Marc E. Levsky

A descriptive analysis of authorship within medical journals, 1995-2005.

Introduction: The emphasis on publications for promotion in academic medicine would lead one to the theory that authorship numbers would increase proportionally with this emphasis. To investigate authorship trends across a number of periodicals, we performed a descriptive study comparing two full years of published articles spaced ten years apart from five medical journals. Methods: Physician reviewers each reviewed all articles of one medical journal for the 1995 and 2005 publication years. Reviewed journals included Academic Emergency Medicine (AEM), Annals of Emergency Medicine (AnnEM), Annals of Internal Medicine (AIM), Journal of Trauma (JT), and New England Journal of Medicine (NEJM). Data collected for each article were number of authors, ordinal number of the corresponding author, type of study described, whether the described study was a multicenter trial, whether authorship listed included a “study group,” and whether any author was also an editor of the journal. Results: A total of 2927 articles were published in the five journals in 1995, and of these, 1401 (47.9%) were analyzed after the exclusion criteria had been applied; for 2005 a total of 3630 articles were published and of these, 1351 (37.2%) were included in the analysis. Across all five journals the mean number of authors per article increased from 4.66 to 5.73 between 1995 and 2005 (P < 0.0001), and four of the five journals individually had statistically significant increases in the number of authors per article. More articles had a journal editor as an author in 2005 (increased from 7.8% to 11.0%, P = 0.004), though no single journal had a statistically significant increase. Conclusion: We describe a trend of increasing mean authors, editorial authorship, study groups, and multicenter trials over time with fewer solo authors now publishing original research or case reports. The academic medical community must pursue an authorship requirement consensus to assure that a standard of contribution for all authors on a given paper is met.

The Effects of an Accelerated Triage and Treatment Protocol on Left Without Being Seen Rates and Wait Times of Urgent Patients at a Military Emergency Department

To combat increasing wait times and left without being seen (LWOBS) rates, our emergency department (ED) implemented an accelerated triage and treatment (TNT) protocol. A TNT team was allocated treatment rooms to begin management of urgent patients if a bed in the main ED was not available. A retrospective database study was performed using three separate 6-month periods: two control periods before the intervention (P1, P2) and one period after the intervention (P3). The primary outcome measures were LWOBS rate, time to evaluation, and total ED time for urgent patients. The time to be seen for EC3 patients improved from P1 to P3 by an average of 12.6 minutes (18.5%, p < 0.0001) and from P2 to P3 by an average of 12.0 minutes (17.6%, p < 0.0001). The EC3 LWOBS rate decreased from 2.0% in P1 and 1.9% in P2 to 0.8% in P3 (p < 0.0001 for both). The use of an accelerated TNT protocol was associated with a significant reduction in EC3 patient LWOBS rates and time to evaluation.

False-positive urine β-HCG in a woman with a tubo-ovarian abscess

Modern urine β-human chorionic gonadotropin (HCG) assays that use enzyme-linked immunosorbent assay (ELISA) technology are sensitive and specific for diagnosing pregnancy, both intrauterine and ectopic, and have become indispensable to the practice of Emergency Medicine. A urine HCG test is often relied on by the Emergency Physician as a critical component in the diagnostic regimen of a patient with a possible ectopic pregnancy. We report a case of a false-positive urine β-HCG test in a patient with a ruptured tubo-ovarian abscess. Though false-positive pregnancy tests with tubo-ovarian abscesses have previously been reported with older methods of HCG detection, we believe that this is the first case where the pregnancy test was the modern ELISA type. The mechanism for the false-positive reaction in this case is unknown, but time may show that the ELISA test kit, like its predecessors, may occasionally give a false-positive reaction in this class of patients.

Choreiform dyskinesia following isolated lamotrigine overdose.

Lamotrigine is an antiepileptic drug that is finding increased use in other areas to include adjunctive therapy for depression and bipolar disorder. While adverse drug reactions such as rash and toxicity in overdose resembling phenytoin are well described, recently chorea in patients chronically taking this medicine has been reported. We present a case of severe choreiform dyskinesia following an acute lamotrigine overdose. A 23-year-old man with a history of bipolar disorder walked into the emergency department (ED) stating he had just taken all of his lamotrigine pills 30–60 minutes prior. He was alert and oriented with a blood pressure of 160/93 mm Hg, heart rate of 115 beats per minute, a respiratory rate of 18 breaths per minute, and a temperature of 98.4°F. He received a single dose of activated charcoal. During the subsequent hour, the patient became agitated and developed rapid, intermittent, choreiform movements of his trunk and extremities without any seizure activity. These movements continued every 30 to 45 seconds during the following 2 hours, but were reduced in frequency as well as severity by the administration of 2 mg of lorazepam. The movements subsided during the first 12 hours of admission. A lamotrigine level drawn 4 hours after admission to the emergency department was 63.9 μg/mL. Although levels are not routinely used for monitoring this agent, it has been suggested that a therapeutic range would be approximately 1–3 μg/mL, with levels drawn 2 to 4 hours following the last dose. This report represents a case of a severe dyskinesia associated with an overdose of lamotrigine. With expanding indications for this drug, novel findings in overdose or therapeutic use are likely to continue to be reported. To our knowledge, this is the first report of choreiform dyskinesia with lamotrigine overdose.

Transdermal Patch Medication Delivery Systems and Pediatric Poisonings, 2002-2006

Transdermal drug delivery systems are an increasingly popular method of medication delivery containing large quantities of medication and presenting new opportunities for toxicity. To provide a description of exposures to transdermal medications in a pediatric population, we studied exposures in individuals less than 12 years of age. This is a retrospective database study in which the Texas Poison Center Network database from 2002 to 2006 was reviewed. In all, 336 poison control center records of patch exposures over the 5-year period were identified. Of those, 110 cases involved children less than 12 years old. A majority of cases resulted in no significant clinical effects. One death resulted from opioid toxicity. Although a majority of patch exposures in children less than 12 years of age resulted in no significant clinical toxicity, practitioners and the public must be made aware of the available patch-based medications and their potential for toxicity in children.

Colchicine Exposures : The Texas Experience

Objectives: Colchicine is a relatively uncommon toxin, but is known to precipitate severe multiorgan failure in overdose. Little is known about exposure patterns and outcomes in cases of colchicine ingestion. Our goal was to add to toxicologic knowledge through a database review and descriptive study of colchicine exposures. Methods: Texas Poison Center Network Data was reviewed for the years 2000 to 2005, and all reports of colchicine exposures were reviewed. Results: A total of 79 cases were found in the time period studied. The most common exposure reasons were unintentional-therapeutic error (33%), unintentional-general (28%), and intentional-suspected suicide (18%). Medical outcomes included no effect (24%), minor effect (20%), moderate effect (15%), and major effect (3%). The most common clinical findings included vomiting (20%), diarrhea (17%), and abdominal pain (7%). The most commonly employed therapies were dilution (28%), single-dose activated charcoal (26%), cathartics (16%), and gastrointestinal lavage (15%). Conclusion: The majority of cases of exposure produced no significant effects, and fatality was uncommon in this sample. Colchicine is a relatively uncommon toxin among therapeutic drugs, and though capable of it, is rarely responsible for significant morbidity or mortality. Meticulous exposure record keeping at poison centers is a key to the study of patterns of toxicity with uncommon toxins such as colchicine.

Clinical Course and Toxicokinetic Data Following Isolated Citalopram Overdose in an Infant

Objective. Despite the frequency of use of citalopram, its clinical effects and pharmacokinetics in overdose in the pediatric patient are not well described. We describe the clinical course and drug levels following the ingestion of citalopram by a 10-month-old female. Case Report. A 10 month-old female ingested an unknown amount of citalopram. Approximately 40 min after ingestion, the child developed horizontal nystagmus, followed by a generalized, tonic-clonic seizure that lasted 2 to 3 min very shortly thereafter. The child received 1 mg of midazolam intramuscularly (IM), followed by 1 mg of midazolam intravenously (IV) for termination of this seizure, and was given a loading dose of 20 mg/kg of fosphenytoin IV. Elective orotracheal intubation was done to protect the airway. Despite the use of midazolam and fosphenytoin, the child had another seizure approximately 85 min following the ingestion. A third seizure was noted at approximately 100 min post-ingestion. In the course of treatment, activated charcoal was administered via nasogastric tube, and IV midazolam and phenobarbital were given. The child was transferred to a nearby facility with pediatric intensive care capabilities in stable condition. The child did not experience any hypotension or dysrhythmia, and the electrocardiographic QTc and QRS complex were normal throughout the clinical course. During the subsequent 48 h, the child awoke and regained normal function. This childs recovery was uneventful, and the child was discharged home without sequelae. Plasma levels of citalopram were 1400 ng/ml, 583 ng/ml, 416 ng/ml, and 296 ng/ml, at one, six, 13, and 23 h post-ingestion, respectively. The first level likely represents a pre-distributional level with subsequent levels giving an elimination t1/2 of 17.38 h. Conclusion. We report a case of citalopram poisoning in a 10‐month-old infant with refractory seizures, and an absence of cardiovascular events with subsequent excellent outcome. The elimination of the parent drug corresponds to an approximate t1/2 of 15–20 h in this single case.

SARS and its impact on current and future Emergency Department operations

A long-standing concern for international spread of new, virulent pathogens became a reality with the advent of Severe Acute Respiratory Syndrome (SARS). This respiratory syndrome, caused by a coronavirus, spread rapidly across 30 nations since its first recognition in late 2002. SARS has presented the greatest recent threat to U.S. public health, and has come at a time when purposeful introduction of pathogens by terrorists is also of heightened concern. SARS has forced the international medical establishment to reexamine how best to manage such incidents.

Experience with bandage contact lenses for the treatment of corneal abrasions in a combat environment.

Corneal abrasions are a common result of eye trauma. Although they usually heal well with conservative therapy, they still tend to be a source of morbidity, in terms of pain and lost work time. We reviewed 15 cases in which a bandage contact lens was used as the primary treatment for corneal abrasions in an austere environment. We found that the lenses performed well, except for patients who had undisclosed risk factors for corneal ulcers at the outset. When used for carefully selected patients, bandage contact lenses may be a highly effective treatment modality that allows for rapid return to duty.

Bradycardia-Associated Torsade de Pointes and the Long-QT Syndromes: A Case Report and Review of the Literature

We report a case of bradycardia-associated torsade de pointes in which the underlying long-QT syndrome appeared to be attributable to primary cardiac conducting system disease. Our patient presented complaining of presyncope and syncope. Serial electrocardiograms obtained over a period of 10 years demonstrated slowly progressive conduction system abnormalities, and evaluation revealed no other cause. The patients dysrhythmia was refractory to magnesium but abated with cardiac pacing at a moderate rate. A review of the relevant literature on congenital and acquired long-QT syndrome is included.