Robert L. Rogers

Venous thromboembolic disease in the HIV-infected patient.

OBJECTIVEnInfection with the HIV has developed into a chronic illness, with longer-term complications increasingly being seen. There is increasing evidence that infection with HIV may be associated with a hypercoagulable state. This study examines the association of HIV infection with the incidence of both pulmonary embolism and deep venous thrombosis.nnnMETHODSnThis study was a weighted analysis of data from National Hospital Discharge Survey, a national annual probability survey of discharges from short-stay non-Federal hospitals, from 1996-2004. The risk of pulmonary embolism and/or deep venous thrombosis in an HIV+ individual was ascertained for each age group by calculation of an odds ratio (OR) with a 95% confidence interval (CI). A common OR was computed across strata to evaluate the overall association between PE/DVT and HIV while adjusting for effects of age.nnnRESULTSnThe overall age-adjusted OR indicates a statistically significant increase of 43% for PE in HIV+ individuals as opposed to HIV- individuals (OR, 1.43; 95% CI, 1.39-1.46). This increase differs by age group, with age group 21 to 50 years having the highest odds for PE among HIV+ individuals (OR, 1.58; 95% CI, 1.54-1.63).nnnCONCLUSIONSnThe data supports the hypothesis that HIV-infected individuals are more likely to have clinically detected thromboembolic disease as opposed to non-HIV-infected individuals. This study reveals up to a 43% increase in OR of developing a PE, 10% increase in developing a DVT, and 40% increase in developing PE or DVT in an HIV-infected individual over the 9-year study period after adjusting for age.

Hypertensive Emergencies in the Emergency Department

Hypertension affects approximately one-third of Americans. An additional 30% are unaware that they harbor the disease. Significantly increased blood pressure constitutes a hypertensive emergency that could lead to end-organ damage. When organs such as the brain, heart, or kidney are affected, an intervention that will lower the blood pressure in several hours is indicated. Several pharmacologic options are available for treatment, with intravenous antihypertensive therapy being the cornerstone, but there is no standard of care. Careful consideration of each patients specific complaint, history, and physical examination guides the emergency physician through the treatment algorithm.

Simultaneous T-wave inversions in anterior and inferior leads: an uncommon sign of pulmonary embolism.

BACKGROUNDnPulmonary embolism (PE), a major cause of morbidity and mortality, remains an elusive diagnosis. Recently investigators have found a new electrocardiographic (ECG) finding, simultaneous T-wave inversions in the anterior and inferior leads, which may distinguish PE from acute coronary syndrome (ACS).nnnOBJECTIVESnOur primary objective was to estimate the prevalence of this finding in PE. We also estimate the inter-rater reliability of this finding, its test characteristics, and assess ECG findings traditionally associated with PE.nnnMETHODSnIn this unmatched case-control study, we selected electrocardiograms from patients diagnosed with PE, ACS, and non-cardiac chest pain. Two emergency physicians, blinded to diagnoses, reviewed electrocardiograms for explicitly defined ECG findings. We calculated kappa (K) for inter-rater agreement and estimated prevalence differences (PD) for findings in the PE group vs. pooled control groups.nnnRESULTSnWe included 97 patients with PE, 89 with ACS, and 105 with non-cardiac chest pain. A 1-mm T-wave inversion was seen in both III and V(1) in 11/97 (0.113) of patients with PE vs. 9/194 (0.046) controls (PD 0.07 [95% confidence interval (CI) -0.01-+0.14]; K = 0.7). Other criteria for anterior and inferior T-wave inversions were less common in PE (0.04-0.05). Among several other ECG abnormalities tested, only sinus tachycardia (PD 0.20 [95% CI 0.09-0.31]; K = 0.7) and the classic S(I)Q(III)T(III) pattern (PD 0.05 [95% CI -0.01-+0.11]; K = 0.5) statistically distinguished PE and were noted with fair or better inter-rater agreement.nnnCONCLUSIONnIn our study, simultaneous T-wave inversions in anterior and inferior leads were associated with PE but are seen in only 4-11% of cases.

Acute necrotising soft-tissue infection

A patient with diabetes presented with redness, pain and swelling in the right leg, which had worsened over 2 months, as well as with recent vomiting and malaise. A physical examination revealed tachycardia and …