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The age at onset and duration of otitis media, feeding position, exposure to cigarette smoke, and group child care were documented. The status of the middle ear was determined by tympanometry every 2 to 4 weeks. A shorter duration of breast feeding was associated with more OME with effusion during the first 6 months of life but not with earlier age at onset of OME or more OME at later ages. Infants who were breast fed for the first 6 months of life had a 10% decrease in the amount of OME compared with infants who were not breast fed at all. Supine feeding position was associated with an earlier onset of OME but not more frequent OME. Cigarette smoke exposure was associated with longer duration of OME during the second year of life. The later children started group child care, the later the onset of otitis media. The authors recommend prolonged breast feeding, upright feeding position, cessation of smoking around children, and limiting child care in large group settings. [Dawn Davidson, MD] Editor’s Comment: Here is further evidence for damage to children from secondhand smoking. It should be interesting to see what kind of spin the tobacco companies will continue to put on this subject.

0 TRAUMA OUTCOMES IN THE RURAL DEVELOPING WORLD: COMPARISON WITH AN URBAN LEVEL 1 TRAUMA CENTER. Mock CN, Adzotor KE, Conklin E, et al. J Trauma. 1993;35:518-23. This study attempts to characterize trauma in a specific rural area of the developing world and to determine where improvements might be made. The authors compared trauma patient statistics from a rural developing area (Berekum, Gana) with a level 1 trauma center (Harborview Hospital, Seattle, Washington). Five hundred thirty-nine trauma patients admitted to Holy Family Hospital (HFH), Berekum, Gana, between 1987 and 1991 were compared to 14,270 trauma patients admitted to Harborview Medical Center (HMC), Seattle, Washington. Demographic data, mechanism of injury, time to presentation, prehospital care, treatment, and outcome were compared for each hospital. Prehospital care and time to treatment varied most significantly between the two hospitals. No organized prehospital care system is available for HFH, with the majority of trauma patients arriving 24 h after injury by public or private transportation versus 95% of trauma patients at HMC arriving within 24 h. Blunt trauma predominated at both institutions, with motor vehicle crashes being the largest subgroup. Overall trauma mortality was 6% at both hospitals, but patients at HMC were more severely injured with higher injury surveillance scores (10.0 versus 6.7). The mortality rate, at both institutions, was highest for patients whose region of principal injury was the head or cervical spine. The authors suggest that hospital-based interventions designed to improve survival of the most severely injured patients are of little proven benefit. They emphasize the relatively inexpensive needed changes in prehospi-

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tal care systems and prevention as the most cost-effective means to decreasemortality from trauma in the rural developing world. [Thomas J. Peitz, MD]

0 BLUNT ABDOMINAL TRAUMA: ARE THERE ANY PREDICTIVE FACTORS FOR ABRUPT10 PLACENTAE OR MATERNAL-FETAL DISTRESS. Dahmus MA, Sibai M. Am J Obstet Gynecol. 1993;169: 1054-9. Trauma during pregnancy is a major cause of obstetrical death. The purpose of this study was to determine the incidence of abruptio placentae and fetal distress in women with noncatastrophic blunt abdominal trauma during the second half of pregnancy. Blunt abdominal trauma included all blows from assaults, falls, and all motor vehicle accidents. Of 233 casesreviewed, the mean age of gestation was 31 weeks. Preterm labor that required tocolysis occurred in 42 (18%) of pregnancies. Preterm delivery within 1 week of trauma was required in only two cases(0.86%). Fetal distress within 1 week of admission occurred in four (1.7%) patients. Abruptio placentae occurred in six (2.6%) cases, with only one case requiring preterm delivery. Eighty-seven patients had a sonogram at time of admission that were all normal. Two patients had subsequent scans that were consistent with abruption. This study suggests that the major morbidity of noncatastrophic abdominal trauma was fetal distress of unknown origin. Minor cases of abruptio placentae may be unimportant unless preterm [Erik D. Barton, MD, MS] delivery occurs. Editor’s Comment: Patients were monitored for a mean of 13 h after injury, which is prudent considering that major morbidity may follow minor traumatic mechanisms.

0 TIME OF HOSPITAL PRESENTATION IN PATIENTS WITH ACUTE STROKE. Barson WG, Brott TG, Broderick JP, et al. Arch Intern Med. 1993;153: 2558-61. This group analyzed charts in an effort to identify factors associated with early arrival in patients presenting with stroke symptoms. They reviewed the charts of 17 participating hospitals from February 1987 to January 1990 and found 2099 eligible patients. They studied time of stroke to arrival and time of day (day divided into 6-h quarters). Of the 2099 patients, 940 had to be excluded since accurate information about the onset of stroke could not be determined leaving 1159 for analysis. Their results showed that two-thirds of the patients presented to the hospital within 4 h, a time frame possibly amenable for treatment. The earliest arrival was associated with those patients that used 911 as their first medical contact, emphasizing the importance of emergency medical services (EMS). Several other factors were identified with

earlier arrival including patients whose onset of stroke was at work rather than at home, and if the symptoms were first felt during waking hours rather than sleep. Age was shown not to be a significant characteristic and was dropped from further analysis. A conclusion drawn from this study shows that, if public education is undertaken and EMS emphasized, rapid stroke treatment may be initiated soon on hospital arrival. [Javier Aristimufio, MD] Editor3 Comment: With the increasing use of urgent stroke treatment protocols, early utilization of EMS is identified as a critical component.

C SERUM DOSAGE LEVELS IN NONPANCREATIC ABDOMINAL PAIN VS ACUTE PANCREATITIS. Gunasse VV, Roditis N, Mehta D, et al. Am J Gastroenterol. 1993;88(12):2051-4. Measurement of serum amylase is the most widely used screening test for acute pancreatitis. However, serum amylase levels may be elevated in many other conditions that cause abdominal pain, and levels may be low or normal in acute alcoholic pancreatitis. This study was done to compare serum lipase and serum amylase levels in patients with nonpancreatic abdominal pain and patients with acute pancreatitis. Ninety-five patients with nonpancreatic abdominal pain were placed in group A, and 75 patients with acute pancreatitis were placed in group P. Serum amylase levels in group A ranged from 11 to 416 U/L (mean 58 f 46), and in group P ranged from 124 to 13,000 U/L (mean 1620 f 1976). Twenty-seven percent of the patients in group P had levels that overlapped those found in group A. The serum lipase levels in group A ranged from 3 to 680 U/L (mean 111 f lOl), and in group P ranged from 711 to 3 I, 153 (mean 6705 f 7022). None of the patients in group P had levels that overlapped those in group A. The sensitivity of serum amylase in detecting acute pancreatitis was 75%; the specificity was 99%. The sensitivity of serum lipase was lOO%, and the specificity was 99%. The authors conclude that a serum lipase level of 3 times normal has a better diagnostic accuracy than serum amylase in detecting acute pancreatitis. [Bernard F. Kennerz, Jr .] Editor’s Comment: Serum lipase levels are also more valuable in the setting of chronic pancreatitis than are serum amylase levels.

[I STRIKING PREVALENCE OF OVER-THE-COUNTER NONSTEROIDAL ANTI-INFLAMMATORY DRUG USE IN PATIENTS WITH UPPER GASTROINTESTINAL HEMORRHAGE. Wilcox CM, Shalek KA, Cotsonis G. Arch Intern Med. 1994;154:42-6. Consecutive patients evaluated for upper gastrointestinal hemorrhage (UGIH) at a large inner city hospital were prospectively evaluated for over-the-counter (OTC) and

prescription use of nonsteroidal anti-inflammatory drugs (NSAID). Over a 2-year period, 421 patients were admitted and evaluated for UGIH. Most of these patients were black males with a mean age of 50 years. A standardized team questioned each patient for OTC or prescription NSAID use during the week prior to admission. It was found that 56% of the patients evaluated for UGIH had taken OTC or prescription NSAIDs the week prior to admission. Gastric lesions were much more common than other causes of UGIH in the patients taking any form of NSAID. The authors point out that the link of UGIH and prescription NSAID use has long been recognized, but in the light of this study they feel it is of great importance to inquire about OTC NSAID use in any patient with suspected UGIH. [Kelly Gray-Eurom, MD] Editor’s Comment: This study re-emphasizes the need for physicians to consider alternatives to NSAIDs for patients at risk for UGIH.

•I MAGNESIUM BOLUS OR INFUSION FAILS TO IMPROVE EXPIRATORY FLOW IN ACUTE ASTHMA EXACFBBATIONS. Tiffany B, Berk W, Todd I, et al. Chest. 1993;104(3):831-4. Standard therapy of acute asthma exacerbations has relied on B-agonist, parental steroids and methylxanthines. Controversial evidence exists to magnesium’s efficacy in acute asthma exacerbations. A prospective, randomized, double-blinded, placebo-controlled study was performed to ascertain whether magnesium provides objective evidence of improvement in expiratory flow when combined with standard therapy in acute asthma. Forty-eight patients who presented to the emergency department with acute asthma and initial peak expiratory flow rate (PEFR) < 200 l/m, and failed to improve by greater than 100% or remained c 2OOL/m after two nebulizer treatments were enrolled. Patients were excluded for first episode of wheezing, history of bronchitis or emphysema, oral temperature > 38.2”C, history of renal failure, CHF, or requiring tracheal intubation. All enrolled patients received 125 mg methylprednisolone IV, a third aerosol treatment, an aminophylline loading dose, and infusion to maintain the level approximately lSmg/L. Subjects were then randomized to three groups: an infusion group that received MgS04, 2 g IV over 20 min followed by continuous infusion of 2/g/h for 4 h; a bolus group that received 2 g MgS04 over 20 min, followed by a placebo infusion; and a placebo group that received a saline bolus and infusion. Pulmonary function measured by spirometry was assessed at 0, 20, 50, 80, 140, 200, and 260 min. Groups were analyzed for differences with respect to age, initial magnesium, theophylline levels, and initial PEFR and FEVl . Spirometric values were analyzed for differences in both absolute values and change from baseline. No significant differences were found between groups at study entry. No significant differences were observed over time in either PEFR, FEVl, or change in these values. It was concluded that IV magne-