Leadership and the emergency department

Emergency medicine, as the nation's health care system's safety net, is facing ever increasing demands on its resources and infrastructure. Classic and modern theories of leadership, which include broader based models that in corporate team responsibilities, should be studied by anyone wearing the mantle of leadership in emergency medicine, and the Realpolitik of the modern hospital must be accommodated if leadership efforts are to succeed.     

Carvedilol for children and adolescents with heart failure: a randomized controlled trial

Context  Although -blockers improve symptoms and survival in adults with heart failure, little is known about these medications in children and adolescents. Objective  To prospectively evaluate the effects of carvedilol in children and adolescents with symptomatic systemic ventricular systolic dysfunction. Design, Setting, and Participants  A multicenter, randomized, double-blind, placebo-controlled study of 161 children and adolescents with symptomatic systolic heart failure from 26 US centers. In addition to treatment with conventional heart failure medications, patients were assigned to receive placebo or carvedilol. Enrollment began in June 2000 and the last dose was given in May 2005 (each patient received medication for 8 months). Interventions  Patients were randomized in a 1:1:1 ratio to twice-daily dosing with placebo, low-dose carvedilol (0.2 mg/kg per dose if weight <62.5 kg or 12.5 mg per dose if weight 62.5 kg), or high-dose carvedilol (0.4 mg/kg per dose if weight <62.5 kg or 25 mg per dose if weight 62.5 kg) and were stratified according to whether each patient's systemic ventricle was a left ventricle or not. Main Outcome Measures  The primary outcome was a composite measure of heart failure outcomes in patients receiving carvedilol (low- and high-dose combined) vs placebo. Secondary efficacy variables included individual components of this composite, echocardiographic measures, and plasma b-type natriuretic peptide levels. Results  There was no statistically significant difference between groups for the composite end point based on the percentage of patients who improved, worsened, or were unchanged. Among 54 patients assigned to placebo, 30 improved (56%), 16 worsened (30%), and 8 were unchanged (15%); among 103 patients assigned to carvedilol, 58 improved (56%), 25 worsened (24%), and 20 were unchanged (19%). The rates of worsening were lower than expected. The odds ratio for worsened outcome for patients in the combined carvedilol group vs the placebo group was 0.79 (95% CI, 0.36-1.59; P = .47). A prespecified subgroup analysis noted significant interaction between treatment and ventricular morphology (P = .02), indicating a possible differential effect of treatment between patients with a systemic left ventricle (beneficial trend) and those whose systemic ventricle was not a left ventricle (nonbeneficial trend). Conclusions  These preliminary results suggest that carvedilol does not significantly improve clinical heart failure outcomes in children and adolescents with symptomatic systolic heart failure. However, given the lower than expected event rates, the trial may have been underpowered. There may be a differential effect of carvedilol in children and adolescents based on ventricular morphology. Trial Registration  clinicaltrials.gov Identifier: NCT00052026      

Purification of Hageman factor (factor XII) on columns of popcorn- agarose

Purification of Hageman factor (HF, factor XII) from human plasma is a tedious procedure and the product is not always in the precursor form. Hojima has described a protein derived from corn kernels that inhibits the enzymatic properties of HF. This inhibitor binds to the precursor form of HF. Rapid purification of HF was achieved by using as the major purification step adsorption of this clotting factor to popcorn inhibitor bound to agarose. The product had a specific activity of 50.0 to 67.1 coagulant units of HF per milligram protein, and the yield was 33% to 40% of the HF content of the starting plasma. The purified protein displayed a single band upon unreduced or reduced sodium dodecyl sulfate polyacrylamide gel electrophoresis and less than 0.1% was in an activated form, as measured in coagulant assays. The technique described is more rapid and reliable than methods described earlier.     

Iliopsoas bursitis: clinical features, radiographic findings, and disease associations

Inflammation of the iliopsoas bursa is a common manifestation of a wide array of inflammatory, degenerative, and traumatic musculoskeletal conditions. The clinical presentation of iliopsoas bursitis is variable, and includes pain, mass lesion, or compression syndromes of the inguinal compartment. Affected individuals frequently have underlying synovitis of the hip or a history of occupational or recreational injury. Early and accurate diagnosis is facilitated by appropriate radiographic studies.     

An evaluation of the two-stage flexor tendon reconstruction technique

The performance of 43 two-stage flexor tendon reconstructions in 39 patients was reviewed. Results were graded by comparing the preoperative passive motion of the proximal and distal interphalangeal joints after stage one to the active motion of these same joints after stage two. The procedures returned 16% excellent, 23% good, 26% fair, and 35% poor results with three graft ruptures. Following the tenolysis of 20 grafts (47%) the results for the entire group were improved to 27% excellent, 28% good, 30% fair, and 16% poor. Stage reconstruction, including tenolysis, was felt to be the best available method for restoration of digital function following flexor tendon loss in the badly scarred digit.     

Relationships between the structure and function of lipopolysaccharide chemotypes with regard to their effects on the human polymorphonuclear neutrophil

Polymorphonuclear neutrophils (PMN), harvested from healthy volunteers, were challenged with endotoxins from Salmonella minnesota smooth-strain and rough-strain mutants (Ra, Rb2, RcP-, Rd1P- and Re) as well as with lipid A in an effort to determine the relationship between lipopolysaccharide (LPS) structure and its ability to affect PMN chemotaxis (CT), random migration (RM) and luminol-dependent chemiluminescence (CL). In the presence of untreated autologous serum (UAS), as has been previously demonstrated for CL, CT in a modified Boyden chamber is stimulated but no significant differences among the chemotypes were observed. In the presence of heat inactivated autologous serum (IAS), significant variations among the LPS chemotypes occurred. Also noteworthy was the observation that, although the total number of cells migrating across the membrane was similar for both UAS and IAS, UAS promoted PMN migration beyond the membrane into the chamber, as opposed to IAS which caused the cells to remain adherent to the distal face of the membrane. In the absence of serum, RM was inhibited in a dose-dependent fashion by LPS from lipid A and the rough-strain mutants, with the degree of inhibition being progressively greater with increasing molecular complexity of the chemotype LPS. The smooth-strain LPS exerted an intermediate effect. In the case of CL, lipid A was the most potent stimulus, with the response decreasing as molecular complexity increased up to RcP-; the remaining core mutant LPS provided slightly greater responses. The LPS from the smooth-strain promoted a response similar to the response to Ra LPS. Based on these data, it is concluded that there are qualitative as well as quantitative effects of the carbohydrate moieties of LPS. These data also suggest that while LPS may provoke active migration in the circulation during endotoxemia, infection localized in tissue might bring about an inhibition of PMN migration while allowing the PMN to mount an oxidative response.