Suits happen

Does your agency have enough malpractice insurance to protect you if you're involved in a lawsuit? Many EMTs are taking matters into their own hands.     

Congenital pulmonary atresia with ventricular septal defect: angiographic and surgical correlates

Of 181 patients with severe congenital pulmonary atresia and ventricular septal defect or "type IV truncus" (an obsolete term), all but 11% had true central pulmonary arteries. These arteries were demonstrable by large serial biplane angiograms using multiple selective injections into collateral vessels, frequent photographic subtraction, and occasional pulmonary vein-wedge angiograms. These techniques are extremely important for accurate diagnosis and in planning corrective or palliative surgery, which was done in 77% of patients with pulmonary arteries.     

A plasma factor enhances activity of vitamin K-dependent coagulation proteins

A plasma factor, "coagulopoietin", present in animals with depleted vitamin K-dependent coagulation factors, appears to enhance activity of these factors in normal animals. We have investigated the effects of "coagulopoietin" on synthesis of certain coagulation proteins by the isolated rat liver perfused for eight hours. Liver donor rats received plasma injections from vitamin K-deficient rats or from normal rats 24 hr before sacrifice. Coagulation activity of Factor VII and Factor II in liver perfusate samples was measured with a coagulation assay; Factor II synthesis was also measured by rocket immunoelectrophoresis and by activation with E. carinatus venom. Cumulative hepatic synthesis of Factor VII coagulation activity was increased by 43% when rat liver donors received vitamin K-deficient rat plasma compared to normal rat plasma. Cumulative synthesis of Factor II coagulation activity was increased by 51%, but synthesis of the protein measured immunologically or by activation with venom was not affected. The "coagulopoietin" factor in these studies appears to increase measurable coagulation factor activity without increasing total protein synthesis.     

Kinetic study of smoking marijuana

Six subjects each smoked a 1% marijuana cigarette and 2 hr later smoked a second one. Plasma levels of delta-9-tetrahydrocannabinol were measured for 9 hr with a radioimmunoassay. Heart rate and self-reported "high" were measured for 2 hr after each cigarette. All three measures showed a rapid increase after the start of smoking with Cmax occurring before the end of smoking. There was a strong correlation between decrease in heart rate and plasma levels from 10 min after smoking until 120 min. All pharmacodynamic response measures returned to baseline values within approximately 2 hr.     

Paroxetine in human breast milk and nursing infants

OBJECTIVE: The purpose of this study was to determine the extent of infant medication exposure through breast-feeding during maternal treatment with paroxetine. METHOD: Breast milk and paired maternal and infant sera were collected after 10 days of maternal treatment with paroxetine at a stable daily dose (10-50 mg/day). All samples were analyzed by means of high-performance liquid chromatography with ultraviolet detection and a limit of detection of 2 ng/ml. RESULTS: Breast milk paroxetine concentrations were highly variable (2-101 ng/ml) and were present in all breast milk samples (N=108). A significant gradient effect was observed, with greater paroxetine concentrations found in later portions of breast milk (hind milk) than in early portions (fore milk). No clear time course of paroxetine excretion into breast milk was demonstrated, although maternal paroxetine daily dose reliably predicted both trough and peak breast milk concentrations over a 24-hour period. In 16 mother and infant serum pairs, no detectable concentrations of paroxetine were found in the serum of the nursing infants. CONCLUSIONS: This study extends previous data by demonstrating the presence of paroxetine in the breast milk of nursing women treated with this medication. The low concentrations of paroxetine in infant serum and lack of any observable adverse effects after maternal use of this medication while breast-feeding parallels the available data on other selective serotonin reuptake inhibitors.     

Failure of Nonoperative Management of Isolated Superior Mesenteric Artery Dissection

A case of isolated dissection of the superior mesenteric artery is presented here. This rare condition was confirmed angiographically in a 46-year-old man with persistent abdominal pain. He was treated initially with anticoagulation alone. One year later, he developed recurrent symptoms and had radiologic documentation of progression of the condition. Operative repair was performed and recovery was uneventful. This case demonstrates a failure of the nonoperative approach to this rare condition and suggests that disease progression may be inevitable. Early surgical correction may ease operative management.     

Bisulfite-containing propofol: is it a cost-effective alternative to Diprivan for induction of anesthesia?

Propofol (Diprivan(TM); AstraZeneca, Wilmington, DE) is a commonly used drug for the induction of general anesthesia in the ambulatory setting. With the availability of a new bisulfite-containing generic formulation of propofol, questions have arisen regarding its cost effectiveness and safety compared with Diprivan(TM). Two hundred healthy outpatients were randomly assigned, according to a double-blinded protocol, to receive either Diprivan(TM) or bisulfite-containing propofol 1.5 mg/kg IV as part of a standardized induction sequence. Maintenance of anesthesia consisted of either desflurane (4%-8% end-tidal) or sevoflurane (1%-2% end-tidal) in combination with a remifentanil infusion (0.125 microg x kg(-1) x min(-1) IV). Patient assessments included pain on injection, induction time, hemodynamic and bispectral electroencephalographic changes during induction, emergence time, and incidence of postoperative nausea and vomiting. The two propofol groups were comparable demographically, and the induction times and bispectral index values during the induction were also similar. However, the bisulfite-containing formulation was associated with less severe pain on injection (5% vs 11%), with fewer patients recalling pain on injection after surgery (38% vs. 51%, P<0.05). None of the patients manifested allergic-type reactions after the induction of anesthesia. The acquisition cost (average wholesale price in US dollars) of a 20-mL ampoule of Diprivan(TM) was $15 compared with $13 for the bisulfite-containing propofol formulation. Therefore, we concluded that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM) for the induction of outpatient anesthesia. Implications: Bisulfite-containing propofol and Diprivan(TM) (AstraZeneca, Wilmington, DE) were similar with respect to their induction characteristics; however, the generic formulation was associated with a smaller incidence of injection pain. Assuming that the drug costs are similar, these data suggest that the bisulfite-containing formulation of propofol is a cost-effective alternative to Diprivan(TM).     

Vascular endothelial growth factor and basic fibroblast growth factor in children with cyanotic congenital heart disease

OBJECTIVE: Vascular endothelial growth factor and basic fibroblast growth factor are potent stimulators of angiogenesis. Children with cyanotic congenital heart disease often experience the development of widespread formation of collateral blood vessels, which may represent a form of abnormal angiogenesis. We undertook the present study to determine whether children with cyanotic congenital heart disease have elevated serum levels of vascular endothelial growth factor and basic fibroblast growth factor. METHODS: Serum was obtained from 22 children with cyanotic congenital heart disease and 19 children with acyanotic heart disease during cardiac catheterization. Samples were taken from the superior vena cava, inferior vena cava, and a systemic artery. Vascular endothelial growth factor and basic fibroblast growth factor levels were measured in the serum from each of these sites by enzyme-linked immunosorbent assay. RESULTS: Vascular endothelial growth factor was significantly elevated in the superior vena cava (P =.04) and systemic artery (P =.02) but not in the inferior vena cava (P =.2) of children with cyanotic congenital heart disease compared to children with acyanotic heart disease. The mean vascular endothelial growth factor level, determined by averaging the means of all 3 sites, was also significantly elevated (P =.03). Basic fibroblast growth factor was only significantly elevated in the systemic artery (P =.02). CONCLUSION: Children with cyanotic congenital heart disease have elevated systemic levels of vascular endothelial growth factor. These findings suggest that the widespread formation of collateral vessels in these children may be mediated by vascular endothelial growth factor.     

A conceptual framework for evaluating information technologies and decision support systems for bioterrorism preparedness and response.

OBJECTIVES: The authors sought to develop a conceptual framework for evaluating whether existing information technologies and decision support systems (IT/DSSs) would assist the key decisions faced by clinicians and public health officials preparing for and responding to bioterrorism. METHODS: They reviewed reports of natural and bioterrorism related infectious outbreaks, bioterrorism preparedness exercises, and advice from experts to identify the key decisions, tasks, and information needs of clinicians and public health officials during a bioterrorism response. The authors used task decomposition to identify the subtasks and data requirements of IT/DSSs designed to facilitate a bioterrorism response. They used the results of the task decomposition to develop evaluation criteria for IT/DSSs for bioterrorism preparedness. They then applied these evaluation criteria to 341 reports of 217 existing IT/DSSs that could be used to support a bioterrorism response. Main Results: In response to bioterrorism, clinicians must make decisions in 4 critical domains (diagnosis, management, prevention, and reporting to public health), and public health officials must make decisions in 4 other domains (interpretation of bioterrorism surveillance data, outbreak investigation, outbreak control, and communication). The time horizons and utility functions for these decisions differ. From the task decomposition, the authors identified critical subtasks for each of the 8 decisions. For example, interpretation of diagnostic tests is an important subtask of diagnostic decision making that requires an understanding of the tests' sensitivity and specificity. Therefore, an evaluation criterion applied to reports of diagnostic IT/DSSs for bioterrorism asked whether the reports described the systems' sensitivity and specificity. Of the 217 existing IT/DSSs that could be used to respond to bioterrorism, 79 studies evaluated 58 systems for at least 1 performance metric. CONCLUSIONS: The authors identified 8 key decisions that clinicians and public health officials must make in response to bioterrorism. When applying the evaluation system to 217 currently available IT/DSSs that could potentially support the decisions of clinicians and public health officials, the authors found that the literature provides little information about the accuracy of these systems.     

Evaluation of the Washington State National Pharmaceutical Stockpile dispensing exercise, part II--dispensary site worker findings.

On January 24, 2002, the Washington State Department of Health, in collaboration with local and federal agencies, conducted an exercise of the Centers for Disease Control and Prevention's National Pharmaceutical Stockpile dispensing portion of the Washington State plan. This exercise included predrill planning, training, and the orchestration of services of more than 40 dispensary site workers. These workers provided education and post-exposure prophylaxis for over 230 patient volunteers in the aftermath of a simulated exposure to B. anthracis. This article discusses findings of a postdrill questionnaire completed by 90% of these dispensary site workers who provided triage, education, dispensary, security and other services during this exercise. In general, this dispensing drill promoted confidence in the worker participants and provided an opportunity for these participants to coordinate their activities. This mock bioterrorist preparedness exercise allowed worker participants and observers to review and evaluate the Washington State plan for dispensing the National Pharmaceutical Stockpile. This article is apparently the first published account of dispensary site workers' subjective impressions and quantitative analysis of their postdrill opinions following a simulated bioterrorist post-exposure chemoprophylaxis dispensing exercise.