiration of barium, pharyngeal stasis, or postpharyngeal transfer dysphagia. PEGs were placed in only 18% of those with abnormal studies. Of the patients with normal barium swallow studies, 25% had a PEG placed. Two hundred thirty-three patients underwent no barium swallow studies, but 11 (4.72%) of these had PEG placed. The rate of PEG placement was not related to any one of the abnormalities noted on the modified barium swallow. Rather, patients who received PEG had significant neurological deficits and increased prevalence of aspiration pneumonitis. The decision to insert PEG was made on clinical grounds and not on abnormal barium studies alone.

Inappropriate Use of Oxygen: Loss of a Valuable Healthcare Resource

BACKGROUND Accurate and timely diagnosis of hemorrhagic and nonhemorrhagic strokes helps in patient management. Neuroimaging studies are useful in diagnosis and distinction of hemorrhagic (HS) and nonhemorrhagic (NHS) strokes. The use of clinical variables, such as Siriraj stroke scores (SSS), has shown good sensitivity, specificity and predictive values (distinguishing stroke types). The aim of our study was to evaluate the use of SSS in a U.S. population and assess whether it could aid to expedite treatment decisions. METHODS Levels of consciousness, vomiting, headache and atheroma markers used in SSS were applied to patients who met the criteria for stroke. RESULTS Of the 302 patients identified, the SSS classified 254 with sensitivity of 36% (HS) and 90% (NHS) and positive predictive values of 77% and 61%, respectively. CONCLUSION Our results suggest that SSS is not reliable in distinguishing stroke types (in a US population). Definite neuroimaging studies are needed prior to thrombolytic therapy.

Risk of Ischemic Heart Disease in Patients With Sjögren’s Syndrome

ABSTRACT: Oxygen (O2) use is well established in hospitalized patients with hypoxemia. However, its value in patients without hypoxemia is not well documented. The authors conducted a retrospective study to evaluate the excess use of O2 and the resulting loss of resources. They established criteria for O2 use by faculty consensus. Ninety‐six patients (102 admissions) receiving O2 between August and October 1991 were identified. Principal discharge diagnoses included cardiac diseases (37%), pulmonary diseases (26.5%), and miscellaneous (36.5%). Cumulative oxygen use was 9,742 hours. Appropriate O2 amounted to 3,272 hours (34%), and inappropriate O2 use was 6,470 hours (66%). The billing for O2 use was

DECREASED RISK OF ISCHEMIC HEART DISEASE IN PATIENTS WITH SJGREN’S SYNDROME: AN ANALYSIS OF UNITED STATES NATIONAL DATABASE

38,468, of which

Enhancing faculty participation and interest in quality improvement in academic centers.

25,880 constituted inappropriate use. In 1991, there were 7,743 admissions, with oxygen charges of

Nonsteroidal Antiinflammatory Drug Use and Lung Cancer: A Metaanalysis

1.06 million. Extrapolation of the data shows billing for inappropriate oxygen was