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Soft-tissue infections caused by halophilic marine vibrios
458
perforation, reveals there to be a significant (P
0 EFFECTS OF SLEEP DISRUPTION ON COGNITIVE PERFORMANCE AND MOOD IN MEDICAL HOUSE OFFICERS. Deary IJ, Tait R. BrMedJ 1987; 295: 1513-1516. This prospective study looked at the effects of sleep deprivation and sleep disruption on cognitive performance and mood in twelve junior house officers. The study compares function and mood under three conditions: a night spent off duty where house officers slept a median of 7 hours; a night spent on call on medical wards, but not taking admissions, with a median of 5 hours slept; and a night on call taking admissions with a median of 1.5 hours slept. Cognitive tasks that mimicked clinical tasks were evaluated. Only short term memory was impaired in the group taking admissions. There was no statistically significant impairment of cognitive function in the group on call. Mood changes were also evident in the group taking admissions in the category of vigor or “deactivation.” It was hypothesized that house officers may compensate for tiredness by drawing on mental reserve capacity, but at a cost. Mood changes may beget pathologically low moods and depressive episodes. The study also found that differences between individuals were significant in five of the eight cognitive tests. A good doctor scored better after a night taking admissions than a poor doctor after a night off duty. [Paul Howes, MD] Editor’s Note: Emergency physicians are well acquainted with the deleterious effects of sleep deprivation. This study raises the interesting point that differences between individuals may be as important as differences in working conditions.
0 DETERMINATION OF LEUKOCYTOSIS IN TRAUMATIC SPINAL TAP SPECIMENS. Mayefsky JH, Roghmann KJ. Am JMed 1987; 82:1175-1181. Traumatic lumbar puncture is a common occurrence, and results in the dilemma of distinguishing peripheral blood leukocytes from cerebrospinal fluid leukocytes. The authors retrospectively reviewed lumbar puncture results over a five-year period. Seven hundred twenty collections met the inclusion criteria of traumatic taps with at least 200 red blood cells. Fifty-eight had culture positive meningitis, 83 had culture negative meningitis, and 539 were culture negative and did not have meningitis. The expected number of leukocytes was estimated by the traditional correction: blood leukocytes (multiplied by CSF red cells) divided by red blood cells. A ratio of observed number of CSF leukocytes divided by expected number of leukocytes of ten or greater was found to have a sensitivity of 88% and specificity of 90% in predicting the presence of culture-positive meningitis. The positive predictive value of a ratio of ten or greater was 48%. The negative predictive value of a ratio less than ten was 99%. The authors conclude that the above
The Journal of Emergency Medicine
ratio is a more useful clinical indicator than adjusted leukocytes in evaluating bloody cerebrospinal fluid, but caution that this should be used in concert with all other laboratory and clinical data before a decision is made not to treat the patient. [R. Scott Israel, MD] Editor’s Note: Since the cutoff value for the ratio was retrospectively derived, it should be used with caution pending prospective validation.
0 EFFECT OF A SINGLE ORAL DOSE OF PREDNISOLONE IN ACUTE CHILDHOOD ASTHMA. Storr J, Barrel1 E, Barry W, et al. Luncet 1987; 1:879-882. This randomized, double-blind controlled study of 143 children with moderate to severe asthma (requiring hospitalization) compared a single dose (30 mg under age 5, 60 mg over 5) of oral prednisolone to placebo. All patients also received nebulized albuterol treatments at the time of admission and 3 to 4 times daily. Clinical assessment scores, length of hospital stay, and PEFR were used to measure efficacy. Initial evaluations of patients were similar, but by five hours after admission, 30% of the prednisolone group could be discharged compared to 3 % in the placebo group. Children receiving the prednisolone had a shorter median duration of hospital stay (24 v 39 hours) and required fewer additional doses of steroids (30% v 60%) than the placebo group. There was a statistically significant difference in PEFR between the treatment groups. The authors conclude that early administration of a single dose of oral prednisolone can reduce morbidity and the need for hospitalization in childhood asthmatics. [John Riccio, MD] Editor’s Note: It would be nice to repeat this study in the ED, and to see if it actually reduces the incidence of admission.
INFECTIONS CAUSED BY HA0 SOFT-TISSUE LOPHILIC MARINE VZBRZOS. Howard RJ, Lieb S. Arch Surg 1988; 123:245-249.
Halophilic marine Vibrios are found in ocean water and marine animals. The bacteria can cause gastroenteritis, speticemia, and soft tissue infections in humans. Infection with Vibrio can occur via direct contact (eg, via a wound) or through eating raw seafood. This paper reviews 51 patients with soft tissue infections caused by marine Vibrios presenting over a 5-year period. The most common species isolated was K vulnificus. This also seemed to be the most virulent species, responsible for 11 of the 13 deaths. Twenty-two of the 51 patients (44%) had an underlying illness that could have rendered them compromised hosts; the most common predisposing condition was alcoholic cirrhosis. Eleven (50%) of these patients developed necrotizing infections, compared with only one necrotizing infection of 29 patients without underlying illness. Thirteen patients died, all of whom had underlying predisposing illnesses. Twelve patients had necrotizing infection requiring debridement; three of these required amputation. Six of the 13 patients who died had necrotizing infections.
Abstracts
Treatment of k’i/ibrioinfections involves supportive care and antibiotics with tetracycline being the drug of choice, followed by erythromycin. When tissue necrosis occurs, debridement as well as antibiotics are needed, with amputation occasionally warranted. [Janyce M. Sanford, MD] Editor’s Note: What a curious article. None of the alcoholics we see are sushi addicts.
0 DIAGNOSIS OF TRICHOMONIASIS: COMPARISON OF CONVENTIONAL WET-MOUNT EXAMINATION WITH CYTOLOGIC STUDIES, CULTURES, AND MONOCLONAL ANTIBODY STAINING OF DIRECT SPECIMENS. Krieger JN, Tam MR, Stevens CE, et al. JAMA 1988; 259:1223-1227. Trichomoniasis is a major sexually transmitted disease affecting 180 million women worldwide. Accurate diagnosis
459
is necessary for proper treatment and control of trichomoniasis, but there is no readily available and effective method to identify this organism. Culture is the most sensitive diagnostic test, but it requires an incubation period of two to seven days. The routine wet-mount test detects only about 60% of the cases confirmed by cultures. The Papanicolaou gynecologic smear is even less sensitive. Direct immunofluorescence using monoclonal antibodies staining is 86% sensitive. The sampling technique is simple, and the procedure can be accomplished within an hour. The disadvantages of this test include the requirement for specialized reagents, a high quality microscope, and trained personnel. With future technical modification, direct immunofluorescence with monoclonal antibodies holds promise as a sensitive and specific alternative to culture for rapid detection of [Nguyen Vo, MD] 7: vaginalis in clinical settings. Editor’s Note: It is depressing to reflect that there may be almost twice as much trichomoniasis in the world as we think.
perforation, reveals there to be a significant (P
0 EFFECTS OF SLEEP DISRUPTION ON COGNITIVE PERFORMANCE AND MOOD IN MEDICAL HOUSE OFFICERS. Deary IJ, Tait R. BrMedJ 1987; 295: 1513-1516. This prospective study looked at the effects of sleep deprivation and sleep disruption on cognitive performance and mood in twelve junior house officers. The study compares function and mood under three conditions: a night spent off duty where house officers slept a median of 7 hours; a night spent on call on medical wards, but not taking admissions, with a median of 5 hours slept; and a night on call taking admissions with a median of 1.5 hours slept. Cognitive tasks that mimicked clinical tasks were evaluated. Only short term memory was impaired in the group taking admissions. There was no statistically significant impairment of cognitive function in the group on call. Mood changes were also evident in the group taking admissions in the category of vigor or “deactivation.” It was hypothesized that house officers may compensate for tiredness by drawing on mental reserve capacity, but at a cost. Mood changes may beget pathologically low moods and depressive episodes. The study also found that differences between individuals were significant in five of the eight cognitive tests. A good doctor scored better after a night taking admissions than a poor doctor after a night off duty. [Paul Howes, MD] Editor’s Note: Emergency physicians are well acquainted with the deleterious effects of sleep deprivation. This study raises the interesting point that differences between individuals may be as important as differences in working conditions.
0 DETERMINATION OF LEUKOCYTOSIS IN TRAUMATIC SPINAL TAP SPECIMENS. Mayefsky JH, Roghmann KJ. Am JMed 1987; 82:1175-1181. Traumatic lumbar puncture is a common occurrence, and results in the dilemma of distinguishing peripheral blood leukocytes from cerebrospinal fluid leukocytes. The authors retrospectively reviewed lumbar puncture results over a five-year period. Seven hundred twenty collections met the inclusion criteria of traumatic taps with at least 200 red blood cells. Fifty-eight had culture positive meningitis, 83 had culture negative meningitis, and 539 were culture negative and did not have meningitis. The expected number of leukocytes was estimated by the traditional correction: blood leukocytes (multiplied by CSF red cells) divided by red blood cells. A ratio of observed number of CSF leukocytes divided by expected number of leukocytes of ten or greater was found to have a sensitivity of 88% and specificity of 90% in predicting the presence of culture-positive meningitis. The positive predictive value of a ratio of ten or greater was 48%. The negative predictive value of a ratio less than ten was 99%. The authors conclude that the above
The Journal of Emergency Medicine
ratio is a more useful clinical indicator than adjusted leukocytes in evaluating bloody cerebrospinal fluid, but caution that this should be used in concert with all other laboratory and clinical data before a decision is made not to treat the patient. [R. Scott Israel, MD] Editor’s Note: Since the cutoff value for the ratio was retrospectively derived, it should be used with caution pending prospective validation.
0 EFFECT OF A SINGLE ORAL DOSE OF PREDNISOLONE IN ACUTE CHILDHOOD ASTHMA. Storr J, Barrel1 E, Barry W, et al. Luncet 1987; 1:879-882. This randomized, double-blind controlled study of 143 children with moderate to severe asthma (requiring hospitalization) compared a single dose (30 mg under age 5, 60 mg over 5) of oral prednisolone to placebo. All patients also received nebulized albuterol treatments at the time of admission and 3 to 4 times daily. Clinical assessment scores, length of hospital stay, and PEFR were used to measure efficacy. Initial evaluations of patients were similar, but by five hours after admission, 30% of the prednisolone group could be discharged compared to 3 % in the placebo group. Children receiving the prednisolone had a shorter median duration of hospital stay (24 v 39 hours) and required fewer additional doses of steroids (30% v 60%) than the placebo group. There was a statistically significant difference in PEFR between the treatment groups. The authors conclude that early administration of a single dose of oral prednisolone can reduce morbidity and the need for hospitalization in childhood asthmatics. [John Riccio, MD] Editor’s Note: It would be nice to repeat this study in the ED, and to see if it actually reduces the incidence of admission.
INFECTIONS CAUSED BY HA0 SOFT-TISSUE LOPHILIC MARINE VZBRZOS. Howard RJ, Lieb S. Arch Surg 1988; 123:245-249.
Halophilic marine Vibrios are found in ocean water and marine animals. The bacteria can cause gastroenteritis, speticemia, and soft tissue infections in humans. Infection with Vibrio can occur via direct contact (eg, via a wound) or through eating raw seafood. This paper reviews 51 patients with soft tissue infections caused by marine Vibrios presenting over a 5-year period. The most common species isolated was K vulnificus. This also seemed to be the most virulent species, responsible for 11 of the 13 deaths. Twenty-two of the 51 patients (44%) had an underlying illness that could have rendered them compromised hosts; the most common predisposing condition was alcoholic cirrhosis. Eleven (50%) of these patients developed necrotizing infections, compared with only one necrotizing infection of 29 patients without underlying illness. Thirteen patients died, all of whom had underlying predisposing illnesses. Twelve patients had necrotizing infection requiring debridement; three of these required amputation. Six of the 13 patients who died had necrotizing infections.
Abstracts
Treatment of k’i/ibrioinfections involves supportive care and antibiotics with tetracycline being the drug of choice, followed by erythromycin. When tissue necrosis occurs, debridement as well as antibiotics are needed, with amputation occasionally warranted. [Janyce M. Sanford, MD] Editor’s Note: What a curious article. None of the alcoholics we see are sushi addicts.
0 DIAGNOSIS OF TRICHOMONIASIS: COMPARISON OF CONVENTIONAL WET-MOUNT EXAMINATION WITH CYTOLOGIC STUDIES, CULTURES, AND MONOCLONAL ANTIBODY STAINING OF DIRECT SPECIMENS. Krieger JN, Tam MR, Stevens CE, et al. JAMA 1988; 259:1223-1227. Trichomoniasis is a major sexually transmitted disease affecting 180 million women worldwide. Accurate diagnosis
459
is necessary for proper treatment and control of trichomoniasis, but there is no readily available and effective method to identify this organism. Culture is the most sensitive diagnostic test, but it requires an incubation period of two to seven days. The routine wet-mount test detects only about 60% of the cases confirmed by cultures. The Papanicolaou gynecologic smear is even less sensitive. Direct immunofluorescence using monoclonal antibodies staining is 86% sensitive. The sampling technique is simple, and the procedure can be accomplished within an hour. The disadvantages of this test include the requirement for specialized reagents, a high quality microscope, and trained personnel. With future technical modification, direct immunofluorescence with monoclonal antibodies holds promise as a sensitive and specific alternative to culture for rapid detection of [Nguyen Vo, MD] 7: vaginalis in clinical settings. Editor’s Note: It is depressing to reflect that there may be almost twice as much trichomoniasis in the world as we think.