Randomized evaluation of octreotide vs prochlorperazine for ED treatment of migraine headache

Patients with headaches account for approximately 2% of all ED visits, with migraines being the most common defined primary headache syndrome. Our goals were to evaluate the efficacy of intravenous octreotide (OC) for the treatment of migraines, when compared to standard therapy with prochlorperazine.     

Incidental detection of a transmigrated intrauterine device

The intrauterine device (IUD) is among the most effective forms of birth control available, with important advantages over other methods of contraception. The most striking adverse event associated with IUD use is uterine perforation and migration of the device. Contrary to what one might assume, perforation is often silent and the wayward device is either detected after further sequellae or found incidentally by imaging. The radiologist should be aware of the natural course, presentations, diagnostic evaluation and treatment (if any) for this misplaced foreign body.     

False-positive urine β-HCG in a woman with a tubo-ovarian abscess

Modern urine β-human chorionic gonadotropin (HCG) assays that use enzyme-linked immunosorbent assay (ELISA) technology are sensitive and specific for diagnosing pregnancy, both intrauterine and ectopic, and have become indispensable to the practice of Emergency Medicine. A urine HCG test is often relied on by the Emergency Physician as a critical component in the diagnostic regimen of a patient with a possible ectopic pregnancy. We report a case of a false-positive urine β-HCG test in a patient with a ruptured tubo-ovarian abscess. Though false-positive pregnancy tests with tubo-ovarian abscesses have previously been reported with older methods of HCG detection, we believe that this is the first case where the pregnancy test was the modern ELISA type. The mechanism for the false-positive reaction in this case is unknown, but time may show that the ELISA test kit, like its predecessors, may occasionally give a false-positive reaction in this class of patients.     

Isopropyl alcohol pad use for blood ethanol sampling does not cause false-positive results

This was a retrospective analysis of prospective data collected from a study of blood ethanol levels after the use of the alcohol-based hand sanitizer (ABHS). A total of 5 male volunteers were enrolled. Eight of the 10 total blood ethanol level measurements were drawn after skin preparation with Kendall WEBCOL Alcohol Preps (APP) containing 70% isopropyl alcohol. All had an initial and post-ABHS application blood alcohol level (BAL) drawn, for a total of 10 BAL measurements. Measurements upon completion of the study were <5 mg/dL in all 5 study participants and in each of the 10 blood draws regardless of skin preparation technique. This study demonstrates that the use of isopropyl skin prep pads is unlikely to cause significant false-positive blood ethanol levels.     

Bedside ultrasound for the detection of soft tissue foreign bodies: a cadaveric study

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm³ in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN^® (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%–56.2%), and overall specificity was 47.2% (95% CI 39.9%–54.5%). Positive predictive value was 79.9% (95% CI 76.3%–83.5%), and negative predictive value was 20.0% (95% CI 16.2%–23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% ± 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% ± 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.     

CT angiography for evaluation of coronary artery disease in inner-city outpatients: an initial prospective comparison with stress myocardial perfusion imaging

To evaluate the utility of CT coronary angiography (CTA) for demonstrating coronary artery disease in inner-city outpatients, we prospectively compared CTA with stress SPECT myocardial perfusion imaging in an ethnically diverse, gender balanced population. All patients gave written informed consent for this IRB approved, HIPAA compliant study. Sixty-one patients completed both CTA and SPECT. About 67% were ethnic minorities, 51% were women. A stenosis of ≥70% on CTA was considered positive. Results were compared with perfusion defects on SPECT and correlated with clinical endpoints (hospital admissions, cardiovascular events, coronary interventions and deaths). CTA and SPECT data were compared with results of coronary angiography, when performed. There was moderate global agreement of 79% (48/61) between CTA and SPECT, κ = 0.483 (SE ± 0.13, P = 0.0001). With SPECT as the reference standard, CTA had sensitivity of 73% (11/15), specificity of 80% (37/46), negative predictive value of 90% (37/41) and positive predictive value of 55% (11/20). Positive SPECT was associated with positive CTA, (P < 0.0001, OR = 22). Eleven (18%) underwent subsequent cardiac catheterization, which was positive in 91% (10/11). CTA and SPECT had positive predictive values of 90 and 83% compared with catheterization. This study lends preliminary evidence to support to the utility of CTA as an alternative modality for the evaluation of CAD in an ethnically diverse, gender balanced inner-city outpatient population. Similar to more homogenous groups, CTA had a high negative predictive value and demonstrated disease occult to SPECT. Further study is necessary to evaluate the impact of CTA on patient outcomes.