Search PubMed⌕ Search

Biomedical subjects

A J Singer

Publications and source records attributed to A J Singer.

At least 73 records · Page 4Linked to original sources
PubMed1997

Comparison of wound infection rates using plain versus buffered lidocaine for anesthesia of traumatic wounds.

Buffered lidocaine has been shown to be less painful than plain lidocaine for anesthetizing wounds. However, the effect of a buffering agent on the local host defenses has not been evaluated. The infection rates of wounds anesthetized with plain lidocaine versus buffered lidocaine were compared in an observational cohort study. Consecutive emergency department patients with traumatic wounds that required sutures had a closed-question wound registry sheet prospectively completed. Follow-up data were obtained at the time of the return visit. Patients failing to return were contacted by telephone. Data were analyzed for wound infection rates comparing plain lidocaine with buffered lidocaine. Chi-squared or Fisher exact tests were used for statistical analysis. Of 2,711 patients analyzed, 2,279 had received plain and 432 had received buffered lidocaine. The infection rate for patients treated with plain lidocaine was 3.5%, versus that for patients treated with buffered lidocaine, 3.9% (P = .63). After adjustment for confounding variables, the infection rate did not differ between plain and buffered lidocaine. The infection rates of wounds repaired after anesthesia with either plain or buffered lidocaine are similar.

Adult↗
PubMed1997

Clostridium perfringens septicemia with massive hemolysis in a patient with Hodgkin's lymphoma.

A 55-year-old woman with stage IV-B nodular sclerosing Hodgkin's lymphoma presented to the emergency department with fever and lethargy of 12 hours' duration. The patient developed massive intravascular hemolysis secondary to Clostridium perfringens sepsis and cardiac arrest unresponsive to transfusions and cardiac pulmonary resuscitation, and died within 4 hours of presentation. The differential diagnosis of massive intravascular hemolysis, as well as the pathogenesis and treatment of C perfringens-induced hemolysis, are discussed.

Bacteremia↗
PubMed1997

Thermal effects of neutralization therapy and water dilution for acute alkali exposure in canines.

OBJECTIVE: To evaluate the change in temperature of the gastric mucosa and lumen contents when a weak acid or water is used to manage acute alkali exposure. METHODS: A prospective in-vivo canine model was used in a university-based animal laboratory setting. Eighteen adult canines weighing 20-25 kg were placed under a surgical plane of anesthesia and a laparotomy was performed. A gastrotomy was then made later ligation of the distal esophagus and proximal duodenum. Separate mucosa and lumen temperature probes were placed. Then 25 mL of room-temperature (24-26 degrees C) 50% sodium hydroxide (NaOH) was instilled in the gastric lumen. After 5 minutes, each canine was given treatment. Group 1 (n = 10) was treated with 75 mL of room-temperature orange juice. Group 2 (n = 8) was treated with 75 mL of room-temperature water. Continuous mucosa and lumen temperatures were observed and recorded at baseline and at specified intervals for 35 minutes after the alkali insult. Repeated-measures analysis of variance was used to evaluate the overall temperature profile. Signed-rank tests were used to compare the changes in temperature immediately following neutralization treatment. RESULTS: Significant temperature decreases of 1.1 degrees C and 2.1 degrees C were observed for both mucosa (p = 0.002) and lumen (p < 0.001) temperature, respectively, following neutralization therapy with room-temperature orange juice. In the group treated with room-temperature water, significant temperature decreases of 2.1 degrees C for mucosa (p = 0.01) and 2.4 degrees C for lumen (p = 0.01) were observed. Posttreatment temperatures did not exceed baseline for the entire observation period. CONCLUSION: Neutralization therapy with room-temperature orange juice or water dilution for acute gastric injuries by liquid alkali does not cause a rise in mucosal or intraluminal temperatures in an in-vivo canine model.

Acids↗
PubMed1997

Comparison of types of research articles published in emergency medicine and non-emergency medicine journals.

INTRODUCTION: As the specialty of emergency medicine (EM) matures, its journals should be publishing research of a quality similar to that which appears in other premier journals. OBJECTIVE: To compare the types of original research published in 4 EM vs 3 non-EM journals. METHODS: Retrospective review of all 1995 articles published in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, Journal of Emergency Medicine, Annals of Internal Medicine, JAMA, and New England Journal of Medicine. Research articles were classified as longitudinal vs cross-sectional, prospective vs retrospective, and interventional vs observational. Other characteristics noted were number of subjects, randomization, blinding, control, and power calculations. Journals were reviewed by 4 investigators who received specific training in research classification, adhering to previously reported criteria for retrospective reviews. Interobserver reliability was independently validated. RESULTS: The authors reviewed 3,524 articles, of which 874 (24.8%) were original research. Compared with research reported in non-EM journals, EM journals contained fewer longitudinal studies (40.5% vs 60.4%, p < 0.0001) and fewer prospective studies (70.8% vs 78.7%, p = 0.008). Fewer EM journals had studies that were blinded (13.7% vs 18.9%, p = 0.047) or controlled (36.3% vs 50.0%, p = 0.003). Studies reported in EM journals had fewer subjects (138 vs 300, p < 0.001). Research reports in EM journals were less likely to have been funded, even after adjustment for the differences in study designs (adjusted odds ratio 7.0, 95% CI 5.1-9.7). CONCLUSION: Significant differences in types of research published in EM and non-EN journals were identified.

Authorship↗
PubMed1997

Comparison of patient satisfaction and practitioner satisfaction with wound appearance after traumatic wound repair.

INTRODUCTION: Existing cosmetic scales for wounds are based only on practitioners' evaluations. They have not been validated using the patient's assessment. OBJECTIVE: To validate a previously developed wound cosmesis scale by determining the relationship between patient and practitioner assessments of cosmetic outcome following traumatic wound repair. METHODS: A convenience sample of patients with lacerations repaired in an ED were evaluated at the time of suture removal. Practitioners assigned 0 or 1 point each for the presence or absence of a step-off of borders; contour irregularities; margin separation; edge inversion; excessive distortion; and overall appearance. A total cosmetic score was calculated by adding the categories above. As previously defined, a score of 6 was considered optimal; < 6 was considered "suboptimal." Patients, blinded to the physician score, assessed their degrees of satisfaction with the cosmetic outcome of the wounds using a 100-mm visual analog scale (VAS). Because VAS scores were not normally distributed, practitioner scores were compared with patient satisfaction scores using a Mann-Whitney U test. RESULTS: 125 patients were enrolled, of whom 64% were male; the median age was 19.5 years (interquartile range = 8-33 years). Wounds were located predominantly on the face, scalp, or neck (47%) and upper extremity (35%), and had a median length of 2 cm. The 86 lacerations given optimal practitioner scores had a median patient satisfaction score of 97 mm; the 39 "suboptimal" lacerations had a median patient satisfaction score of 87 mm (p = 0.0006). CONCLUSION: Lacerations that practitioners considered to have optimal cosmetic appearances at the time of suture removal received higher patient satisfaction scores than did lacerations considered to be suboptimal. This provides a measure of validity to this 6-item categorical cosmetic scale.

Adolescent↗
PubMed1996

Blood pressure. Assessment of interarm differences.

BACKGROUND: Although a large interarm blood pressure difference is assumed to help identify patients with aortic dissection, the degree of normal interarm blood pressure variation has not been well defined. METHODS: To determine the normal variation in bilateral upper-extremity blood pressure measurements, we conducted a prospective observational study on a convenience sample of ambulatory patients who were seen at a university hospital emergency department. Bilateral upper-extremity blood pressure measurements were performed with an automated blood pressure monitor at the time the patient was seen. Clinical and demographic data collected included age, sex, race, medical history, chief complaint, cardiac risk factors, pulse, bilateral blood pressure measurements, and discharge diagnosis. The primary outcome measures were the interarm blood pressure differences. RESULTS: Of 610 patients, 324 (53%) had a systolic or a diastolic interarm blood pressure difference of more than 10 mm Hg, and 113 (19%) had a systolic or a diastolic interarm blood pressure difference of more than 20 mm Hg. The variation in interarm blood pressure measurements was unrelated to age, gender, race, mean arterial pressure, cardiovascular risk factors, or discharge diagnosis. The mean interarm systolic blood pressure difference was significantly greater in patients with known coronary artery disease (14.5 vs 10.4 mm Hg; P = .05, Student t test). CONCLUSION: Bilateral upper-extremity blood pressure determinations, as measured by automated indirect measurement, have a wide degree of interarm variation.

Adolescent↗
PubMed1996

Neurilemoma of the kidney.

Neurilemomas are neoplasms that originate from Schwann cells of the central and peripheral nervous systems. Thirteen case reports of neurilemomas involving the kidney have been described in the English literature. We report the fifth case of a neurilemoma within the renal sinus and review the previous cases of renal neurilemoma. This neoplasm is usually found incidentally. Presenting signs are nonspecific and radiographic features are highly variable. These factors make a preoperative diagnosis extremely difficult. Accurate identification relies heavily on detailed pathologic evaluation. Wide local excision is the treatment of choice, since malignancy is found in up to 30% of cases and there is a tendency for local recurrence and distant metastasis.

Aged↗
PubMed1996

Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis.

STUDY OBJECTIVE: To assess the ability of various clinical and laboratory parameters to predict the results of hepatobiliary scintigraphy (HBS) in patients with suspected acute cholecystitis. METHODS: This was a retrospective chart review of all patients referred from the emergency department for an HBS in 1993 to exclude acute cholecystitis. The setting was a university-affiliated tertiary care hospital with an annual census of approximately 42,000. The participants were 100 consecutive patients who were seen in the ED and had an HBS and obtainable medical records. Medical records of all patients referred from the ED for an urgent HBS in 1993 were retrospectively reviewed for the following information: demographics, historical information, physical findings, laboratory findings, biliary scintigraphic findings, and surgical pathologic findings. Comparisons were made between patients with a positive or negative HBS. Sensitivities, specificities, and positive and negative predictive values were calculated for dichotomous variables with a positive HBS as a control standard. A separate analysis was performed for patients with pathologically confirmed acute cholecystitis. RESULTS: Fifty-three patients had a positive HBS, and 47 had a negative HBS. A history of fever had a positive predictive value of 100% and a sensitivity of 14.6%. The presence of Murphy's sign was both sensitive (97.2%) and highly predictive (93.3%) of a positive HBS yet was not documented in 35 cases. All other variables were not found to be helpful in predicting the results of HBS. Pathologic diagnoses were available in 44 patients. Of 40 patients with pathologically confirmed acute cholecystitis, fever and leukocytosis were absent at the time of presentation in 36 (90%) and 16 (40%) of the cases, respectively. Murphy's sign was absent in 3 (10%) of 29 of these patients. A stepwise analysis failed to identify any combination of clinical variables that was associated with a higher probability of a positive HBS. CONCLUSION: No single or combination of clinical or laboratory findings at the time of ED presentation identified all patients with a positive HBS. Murphy's sign had the highest sensitivity and positive predictive value yet was poorly documented. Liberal use of biliary scintigraphy or ultrasound is encouraged to avoid underdiagnosis of acute cholecystitis.

Acute Disease↗
PubMed1996

Association of training level and short-term cosmetic appearance of repaired lacerations.

OBJECTIVE: To determine the association between emergency practitioner level of training and cosmetic appearance of primarily closed wounds as evaluated at the time of suture removal. METHODS: A retrospective analysis of wound registry data was performed. At the time of wound closure, standard data were collected including details of patient demographics, wound characteristics, preparation, closure, and postoperative care, for consecutive patients sutured in the ED. Follow-up data were obtained at the time of the return visit using a previously described cosmetic scale. With the scale, all lacerations were assigned 0 or 1 point each for the presence or absence of six items: a step-off of borders; contour irregularities; margin separation; edge inversion; excessive distortion; and overall appearance. For analysis, the proportion of wounds with a score of 6 (optimal cosmetic appearance in all categories) was associated with practitioner level of training. RESULTS: Five hundred fifty-two patients' wounds were evaluated. The percentages of various practitioners' achieving an optimal cosmetic score were: medical students (MSs), 50%; first-year residents (EM1s), 54%; second-year residents (EM2s), 66%; third-year residents (EM3s), 68%; physician assistants (PAs), 70%; and attending physicians (APs), 66%. The senior practitioners (EM2s, EM3s, PAs, APs) were significantly more likely to obtain a maximal cosmetic score than were the junior practitioners (MSs, EM1s) (68% vs 52%, p = 0.016). CONCLUSION: Significant improvement in short-term cosmetic results following wound repair is associated with a training level beyond PGY1. These data reinforce the need for careful patient selection and close supervision of wound repair by trainees, especially of wound repair by medical students and interns.

Adolescent↗
PubMed1996

Hydrogen peroxide 3% exposures.

OBJECTIVE: To present a child who developed gastric ulcers and duodenal erosions after ingestion of hydrogen peroxide 3% and delineate the epidemiology, medical outcomes, and toxicity of exposures to this agent managed by a poison control center. METHODS: A retrospective chart review of exposures to hydrogen peroxide 3% reported to the Long Island Regional Poison Control Center from January 1992 to April 1995 was conducted. Data extracted included age, route of exposure, amount of agent, symptoms, therapy, and medical outcome. RESULTS: There were 670 exposures to hydrogen peroxide 3% of 81,126 total exposures reported during the 40 months. Most exposures were by oral route (77%), occurred in children < 17 years old (67%), and were asymptomatic (85.6%). All but one exposure resulted in a benign outcome. One child, who presented with bloody emesis, developed multiple gastric ulcers and duodenal erosions after ingestion of hydrogen peroxide 2-4 oz. CONCLUSIONS: Exposure to hydrogen peroxide 3% is usually benign, however, severe gastric injury may occur following small ingestions in children. Patients who report persistent vomiting or bloody emesis require medical evaluation and consideration of endoscopy to evaluate gastrointestinal injury.

Child, Preschool↗
PubMed1995

Level of training, wound care practices, and infection rates.

This prospective, nonrandomized descriptive study compares the traumatic wound infection rates in patients based on level of training of emergency department (ED) practitioners. Wounds were evaluated in 1,163 patients. A wound registry data sheet was prospectively completed on all patients sutured in the ED. All practitioners were assigned a unique identification number. Follow-up data was obtained at the time of the return visit. Patients failing to return were contacted by telephone. Data were analyzed for patient wound infection rates by practitioner level of training. Patient wound infection rates by practitioner level of training were: medical students, 0/60 (0%); all resident physicians, 17/547 (3.1%); physician assistants, 11/305 (3.6%); and attending physicians 14/251 (5.6%), P was not significant. Comparison of junior (medical students and interns) to senior practitioners (all other practitioners) found no difference in infection rates (8/262 [3.1%] v 34/901 [3.8%], P = .58). In conclusion, carefully selected patients sutured by closely supervised medical students and junior residents have infection rates as low as those sutured by more experienced practitioners.

Adolescent↗
PubMed1995

Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments.

STUDY OBJECTIVE: Chest pain and myocardial infarction following the use of cocaine have been well documented. We assessed the prevalence of cocaine use in patients who presented to the emergency department with chest pain of possibly ischemic origin. DESIGN: During times of research assistant availability, consecutive adults with the chief complaint of chest pain unexplained by trauma or radiographic abnormality were questioned about cocaine use in the preceding week. Urine was tested for the presence of cocaine or cocaine metabolites with a highly accurate bedside urine test kit (specificity, 100%; sensitivity 98%). Anonymous unlinked data-collection methods were used. Therefore we could not determine whether the patients who used cocaine had sustained myocardial infarctions. SETTING: One suburban and three urban EDs. RESULTS: We enrolled 359 patients with a mean age of 51 years, 8% of whom sustained myocardial infarctions. Sixty patients (17%) had cocaine or cocaine metabolites in urine. The likelihood of testing positive for cocaine varied by age group: 18 to 30 years, 29%; 31 to 40 years, 48%; 41 to 50 years, 18%; 51 to 60 years, 3%; 61 years or older, 0% (P < .0001). Of the 60 patients who tested positive for cocaine, only 43 (72%) admitted recent use. CONCLUSION: Many ED patients with chest pain have recently used cocaine. Because the recent use of cocaine is not uncommon in patients with chest pain up to 60 years old, such patients should be questioned about cocaine use. When treatment or disposition may be altered, consideration should be given to objective assessment of cocaine use because patient self-report does not appear reliable.

Adolescent↗
PubMed1995

Wound registry: development and validation.

STUDY OBJECTIVE: More than 11 million patients with traumatic wounds are seen annually in emergency departments. We developed and validated a data registry for traumatic wounds treated in the ED. DESIGN: Prospective, consecutive patient enrollment with a validation cohort of a convenience sample of 100 patients. SETTING: University-affiliated hospital ED. PARTICIPANTS: For all patients with traumatic wounds requiring sutures, wound registry data sheets were completed at the time of initial visit using a closed-question format. Data recorded included demographic characteristics, time from injury to evaluation, pertinent medical history, wound characteristics, type of anesthesia, details of wound-cleansing methods, details of wound closure, and postoperative care. We devised a follow-up tool to evaluate for the presence of infection and short-term cosmetic appearance. Interphysician reliability was assessed for wound description, presence of infection, and cosmetic appearance by use of the kappa statistic. RESULTS: A wound registry data collection instrument that takes less than 1 minute to complete and enables the collection of most wound management techniques used by emergency physicians was found to have substantial interobserver concordance for wound description (kappa range, .55 to .97), wound infection (kappa = 1.0) and overall cosmetic appearance (kappa = .61). CONCLUSION: The wound registry is a reliable data collection instrument that is easy to use. It may be useful as a continuous quality-improvement tool or for standardization of wound surveillance and treatment data to facilitate future prospective studies in wound management.

Adolescent↗
PubMed1995

The temporal profile of increased transaminase levels in patients with acetaminophen-induced liver dysfunction.

STUDY OBJECTIVE: It is often taught that acetaminophen-induced liver dysfunction occurs only after a latent period of 24 to 48 hours. This study was designed to evaluate the temporal profile of transaminase levels in patients with acetaminophen-induced hepatotoxicity. DESIGN: Prospective data collection using standard poison control center data sheets. PARTICIPANTS: Hospitalized patients with acetaminophen exposure who were reported to the Long Island Poison Control Center between January 1993 and June 1994. Patients who presented within 24 hours of ingestion and in whom increased aspartate aminotransferase (AST) levels developed during hospitalization were included in the data analysis. Patients who presented more than 24 hours after ingestion, who had ingested another potentially hepatotoxic agent, or who had ingested acetaminophen over a period of more than 2 hours were excluded. RESULTS: Of 1,825 patients with reported acetaminophen exposure, 779 had potentially toxic ingestions and were examined in an emergency department. Of 291 patients with toxic acetaminophen levels who were admitted, 36 (12%) had increased levels of AST at some point during hospitalization. All received oral N-acetylcysteine within 2.5 hours of presentation. In 11 of 19 patients who met all inclusion criteria (58%), AST levels were noted to be increased in the 24 hours after ingestion. The median peak AST level was 422 IU/L (range, 74 to 8,538 IU/L). AST levels peaked within 48 hours in 4 patients (21%) and within 72 hours in 18 patients (95%). Six of eight patients with peak AST levels greater than 1,000 IU/L had increased transaminase levels during the 24 hours after acetaminophen ingestion. CONCLUSION: Acetaminophen poisoning may cause the serum transaminase level to increase during the 24 hours after ingestion.

Acetaminophen↗
PubMed1995

Infiltration pain and local anesthetic effects of buffered vs plain 1% diphenhydramine.

OBJECTIVE: To compare the levels of infiltration pain and local anesthetic effects of plain and buffered 1% diphenhydramine. METHODS: A prospective, randomized, double-blind, paired study was performed using 30 adult volunteers. Intradermal injections (0.5 mL) of plain and buffered 1% diphenhydramine were made in the subjects' forearms, one in the left and the other in the right. The pain of infiltration was recorded on a previously validated 10-cm visual analog scale (VAS). The volunteers also were asked which injection was less painful. Sequential measurements of the diameter of anesthesia to pinprick were made at 1, 2, 5, 10, 15, 20, 25, and 30 minutes. The VAS scores and anesthetic diameters were compared for plain and buffered diphenhydramine using a paired Wilcoxon rank sum test. RESULTS: There was no statistically significant difference between buffered diphenhydramine and plain diphenhydramine for pain of injection (23.5 +/- 19.2 mm vs 28.2 +/- 18.7 mm, p = 0.24). Repeated-measures analysis of variance for anesthetic diameters demonstrated no significant difference between buffered diphenhydramine and plain diphenhydramine (p = 0.87). At no single measurement period were the anesthetic diameters different. CONCLUSIONS: In a study with a sample size large enough to detect an 11-mm difference in VAS scores (power = 80%), no difference was found in pain of infiltration and anesthetic effects when plain 1% diphenhydramine was compared with buffered 1% diphenhydramine. Buffering of diphenhydramine does not appear to result in a clinically significant reduction in the pain of infiltration.

Adult↗
PubMed1995

Poor correlation of short- and long-term cosmetic appearance of repaired lacerations.

OBJECTIVE: To describe the consistency of a cosmetic scale for repaired lacerations and to determine whether the appearance of lacerations at the time of suture removal correlates with the appearance six to nine months later. METHODS: A convenience sample of patients who had lacerations repaired in a university teaching hospital were evaluated at the time of suture removal and six to nine months following repair. All lacerations were assigned 0 or 1 point each for the presence or absence of a step-off borders, contour irregularities, margin separation, edge inversion, excessive distortion, and overall appearance. A total cosmetic score (0-6) was calculated by adding the scores for the categories above. The consistency of the cosmetic scale was assessed by comparison of scores given by two different practitioners evaluating each patient at suture removal and long-term follow-up. The 38 evaluating practitioners were assigned based on availability and did not necessarily perform serial evaluations of the same patient. RESULTS: The 41 participating patients had a median age of 19 years (range, 2-82 years). Wounds were located predominantly on the head (73%) and upper extremity (22%). Long-term follow-up was performed at a median of 219 days (range, 155-280 days) after suture removal. Interpractitioner concordance regarding optimal appearance (score of 6 vs < or = 5) was moderate (kappa = 0.52) at the time of suture removal and substantial at the time of long-term follow-up (kappa = 0.68). However, the correlation of actual scores at the time of suture removal vs at long-term follow-up was poor (r = 0.17, p = 0.29). CONCLUSION: For our clinicians, the six-item categorical scale appears consistent as a tool for the assessment of the cosmetic appearance of wounds. However, correlation between laceration appearance at the time of suture removal and six to nine months later is poor.

Adult↗