Anti-oxidized low-density lipoprotein antibody levels are associated with the development of type 2 diabetes mellitus

Background  Anti-oxidized low-density lipoprotein (LDL) antibodies are associated with the oxidative capacity of plasma, but whether they protect or promote diabetes is unknown. We undertook a prospective study to determine the predictive capacity of anti-oxidized LDL antibodies for the onset of type 2 diabetes mellitus (T2DM).
Materials and methods  We selected 391 non-diabetic women aged 18–65 years. The subjects were classified as being normal (oral glucose test tolerance normal, OGTT-N), or having impaired glucose tolerance (IGT), impaired fasting glucose (IFG) or T2DM according to their baseline glucose levels and after an OGTT. The same subjects were studied six years later. The levels of anti-oxidized LDL antibodies were classified as above or below the 50th percentile.
Results  Of the women who were OGTT-N at the start of the study and who had anti-oxidized LDL antibody levels below the 50th percentile, only 65·1% were still OGTT-N after 6 years versus 79·5% of those who had anti-oxidized LDL antibody levels above the 50th percentile ( P  = 0·015). Women who had IGT or IFG at the start of the study whose anti-oxidized LDL antibody levels were below the 50th percentile had a relative risk of 9·79 (95% confidence interval, 1·40–68·45) of developing diabetes ( P  < 0·001). Logistic regression analysis showed that the variables predicting the development of a carbohydrate metabolism disorder in the women after 6 years were body mass index ( P  < 0·001) and the levels of anti-oxidized LDL antibodies ( P  = 0·042).
Conclusions  Levels of anti-oxidized LDL antibodies are independent predictors for the development of T2DM in women.     

The Epidemiology and Diagnosis of Penetrating Eye Injuries

It is estimated that there are 3.1 penetrating eye injuries per 100,000 person-years in the United States. OBJECTIVES: To evaluate the epidemiology of penetrating eye injuries and to identify physical examination findings that facilitate the diagnosis and ophthalmologic referral of patients with these injuries. METHODS: This was a retrospective chart review of emergency department patients with penetrating eye injuries seen for evaluation from July 1987 to January 1999. The setting was a tertiary referral, university hospital. Three hundred eighty-four patients with 390 penetrating eye injuries were enrolled; 56% were transferred from outlying hospitals. RESULTS: Penetrating eye injuries were seen almost three times per month. Eighty percent of the injuries occurred in males, and the mean age was 29 years. Twenty-five percent of the patients had used alcohol in the period immediately preceding the injury. Final visual outcome was 28% with enucleation, "no light perception" (NLP) in 10%, light perception to 20/200 in 24%, and light perception of 20/200 or better in 38%. Poor visual outcome was associated with poor initial visual acuity, alcohol use, and delayed presentation (p = 0.036, 0.025, 0.036, respectively). Gun-related injuries caused 33% and motor vehicle crashes (MVCs) caused 21% of the worst outcomes (enucleation or NLP). In MVCs where seat belt use was reported, 71% of injured patients were unrestrained. The most common initial physical findings were hyphema (76%), abnormality of the pupil or uvea (94%), and initial visual acuity worse than 20/200 (77%). All patients had at least one of these findings. Complications occurred in 25% of cases, most commonly traumatic cataract or infection. Complications occurred more commonly in those patients transferred than in those presenting directly (p = 0.002). CONCLUSIONS: Penetrating eye injuries are relatively common, occur predominantly in young males, and often result in poor visual outcome in the affected eye. Motor vehicle crashes, alcohol use, and fire-arm use are associated with more severe injuries.     

On-Call Radiology: Community Standards and Current Trends

The issues regarding on-call radiology are complex and contentious. Both academic and private practice radiology centers have encountered increasing workloads in recent years. Some academic centers are utilizing night float systems or other models of call to address the increasing complexity and volume of after-hours cases. Many private practice groups are outsourcing after-hours work to commercial nighthawk radiology services. Emergency medicine department and ACR guidelines place additional expectations on the on-call radiologist.     

Competitive and cooperative effects of Bay K8644 on the L-type calcium channel current inhibition by calcium channel antagonists

Phenylalkylamines, benzothiazepines, and dihydropyridines bind noncompetitively to the L-type calcium channel. The molecular mechanisms of this interaction were investigated in enzymatically isolated rat ventricular myocytes using the whole-cell patch-clamp technique. When applied alone, felodipine, verapamil, and diltiazem inhibited the L-type calcium current with values of inhibitory constant (K(B)) of 11, 246, and 512 nM, respectively, whereas 1,4-dihydro-2,6-dimethyl-5-nitro-4-(2-[trifluoromethyl]phenyl)-3-pyridine carboxylic acid methyl ester (Bay K8644) activated I(Ca) with activation constant (K(A)) of 33 nM. Maximal activation of I(Ca) by 300 nM Bay K8644 strongly reduced the inhibitory potency of felodipine (apparent K(B) of 165 nM), significantly reduced the inhibitory potency of verapamil (apparent K(B) of 737 nM), but significantly increased the inhibitory potency of diltiazem (apparent K(B) of 310 nM). In terms of a new pseudoequilibrium two-drug binding model, the interaction between the dihydropyridine agonist Bay K8644 and the antagonist felodipine was found purely competitive. The interaction between Bay K8644 and verapamil or diltiazem was found noncompetitive, and it could be described only by inclusion of a negative interaction factor nu = -0.60 for verapamil and a positive interaction factor nu = +0.24 for diltiazem. These results suggest that at physiological membrane potentials, the L-type calcium channel cannot be simultaneously occupied by a dihydropyridine agonist and antagonist, whereas it can simultaneously bind a dihydropyridine agonist and a nondihydropyridine antagonist. Generally, the effects of the drugs on the L-type calcium channel support a concept of a channel domain responsible for binding of calcium channel antagonists and agonists changing dynamically with the membrane voltage and occupancy of individual binding sites.     

A New Model for Teaching Corneal Foreign Body Removal

Objective: To determine whether a skills laboratory for corneal foreign body and rust ring removal improves self-assessed skill and confidence.
Methods: A prospective trial was conducted as part of the didactic curriculum of a university-based residency program in emergency medicine (EM). A convenience sample of 26 EM residents and five fourth-year medical students participated. The skills laboratory used model corneas made by coating 3.2-cm glass spheres with a 1–2-mm film of paraffin. Foreign bodies were simulated by embedding small pieces of metal into the paraffin. Rust rings were simulated by dipping a hot, straightened paper clip into a rust-colored crayon and then into the paraffin. The model eyes fit into a life-sized model of a human head. Participants removed the foreign bodies and rust rings under supervision, using the slit lamp. Each participant anonymously completed a questionnaire before and after participating in the skills laboratory. The questionnaire recorded educational level, previous experience, and self-assessed comfort and skill levels (0 = lowest, 10 = highest).
Results: Most (66%) of the participants had not previously removed a corneal foreign body; 86% had not previously removed a rust ring. On a ten-point scale, the median comfort level for removing a foreign body rose from 2 to 7, and the self-assessed skill level rose from 1 to 7 (p = 0.0001). Similar improvements in self-assessed comfort and skill levels were seen for rust ring removal.
Conclusions: Participation in this skills laboratory significantly improved the self-reported comfort and self-assessed skill levels in removing corneal foreign bodies and rust rings. This technique provides useful practice of a fine-motor procedural skill requiring eye-hand coordination prior to supervised application of these skills in clinical practice.     

Weaning from mechanical ventilation

Practice guidelines on weaning should be based on the results of several well-designed randomized studies performed over the last decade. One of those studies demonstrated that immediate extubation after successful trials of spontaneous breathing expedites weaning and reduces the duration of mechanical ventilation as compared with a more gradual discontinuation of ventilatory support. Two other studies showed that the ability to breathe spontaneously can be adequately tested by performing a trial with either T-tube or pressure support of 7 cmH₂O lasting either 30 or 120 min. In patients with unsuccessful weaning trials, a gradual withdrawal for mechanical ventilation can be attempted while factors responsible for the ventilatory dependence are corrected. Two randomized studies found that, in difficult-to-wean patients, synchronized intermittent mandatory ventilation (SIMV) is the most effective method of weaning.     

A Survey of Oregon Emergency Physicians to Assess Mandatory Reporting Knowledge and Reporting Patterns Regarding Intoxicated Drivers in the State of Oregon

Objectives: To assess emergency physician reporting patterns in Oregon before and after the passage of a mandatory intoxicated driving reporting law. Methods: A one‐page survey was mailed to 504 emergency physicians in Oregon in April 2004. Data on reporting frequency were collected using a four‐point ordinal scale regarding motor vehicle crash–involved drivers (MIDs) and intoxicated persons attempting to drive away from the emergency department (DAEDs). Paired observations were assessed for a stated increase in reporting activity following passage of the law using the Wilcoxon signed‐rank test. Associations of postlaw reporting and demographic and knowledge factors were sought using Spearman rank correlation analysis. Results: Of the 504 surveys mailed, 298 (59%) were adequate for analysis. Many respondents (57%) were already aware of the law. Most (92%) agreed that physicians should be mandated to report some crimes. MIDs were always reported by 18% of physicians before the law and by 47% afterward, whereas DAEDs were always reported by 56% of physicians before the law and by 69% afterward. Emergency medicine–trained physicians, higher emergency department census, and increased years of experience were associated with a significantly higher increase in reporting pattern after passage of the law for both MIDs and DAEDs. Conclusions: Although 44% of responding emergency physicians in Oregon were unaware of a mandated reporting law for intoxicated drivers presenting to the ED, most physicians stated an increase in their reporting practice.     

Motor Vehicle Crash Fatalities among Hispanics in Rural North Carolina

OBJECTIVES: Deaths from motor vehicle crashes (MVCs) have decreased significantly over the past three decades. Unfortunately, few data have been collected regarding death rates for MVCs in minority populations. The purpose of this study was to compare the death rate of whites versus Hispanics for MVCs in a rural environment. METHODS: This study examined one rural county in North Carolina from January 1, 1999, to December 31, 1999. A retrospective cohort study was performed using the North Carolina State Highway Patrol computerized database of MVCs. Data regarding the total number of MVCs, fatalities, alcohol-related deaths, seatbelt usage, and cause of the collision were analyzed for both whites and Hispanics. Census information regarding population in this region also was obtained from the U.S. Bureau of Census. Data were analyzed using a chi-square test, with an alpha value of 0.05 used to establish statistical significance. RESULTS: During the study period, whites were involved in 2,689 MVCs, compared with 158 MVCs for Hispanics. Whites were involved in ten fatal MVCs, compared with seven fatal MVCs involving Hispanics. The percent of fatal MVCs for whites was 0.3%, or 10 deaths per 2,689 MVCs. In contrast, the percent of fatal MVCs for Hispanics was 4.4%, or 7 deaths per 158 MVCs; odds ratio (OR) = 12.4, 95% CI = 4.7 to 33.1. The 2000 Census Report for Pitt County noted a white population of 81,613 and a Hispanic population of 4,216. Based on these population data, the death rate for MVCs per 100,000 population was 12.3 for whites versus 166.0 for Hispanics, OR = 13.6, 95% CI = 5.2 to 35.6. Although the cause for this disparity was not determined, previous studies suggest that alcohol and decreased seatbelt usage are contributing factors. CONCLUSIONS: In this study, the death rates among Hispanics for rural MVCs were significantly higher than for whites. The causes of this disparity are not clear but are important to define. Only by understanding this disparity can we begin to develop appropriate interventions that may prevent these deaths.