Orthopedic pitfalls in the ED: pediatric supracondylar humerus fractures

Supracondylar humerus fractures are the most common fracture around the elbow in the pediatric population. They are the result of a fall on an outstretched arm and are seen primarily in the first decade of life. The diagnosis of these fractures can be subtle and, if missed, can result in vascular, structural, or neurologic injuries. Prompt diagnosis and treatment of these injuries is important to improved clinical outcome. The emergency physician needs to remain vigilant for this diagnosis to avoid this orthopedic pitfall. This review article examines the clinical presentation, diagnostic technique, and management options applicable to the emergency physician in the treatment of supracondylar humerus fractures.     

Home Health Compare: Web site offers critical information to consumers and professionals

The Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services, has released new data about the quality of care provided by Medicare-certified home health agencies as part of an expanding initiative to continue to improve the home care services that are provided to millions of Americans. The initiative combines information about the quality of care provided by individual home health agencies-for use by consumers, their families, and health care professionals-with important resources to assist home health agencies working to improve quality of care. This article provides an overview of that initiative, and discusses information available on the Home Health Compare Web site that case managers and discharge planners will find useful for helping patients and their families select a home health agency.     

Resolution of infection status of human immunodeficiency virus (HIV)- seroindeterminate donors and high-risk seronegative individuals with polymerase chain reaction and virus culture: absence of persistent silent HIV type 1 infection in a high-prevalence area

To address concerns over the prevalence of silent (antibody-negative) infections among blood donors and high-risk populations, a combination of proviral amplification by polymerase chain reaction (PCR) and viral isolation by co-culture techniques was employed to resolve the human immunodeficiency virus type 1 (HIV-1) infection status of well-characterized groups of suspect blood donors and others identified in the blood bank setting. No silent infections were found in 65 follow-up samples from 26 persistently HIV-1-seroindeterminate blood donors, 16 persistently seronegative heterosexual partners of infected transfusion recipients, and 6 high-risk seronegative homosexual men identified through donor look-back investigations. In contrast, 21 seropositive controls tested positive. These results suggest a low prevalence of persistently silent infections in at-risk populations, even in high HIV prevalence regions. The PCR assay, with a co-detected internal positive control, and appropriate confirmatory algorithms, was found to be a useful direct assay to rule out infection, especially in concert with confirmatory virus isolation.     

Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease

BACKGROUND:

It is uncertain if the presence and severity of airflow obstruction in chronic obstructive pulmonary disease (COPD) is predictive of surgical morbidity and mortality after coronary artery bypass grafting (CABG).

METHODS:

Retrospective study of patients who underwent CABG between 1998 and 2003 in a university-affiliated hospital for whom a preoperative spirometry was available. COPD was diagnosed in smokers or ex-smokers 50 years of age or older in the presence of irreversible airflow obstruction. Patients were divided into three groups depending on the spirometry: controls (forced expiratory volume in 1 s [FEV₁] 80% or more, FEV₁/forced vital capacity [FVC] greater than 0.7), mild to moderate COPD (FEV₁ 50% or more and FEV₁/FVC 0.7 or less) and severe COPD (FEV₁ less than 50% and FEV₁/FVC 0.7 or less).

RESULTS:

Among the 411 files studied, 322 (249 men, 68±8 years of age) were retained (controls, n=101; mild to moderate COPD, n=153; severe COPD, n=68). The mortality rate (3.0%, 2.6% and 0%, respectively) was comparable among the three groups. Patients with severe COPD had a slightly longer hospital stay than controls (mean difference 0.7±1.4 days, P<0.05). Pulmonary infections were more frequent in severe COPD (26.5%) compared with mild to moderate COPD (12.4%) and controls (12.9%), P<0.05. Atrial fibrillation tended to be more frequent in severe COPD than in the other two groups.

CONCLUSION:

Mortality rate associated with CABG surgery is not influenced by the presence and severity of airflow obstruction in patients with COPD. The incidence of pulmonary infections and length of hospital stay were increased in patients with severe COPD.     

Reducing the harm of "harm reduction"

The US Food and Drug Administration (FDA) is committed to working with the oncology community to expedite the drug evaluation process in view of the many promising new oncology drugs under laboratory development and the time and expense required for such new drugs to reach the patient population. One significant advance would be to enable quantitative imaging as a tumor biomarker. The FDA is working with the pharmaceutical industry, academia, and sister stakeholders in the government, primarily through collaborative educational and research efforts, to identify how imaging can serve this function.     

Relation of the "hypertriglyceridemic waist" phenotype to earlier manifestations of coronary artery disease in patients with glucose intolerance and type 2 diabetes mellitus

This study tested the hypothesis that the "hypertriglyceridemic waist" phenotype (waist girth >90 cm [35.4 inches] in men and >85 cm [33.5 inches] in women, along with a plasma triglyceride concentration of >or=2.0 mmol/L [177 mg/dl]) as a covariate of metabolic syndrome features (hyperinsulinemia, hyperapolipoprotein B, and small low-density lipoprotein particles), is predictive of premature coronary artery disease (CAD) among patients with glucose intolerance or type 2 diabetes. Glucose intolerance and type 2 diabetes were assessed after an oral glucose tolerance test among 1,190 men and women using the American Diabetes Association criteria. Glycemic control was evaluated using hemoglobin A1c levels. CAD was considered present on the basis of a clinical history of retrosternal pains on exertion, electrophysiologically and clinically documented myocardial infarction, or angiographic evidence of coronary lesions. More than 53% of men (n = 103) with a waist circumference >or=90 cm (35.4 inches) and nearly 80% of women (n = 122) with a waist circumference >or=85 cm (33.5 in.) with triglyceride levels >or=2 mmol/L (177 mg/dl) were diagnosed with glucose intolerance or type 2 diabetes. Survival models revealed that those with glucose intolerance or type 2 diabetes with the "hypertriglyceridemic waist" phenotype experienced their first CAD symptoms 5 years earlier than those without this phenotype. This elevated and earlier risk of CAD was statistically significant (hazard ratio 2.0, 95% confidence interval 1.2 to 3.7, p = 0.02). In conclusion, the "hypertriglyceridemic waist" phenotype, an inexpensive and simple tool identifying subjects with metabolic syndrome features, is a significant marker of CAD manifestations occurring at an earlier age in those with glucose intolerance or type 2 diabetes.     

Morphological properties of the action-observation cortical network in adolescents with low and high resistance to peer influence

Children with high resistance to peer influences differ from their low-resistance counterparts in the degree of functional connectivity in fronto-parietal and prefrontal cortical networks. Here we explored the possibility that the degree of morphological similarities across the same cortical regions also varies as a function of this behavioral trait. Using structural magnetic-resonance (MR) images, we measured cortical thickness in a total of 295 adolescents (12 to 18 years of age). We found that inter-regional correlations in cortical thickness increased with the resistance to peer influence (RPI); this was especially the case, in female adolescents, in the premotor and prefrontal networks. We also observed significant differences between the adolescents with high and low RPI scores in their general intelligence and the scores of positive youth development. We suggest that these morphological findings might reflect differences, between adolescents with high vs. low resistance to peer influences, in a repeated and concurrent engagement of these networks in social context.     

A comparison of central venous and arterial base deficit as a predictor of survival in acute trauma

Background

The arterial base deficit has been demonstrated to be a marker of shock and predictive of survival in injured patients. The venous blood, however, may better reflect tissue perfusion. Its usefulness in trauma is unknown. We compared central venous with arterial blood gas analysis to determine which was a better predictor of survival in injured patients.

Methods

A prospective, nonrandomized series of acutely injured patients was investigated. Patients who had an arterial blood gas analysis for acid-base determination had a simultaneous central venous blood gas analysis and routine blood tests. Patient demographics, Injury Severity Score, and survival past 24 hours were recorded. Arterial and venous blood samples were analyzed for pH, Pco₂, Po₂, HCO₃, hemoglobin-oxygen saturation, base deficit, and lactate.

Results

One hundred patients were enrolled. There were 76 survivors and 24 nonsurvivors. Wilcoxon rank sum test and multivariate logistic regression were used for each recorded variable; only central venous base deficit was predictive of survival past 24 hours (P = .0081). Specifically, arterial base deficit was not predictive of survival past 24 hours.

Conclusion

In a prospective series of acutely injured patients, central venous base deficit, not arterial base deficit, was predictive of survival past 24 hours.