Abstracts of scientific papers. (A-F).

Section on Anesthesiology

THE EFFECT OF ANGELICA ON PROTEIN KINASE C DURING MYOCARDIAL ISCHEMIA/REPERFUSION INJURY IN RATS. Yanlin Wang, MD, Yongping Zheng, MD, Chengyao Wang, MD, and Chris C. Li, PhD, MD. Zhongnan Hospital of Wuhan University, Hubei, China, and Washington University School of Medicine, St. Louis, MO.

Angelica, a Chinese herbal medicine, is known to exert cardioprotective effects and has been used in treating ischemic cardiovascular diseases with good prognoses for several decades in China. However, the molecular mechanism remains unclear. Prolonged tissue ischemia and subsequent reperfusion during surgery and anesthesia result in significant ischemia/reperfusion injury. It has been previously reported that protein kinase C (PKC) is related to myocardial ischemia/reperfusion syndrome, and protects myocardium by regulating the myocardial cell's metabolism and physiological function. We tested the hypothesis that Angelica may play a major role in the activation of the PKC-dependent signal pathway. With the approval of the Animal Care Committee, 40 Sprague Dawley rats were randomly divided into three groups: a control group (A), an ischemia/reperfusion group (B), and the Angelica-treated group (C). Injury to the rat heart was induced by ischemia and reperfusion in situ. Regional myocardial perfusion and myoca rdial infarct size were measured with radioactive microspheres and 1% solution of triphenyltetrazolium chloride (TTC) staining, respectively. PKC activity and level were assayed. Data were analyzed by ANOVA followed by Kruscal Wallis test. A level of P < .05 is considered to be significant. Group C demonstrated a significant reduction in myocardial infarction size (44.71 [+ or -] 3.07% vs 67.81 [+ or -] 1.89%), and a significant increase in both myocardial PKC levels (139.83 [+ or -] 5.87 vs 120.14 [+ or -] 2.86) and PKC activity (116.12 [+ or -] 9.45 pmol pi/106 cells vs 51.10 [+ or -] 11.36 pmol pi/106 cells) when compared to Group B. PKC activity remained unchanged in group A. PKC in group C was located in the plasma membrane while in groups A and B, it was located in the cytoplasm. The results indicate that Angelica has a cardioprotective effect in the myocardium of rats by reducing experimental myocardial infarct size. This protection was demonstrated by the increase in PKC activity levels in the rat myo cardium and translocation of PKC from the cytoplasm to the plasma membrane. Our findings suggest that Angelica may play a major role in the activation of the PKC-dependent signal pathway.

Section on Cardiology

BLOOD PRESSURE CONTROL BY ANTIHYPERTENSIVE TREATMENT REGIMEN: A MULTI-SITE ASSESSMENT WITHIN THE SOUTHERN UNITED STATES. Susan K. Maue, PhD, James H. Jackson, PharmD, and Eileen W. Farrelly, MHP. Tampa, FL.

Hypertension, a primary risk factor for stroke, myocardial infarction, and congestive heart failure, is linked to 10% of all deaths each year in the US. Hypertensive patients who are not treated to goal blood pressure (BP) are at even greater risk of death. The presence of risk factors/comorbidities and BP level are critical when determining an effective hypertension management strategy. There were five primary objectives for this research initiative: (1) to identify hypertensive patients within the southern US using a large, nationwide managed care database of pharmacy and medical claims; (2) to determine the prevalence of cardiovascular (CV) risk factors; (3) to assess BP control by treatment group, where control is defined by JNC-VI as BP of <140/90 mm Hg for nondiabetic patients and <130/85 mm Hg for diabetic patients; (4) to implement effective quality improvement interventions for increasing BP control; and (5) to assess the BP control by treatment group following the intervention phase. The treatment g roups are based on the following criteria: no therapy--patients receiving no antihypertensive agents; single therapy--patients receiving one antihypertensive agent; dual therapy--patients receiving two antihypertensive agents (fixed-dose combination and separate agents); and multiple therapy--patients receiving three or more antihypertensive agents. Using pharmacy and medical claims databases, hypertensive patients from health plans covering more than 500,000 lives in the southern US (Alabama, Florida, and Texas) were identified. From this hypertensive population, patients were randomly selected for medical chart review. Measures of interest included demographic characteristics, CV risk factors, antihypertensive therapy, and BP control. Analyses were performed to assess overall demographic characteristics of the hypertensive population, to stratify patients according to treatment group, and to determine the level of BP control by treatment group. Each health plan provided evidencebased educational programs to their providers through several channels, including physician-specific reports, live CME programs, provider newsletters, and teleconferences. The primary messages delivered focused on: (1) assessing CV risk factors when determining patient BP goal; (2) treating patients to goal; and (3) using less complex, fixed-dose combination medications that are effective and may lead to improved patient compliance. A follow-up assessment was conducted to determine the impact of the intervention programs. From over 120,000 hypertensive patients identified, 1,370 patients were randomly selected for chart review for baseline and 1,354 selected for follow-up assessments. The majority of hypertensive patients were female (57.7% at baseline and 53.9% at follow-up) with a mean age >62.5 years in both assessments. The most common risk factors reported at baseline and follow-up, respectively, were male/post-menopausal female (86.4% and 88.8%), age greater than 60 (66.1% and 58.6%), hyperlipidemia (45.5% and 56.6%), and diabetes mellitus (20.0% and 21.0%). At baseline, approximately 34% of hypertensive patients had controlled BP. At follow-up, the percentage of patients with controlled BP increased to 41%. An increase in BP control was noted in all treatment groups. Specifically, the highest increase in BP control by treatment group was realized in patients receiving no therapy and multiple therapy. Due to a lower than expected increase in BP control, a subanalysis was performed on the dual therapy group. Findings revealed that fixed-dose combination therapy yielded a more substantial increase in BP control versus two separate agents taken concurrently. The results of this study suggest that evidence-based interventions for improving BP management may be effective. Providers should be encouraged to treat patients to goal and to continue using more aggressive, less complex therapeutic antihypertensive regimens.

Further investigation is required to determine why patients receiving fixed-dose combination agents displayed improved BP control as compared to patients receiving two separate agents.

EFFECTS OF LEPTIN ON PLATELET GLYCOPROTEIN RECEPTOR EXPRESSION. N. Elgharib, D.S. Chi, and G. Krishnaswamy. Department of Internal Medicine, East Tennessee State University, Johnson City, TN.

Obesity and insulin resistance are major risk factors for arterial thrombosis as observed in ischemic heart disease and stroke. A major determinant of thrombotic disease in such individuals is the formation of a platelet plug, mediated by adhesion of platelets to each other and to substrates such as fibrinogen. Leptin, synthesized in adipose tissue, is elevated in most obese individuals. It has been shown that leptin promotes platelet aggregation in the presence of ADP in a dose-dependent manner. Glycoprotein IIb/IIIa receptors play an important role in platelet aggregation by binding to fibrinogen. We hypothesized that leptin, by virtue of its effects on glycoprotein receptor expression, modulates platelet aggregability and thereby predisposes to ischemic coronary events and stroke. To study the effect of leptin on those receptors, platelet rich plasma was activated with 1, 10, and 100 ng/mL of leptin with and without ADP, and assayed for receptor expression by flow cytometry using tagged monoclonal antibodi es (FACScan). FACScan showed no significant increase of GP IIb/IIIa receptor expression at any of the leptin concentrations. The addition of ADP made no difference. ADP by itself also failed to upregulate these receptors. Furthermore, Leptin did not upregulate P-selectin on the platelet surface. These data suggest that the leptin effect of potentiating platelet aggregation is not via its receptors on the platelets' surface and different mechanisms may be operative. Further studies are required to understand the mechanism behind the increased platelet aggregation induced by leptin.

ELECTROCARDIOGRAPHIC ABNORMALITIES IN PATIENTS WITH CHRONIC RENAL FAILURE. C. Gowda, MD, V. Mukerji, MD, and R. Nonneman, RN, MS, APN/ANP. Department of Medicine, Southern Illinois University School of Medicine, Springfield, IL.

The purpose of this study was to document the electrocardiographic abnormalities seen in patients with chronic renal failure. The records of patients with chronic renal failure admitted to the hospital over a 5-year period were reviewed. Patients with other major medical conditions not directly related to chronic renal failure were excluded from the study. Patients with coronary artery disease or other primary cardiac diagnoses were also excluded. The admission 12-lead electrocardiograms of these patients were reviewed for abnormalities. In the period January 1, 1997, to December 31, 2001, 2,200 patients were admitted to the hospital with chronic renal failure. The electrocardiographic abnormalities noted in these patients could be classified into five major categories: (1) pericarditis and pericardial effusion; (2) electrolyte imbalance; (3) hypertension with myocardial strain; (4) drug toxicity; and (5) nonspecific abnormalities. A spectrum of changes was noted within each category. Patients with chronic re nal failure may manifest a variety of abnormalities on their resting 12-lead electrocardiogram. These changes frequently identify secondary problems related to chronic renal failure.

COMPARISON OF COMPLICATION RATE IN DIRECT CORONARY STENTING AND CORONARY STENTING WITH BALLOON PREDILATATION. Benjamin G. Romick, MD, and Michael A. Ferguson, MD. Keesler Medical Center, Keesler Air Force Base, MS.

The standard technique for coronary stent implantation has involved balloon predilatation of a coronary plaque prior to stent placement. With advances in coronary stent technology, direct stenting of coronary plaques is now becoming more common. Several recent investigations have focused on comparing the two techniques, including success rates, immediate and late outcomes, procedure time and cost, fluoroscopic time, and amount of contrast agent used. The aim of the current study is to compare the in-hospital complications of direct stenting versus stenting with balloon predilatation. Complications examined include coronary dissection, restenosis, unbreakable coronary spasm, and cardiac arrest. All cases of single stent implantation in patients with recent acute myocardial infarction, acute coronary syndrome, or electively requiring percutaneous transluminal coronary angioplasty (PTCA) between March 1, 2000, and September 1, 2001, at Keesler Medical Center were retrospectively reviewed. Data include type of co mplication, type of lesion stented (A, Bi, B2, C), and pre- and post-procedure levels of creatine phosphokinase, creatine phosphokinase subtype MB, and troponin I enzyme. To date, 115 PTCA cases (57 direct stents, 42 standard, 16 excluded) have been reviewed. A 5.2% rate of complications occurred (n=3) in the direct stent group versus a 38.1% complication rate (n=16) in the nondirect stent group. Complications in the direct stent group included 3 dissections. Complications in the group stented with balloon predilatation included 12 dissections, 2 restenoses, 1 unbreakable spasm, and 1 cardiac arrest. Data from the current study suggest a lower rate of complications associated with direct stenting compared with balloon predilatation prior to stent implantation in this institution. We hypothesize that direct stenting may involve less manipulation of coronary plaques and, therefore, less trauma to coronary vessel walls and less likelihood of an ensuing complication as compared with stenting with predilatation of plaques. Further investigation with a larger randomized prospective study is needed to determine shortterm and long-term outcomes of direct stenting.

HEMODYNAMIC EFFECTS OF NONINVASIVE BILEVEL POSITIVE AIRWAY PRESSURE (BIPAP) ON PATIENTS WITH DIASTOLIC DYSFUNCTION AND NORMAL SYSTOLIC FUNCTION. Ali R. Rahimi, MD, FACP, AGSF, Robert J. DiBenedetto, MD, FACP, FCCP, Hossein Akhondi, MD, Maria Francesca Acosta, MD, Matthew P. Chanin, MD, Prakash V. Reddy, MD, An Van Nguyen, RRT, RCP, and Christian M. Richard, MSc. Department of Internal Medicine at Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center, Savannah, GA.

Bilevel noninvasive positive airway pressure (BIPAP) has been shown to play a significant role in the management of patients with congestive heart failure. Previously we reported the effect of bilevel noninvasive positive airway pressure in patients with heart failure and systolic dysfunction. The main objective of this study is to investigate the effect of BIPAP on the performance and volumetric properties of the left ventricle in patients with diastolic dysfunction. This was a prospective cohort nonrandomized study in an outpatient medicine clinic. Twenty patients (14 women [9 white and 5 black]; 6 men [3 white and 3 black]) (ages 52-86 years with an average of 68.05 years) with history of congestive heart failure secondary to diastolic dysfunction and normal systolic function participated in the study. BIPAP via nasal mask at inspiratory pressure of 6 cm [H.sub.2]O and expiratory pressure of 4 cm [H.sub.2]O on spontaneous mode at room air for 1 hour. Volumetric and myocardial performance were assessed usin g clinical, Doppler, and echocardiographic parameters at baseline during and after 1 hour of bilevel positive airway pressure. Using Wilcox matched pair signed-rank test, values of P < .05 were accepted as statistically significant. No changes in cardiac output or left ventricular ejection fraction were noticed during or one hour after discontinuation of BIPAP. Cardiac work load as measured by heart rate, peripheral vascular resistance, double and triple production improved during the BIPAP and maintained one hour after BIPAP (P = .001, P = .008, P = .005, P = .049, and P = .041, respectively). Volumetric studies across mitral valve and in pulmonary vein revealed normalization of E/A velocity ratio (P = .355), and decrease in pulmonary vein flow velocity (P = .07), which points to improvement in left ventricular compliance and stiffness, which are usually elevated in patients with diastolic dysfunction. Bilevel positive airway pressure has promise and potential for improving left ventricular performance and i mprovement in left ventricular hemodynamic properties in patients with diastolic dysfunction presenting with heart failure.

Section on Chest Diseases

TENECTEPLASE TREATMENT OF FULMINANT PULMONARY EMBOLISM IN CARDIAC ARREST RESULTS IN SURVIVAL AFTER REFRACTORY CPR. Bruce D. Adams, MD, and Walter Jackson, MD. Department of Emergency Medicine, Medical College of Georgia, Augusta, GA.

Approximately 500,000 Americans suffer sudden cardiac arrest (CA) annually. Even with benefit of cardiopulmonary resuscitation (CPR), the prognosis remains poor, with 10% to 30% survival rates. The few uncontrolled studies of thrombolytics in CA report up to 50% survival rates. Presumably thrombolysis treats that subset of patients whose CA is caused by fulminant pulmonary embolism (FPE) or myocardial infarctions. Published reports to date exclusively used streptokinase, urokinase, reteplase, or recombinant tissue plasminogen activator (t-PA). We now report the first case of CA survival associated with administration of tenecteplase (TNK), a new third-generation thrombolytic. A 79-year-old white man developed sudden CA two days after total knee replacement surgery. Asystole and ventricular fibrillation proved refractory to standard CPR Because of multiple risk factors, the diagnosis of FPE was considered likely. Twenty-one minutes into CPR, a 50 mg bolus of tenecteplase was administered intravenously. Less th an 60 seconds later, the patient had a spontaneous return of circulation and he was transferred to the intensive care unit. TNK is a recently developed genetic variant of t-PA with increased fibrin specificity, prolonged half-life, and enhanced lytic potency on arterial thrombi. Logistically, TNK is relatively simple to administer during CPR because of bolus administration, a simple dosing regimen, and no immediate need for heparin co-administration. Notably the recent ASSENT trial demonstrated equivalent efficacy and safety of TNK and t-PA. Our case is the first known report of using TNK in the setting of CPR. We feel that a prospective randomized trial is warranted to determine whether TNK conveys benefit in select patients suffering CA.

AN UNUSUAL CASE OF TWO POST-TRAUMATIC THO RACIC ARTERIOVENOUS FISTULAS OCCURRING IN A SINGLE PATIENT. Payam Pooyan, MD, Michael Puruckherr, MD, Pradeep Kumar, MD, Ryland P. Byrd, Jr., MD, Thomas M. Roy, MD. Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

A 70-year-old man was referred for evaluation of a left posterior chest wall bruit that was discovered incidentally on a routine physical examination. He had fallen off a bridge at 7 years of age and injured the left side of his back. He had subsequently undergone a left diaphragmatic surgery at 22 years of age, reportedly to repair the damage to the diaphragm that it had sustained in the fall at age 7. He had no complaints of chest pain, shortness of breath, dyspnea, or hemoptysis. A systolic bruit was noted in the lower left posterior chest wall that was loudest near the thoracotomy scar. The bruit could not be obliterated by pressure over the chest wall. There was no tenderness, palpable thrill, or pulsatile mass. He had no digital clubbing or cyanosis and the remainder of the physical examination was normal. His arterial oxygen saturation was normal and his hematocrit was 42%. A chest roentgenogram demonstrated a vague density in the left lung base in the anteroposterior view. Computerized tomography of t he chest documented enlarged tortuous vessels along the left posterior chest wall. Pulmonary angiography documented a fistulous communication between intercostal artery and pulmonary vein. Magnetic resonance angiogram of the chest also identified a fistula between the 10th intercostal artery and 10th intercostal vein. Post-traumatic arteriovenous fistulas (AVFs) involving thoracic structures are unusual entities. Thoracic AVFs are based on their anatomic circulatory communications and are classified into three groups: systemic to systemic, pulmonary to pulmonary, and systemic to pulmonary connections. Systemic to systemic arteriovenous fistulas (SAVF) of the chest wall are rare and usually occur after blunt or penetrating injury to the chest wall. However, even seemingly insignificant injuries to the chest wall have been described to cause SAVF. For example, intercostal SAVF have been reported following minor invasive procedures such as thoracenteses. Pulmonary to pulmonary arteriovenous fistulas (PAVF) are u sually congenital in origin. However, PAVF are infrequently acquired as a consequence of stab wounds or missile penetration. Systemic to pulmonary arteriovenous fistulas (SPAVF) are encountered less frequently than the two previous categories of thoracic AVF. SPAVF usually result from missile penetration or stab wound, although iatrogenic injury is a potential cause. Our patient presented with two different types of thoracic AVF. He had an abnormal communication between his intercostal artery and pulmonary vein (SPAVF) and a 10th intercostal artery to intercostal vein connection (SAVF). Whether these two AVF occurred as a result of his fall as a child or a consequence of his thoracic surgery is debatable. In follow-up over the last two years, our patient has not developed any complications from the fistulas and has remained symptomfree. It is, nevertheless, important for the clinician to distinguish which type of thoracic AVF is present. As our patient illustrates, unless the patient is symptomatic, no interv ention is typically undertaken for either an SAVF or SPAVF, and the patient can be followed up expectantly. However, since blood is shunted from the peripheral venous system through a PAVF to the systemic circulation, there is a risk of thromboembolism to other organs in patients with this type of AVE In addition, blood passing through a PAVF does not participate in gas exchange and the patient may be hypoxemic. Obliteration or surgical removal of a PAVF should be considered on an individual basis in patients with this form of anomaly.

NEGATIVE PRESSURE PULMONARY EDEMA: AN UNDERDIAGNOSED CAUSE OF NONCARDIAC PULMONARY EDEMA. Anil K. Goli, MD, Sujatha A. Goli, MD, Celso T. Ebeo, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

A previously healthy 31-year-old man underwent elective septoplasty for a deviated nasal septum. Rapid sequence induction anesthesia was performed using Versed and succinylcholine. Anesthesia was maintained with isoflurane and nitrous oxide. The surgery was uneventful. However, immediately following extubation, the patient became agitated and exhibited stridor with vigorous inspiratory efforts. His arterial oxygen saturation fell below 70%. The patient was diagnosed clinically with laryngospasm and was reintubated. Coarse inspiratory crackles were heard bilaterally on auscultation after intubation, and copious amounts of a pink, frothy sputum were obtained with endotracheal suctioning. Blood gas analysis documented a pH of 7.31, a [PCO.sub.2] of 54.9 mm Hg, and a [PO.sub.2] of 60.1 mm Hg on a fraction of inspired oxygen of 100%. His complete blood cell count, coagulation profile, comprehensive panel, and cardiac enzyme values were normal. Electrocardiogram demonstrated an old incomplete right bundle branch bl ock, and no ischemic changes were present on the tracing. Chest radiography (CXR) revealed alveolar opacification of both hemithoraces. Echocardiogram documented no wall motion abnormalities. The patient's oxygen requirement decreased progressively and his CXRs showed resolution of alveolar infiltrates over the next 5 days. He was gradually weaned off positive pressure mechanical ventilation, was successfully extubated, and discharged home without further complication. Negative pressure pulmonary edema (NPPE) has been reported infrequently in the medical literature but may be underdiagnosed. Postanesthetic laryngospasm is the most common cause of NPPE in adults. The postintubation incidence of NPPE is reported as high as 1 in 1,000. The mechanism underlying the formation of NPPE is due to markedly negative intrathoracic pressure from forced inspiration against a closed upper airway, resulting in transudation of fluids from pulmonary capillaries to the interstitium. Since young healthy males can generate the g reatest intrathoracic negative pressures, they are at highest risk for NPPE. NPPE usually resolves clinically and radiologically in 12 to 48 hours with supportive care. Maintenance of oxygenation and a patent upper airway are the mainstays of medical management. This report highlights the clinical features of NPPE and serves as a reminder to the clinician that while NPPE can cause significant morbidity, conservative supportive therapy usually results in a good outcome.

TRACHEAL EROSION BY A PROSTHETIC INNOMINATE ARTERY GRAFT: PRESENTATION AND SURGICAL REPAIR. Lori D. Conklin, MD, Scott A. LeMaire, MD, and Joseph S. Coselli, MD. University of Texas, Houston, TX.

The purpose of this study was to illustrate the presentation, diagnosis, and surgical management of a unique case involving a prosthetic innominate artery graft which eroded into the trachea. A 60-year-old man with a history of non-Hodgkin's lymphoma presented with increasing dyspnea, hoarseness, and pharyngitis. A chest radiograph demonstrated a large upper mediastinal mass with rightward tracheal deviation. Subsequent computed tomography revealed an innominate artery aneurysm causing tracheal compression. At the time of referral for surgical treatment, he developed respiratory distress due to progressive airway obstruction. Emergency operation revealed a mycotic pseudoaneurysm of the innominate artery. Resection and prosthetic graft replacement of the innominate artery was performed, and the patient was discharged following an uneventful recovery. Six months after operation, he returned complaining of increasing cough, dyspnea, and pharyngitis. Fiberoptic bronchoscopy revealed that the prosthetic graft had eroded through the lateral tracheal wall, causing obstruction of the tracheal lumen. In preparation for graft excision, a right femoral to right axillary artery bypass was performed in order to preserve perfusion of the right common carotid artery. He then underwent excision of the innominate artery graft and primary repair of the tracheal defect; the tracheal repair was buttressed with a pedicled left sternocleidomastoid muscle flap. The patient awoke without neurologic deficit and has remained asymptomatic since discharge home 18 months ago. Tracheal erosion by an adjacent vascular prosthetic graft presents as recurrent respiratory symptoms and is diagnosed by fiberoptic bronchoscopy. This uncommon problem can be successfully managed by extra-anatomic bypass, graft excision, and tracheal repair.

COMPRESSION OF THE TRACHEA BY A RIGHT-SIDED AORTIC ARCH MISDIAGNOSED AS ASTHMA SINCE CHILDHOOD. Kristen C. Sladek, MD, Michael Puruckherr, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. Department of Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

A 49-year-old white man who was diagnosed with asthma in childhood was referred for evaluation of his chronic dyspnea on exertion. Other than exercise, there was no seasonal variation or exacerbating factor that triggered his shortness of breath. The patient's asthma therapy included a scheduled dose of inhaled steroids and an albuterol inhaler that he used intermittently, once or twice weekly He admitted that little if any relief of his symptoms was achieved with these medications. Blood pressures obtained in his upper extremities were equal bilaterally. There was no delay in femoral artery pulsation when compared to the radial pulse. Auscultation of the chest revealed clear lung fields with no wheezes, crackles, rhonchi, or rubs. No upper airway noises were heard when the patient inhaled or exhaled forcefully. Pulmonary function tests revealed no evidence of airway obstruction. Methacholine bronchoprovocation testing caused no airflow limitation. His chest radiograph was interpreted as normal except for pos sible widening of the mediastinum. Computerized tomography scan of the chest demonstrated a right aortic arch causing a narrowing the trachea and anterior displacement of the trachea. Magnetic resonance angiography confirmed the right-sided aortic arch, a right-sided descending aorta, and tracheal shift. The patient was informed of his diagnosis and reassured. No further intervention was undertaken. Asthma is a common disease afflicting approximately 4% to 5% of the population of the United States. Asthma is characterized by inflammation and hyperresponsiveness of the airways. This leads to obstruction of the airways and causes the typical signs and symptoms of asthma, including dyspnea, cough, and wheezing. A number of other medical conditions, however, present similarly to and may be misdiagnosed as asthma.

Notably, vascular compression of the airway mimics asthma. It is estimated that up to 3% of humans have a congenital malformation of the aortic arch complex. Double aortic arch, various other vascular ring deformities, and large vessel compression are some of the vascular aberrations that can present with characteristic symptoms of airway obstruction. These vascular variations result from persistence of embryonic structures or from incomplete atrophy or regression of these structures. Many of these anomalies do not elicit symptoms attributable to compression of the respiratory system. However, when symptoms of airway obstruction are present, the vascular anomaly is most often recognized in childhood. A vascular anomaly of the superior mediastinum should be considered in any young child with respiratory distress, stridor, apnea, clysphagia, or a raspy cough. In addition, physicians should have an increased index of suspicion of airway compression by a vascular malformation in any infant with congenital heart d isease who develops signs of airway obstruction. Our patient is unusual in that he was 49 years old before diagnosis of compression of his trachea by a right-sided aortic arch. This case illustrates that although a congenital vascular aberrancy may initially elude diagnosis, a thoughtful and thorough investigation can lead to identification of the anomaly.

REVERSIBLE BLEOMYCIN TOXICITY IN THE TREATMENT OF HODGKIN'S LYMPHOMA: EOSINOPHILIC PNEUMONITIS. M. Y. Perry, J. E. Ramage, and W. E. Check. Departments of Obstetrics and Gynecology Medicine, and Pathology, Memorial Health University Medical Center, Mercer School of Medicine, Savannah, GA.

Bleomycin is a chemotherapeutic agent essential to many cancer regimens. Toxicity may occur at doses greater than 500 mg/[m.sup.2], resulting in irreversible pulmonary fibrosis. Few documented cases describe bleomycin toxicity responding completely to corticosteroid treatment. We present a case of reversible bleomycin toxicity in a 61-year-old woman with stage II Hodgkin's lymphoma. She was initially treated with six cycles of ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). Three weeks after her last cycle, she was admitted for persistent high-grade fever. Chest radiograph revealed bilateral upper lobe opacities. Her peripheral white blood cell count differential was significant for 8% eosinophils. Six days after admission, she continued to have significant fever despite IV antibiotic therapy. Bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) were performed. BAL revealed eosinophilia (30%). TBBx showed multinucleated giant cells suggesting a hypersensitivity reaction without evidence of the usual fibroblast proliferation or fibrosis seen with bleomycin toxicity. All cultures were negative for a causative infectious agent. She was treated with IV methylprednisolone and was afebrile at 24 hours with resolution of the eosinophilia. She was discharged afebrile receiving oral prednisone and six weeks later, chest radiograph demonstrated complete resolution. No relapse was seen at 8-month follow-up. This case outlines a rarely reported eosinophilic pneymonitis associated with bleomycin therapy treated successfully with corticosteroid therapy. When a patient presents with fever, eosinophilia, and a recent history of bleomycin therapy, the physician should consider drug toxicity and corticosteroid therapy.

FACTORS CONTRIBUTING TO THE USE OF CORTICOSTEROIDS FOR ASTHMATIC EXACERBATIONS IN EMERGENCY DEPARTMENTS IN THE US. Chao Sun, MD, MPH, and Sherman Jew, JD, MS. The University of Health Sciences, Kansas City, MO.

Based on the recommendation from the Expert Panel on the Management of Asthma, use of corticosteroids is essential to suppress and reverse airway inflammation for asthmatic exacerbations in addition to symptomatic relief of bronchoconstriction. Effective implementation of the National Asthma Guidelines requires an in-depth understanding of the interaction between use of corticosteroids and health-related factors. The objective of this study is to identify factors related to the use of corticosteroids for asthmatic exacerbations in emergency departments (EDs) in the US. We analyzed the 1999 National Hospital Ambulatory Medical Care Survey conducted by the National Center for Health Statistics. The survey contains information on the utilization and provision of ambulatory care services in hospital emergency departments in 50 US states and the District of Columbia. Asthmatic exacerbation was defined as the primary diagnosis of asthma for a visit to the ED. The use of corticosteroids was measured by any form of c orticosteroids prescribed during the visit. Comparisons were made between the use and nonuse of corticosteroids according to characteristics of patients and health services. Multiple logistic regression modeling was used to assess the independent contribution of these factors to the use of corticosteroids. In 1999, there were about 2 million asthmatic visits to the ED. Of those visits, 76.7% of patients were given beta-2 agonists and corticosteroids were prescribed in only 49.5% of them. Older patients, patients with private health insurance, patients living in metropolitan areas, patients with more urgent conditions, patients requiring more medications, or patients being admitted to the hospital were more likely given corticosteroids. On the other hand, residents and physicians working in governmental or proprietary hospitals were less likely to prescribe corticosteroids. Despite extensive national educational efforts, management of asthmatic exacerbations in the ED remains suboptimal. Factors related to a p atient's symptomatic condition are strong predictors for the use of corticosteroids. Patients living in rural areas or enrolling in Medicaid/Medicare programs are at risk for not having corticosteroid treatment. Further educational efforts should be focused on residents and physicians working in governmental or proprietary hospitals regarding the need to adhere to the National Asthma Guidelines.

THE SOLITARY PULMONARY NODULE: NEW IMAGING MODALITIES. Eric Bensadoun, MD. Division of Pulmonary and Critical Care Medicine, University of Kentucky, Lexington, KY.

The solitary pulmonary nodule (SPN) on a chest x-ray is a common diagnostic problem in chest medicine. A variety of etiologies ranging from benign granulomas to lung cancer can have this appearance on chest x-ray film. If malignant, SPNs usually represent early-stage lung cancer and these patients have the best chance at prolonged survival after resection. Therefore the goal of the evaluation of SPNs is to promptly identify and take to surgery patients with malignant nodules while avoiding invasive procedures and thoracotomies in patients with benign nodules. Recently, three new imaging techniques--contrast-enhanced CT, PET scan, and Depreotide scan--have shown great potential as noninvasive tests in the evaluation of SPNs. The current state of the art regarding these tests, as well as their potential place in the diagnostic algorithm for SPNs will be discussed.

Section on Colon and Rectal Surgery

FACTORS ASSOCIATED WITH COMPLICATIONS AFTER RESECTION FOR DIVERTICULITIS. Timothy Simon, MD, Guy R Orangio, MD, and David N. Armstrong, MD. Atlanta, GA.

This study critically reviews the operative treatment of diverticulitis, comparing open and laparoscopic techniques. Potential factors leading to complications and the relative merits of open and laparoscopic resection are discussed. All open and laparoscopic cases of diverticulitis between 1992 and 2001 were examined retrospectively. Patients were divided into four groups depending on their age being greater or less than 50 years and their operation being laparoscopic or open. Collected data were then analyzed among these groups and included the indication for operation, postoperative complications, and conversion rate. Complications were then further analyzed in relation to their association with the patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, and type of resection performed. The length of stay (LOS) and estimated blood loss (EBL) were also recorded. Operations were performed primarily by five attending surgeons. Statistical analysis based on the hypothesis fo r proportion testing identified relevant differences between groups. A total of 166 resections for diverticulitis were performed over a 10-year period, including 126 open cases and 40 laparoscopic cases. There were no significant differences in patient characteristics between the open and laparoscopic groups. Mean age among those undergoing open resection was 56 years; it was 52 years in the laparoscopic group. A full 35% of patients were <50 years old. Major complications occurred in 16% of patients overall. Laparoscopic resection yielded a 27% complication rate, while 13% of patients who had open resection suffered complications. Anastomotic leak occurred in 2% of patients. Complications were not related to splenic flexure mobilization in either open or laparoscopic cases. The laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate in patients >50 years old undergoing open resection. This observance was not evident in either laparoscopic age group or in patients less than 50 years old who had an open resection. The LOS for patients undergoing laparoscopic resection was significantly less than that for patients having open resection. Advanced laparoscopic sigmoid resection is an excellent alternative to open resection in selected patients. Open sigmoid resection may have a higher complication rate than laparoscopic resection in complicated diverticulitis. Laparoscopic sigmoid resection is associated with shorter LOS compared with open resection. However, when complications occur, there is no difference between the LOS in patients with open vs laparoscopic resection.

Section on Dermatology

OBJECTIVE MEASUREMENT OF SKIN COLOR IN VARIOUS ETHNIC GROUPS. Pavan Kumar Nootheti, MD. Howard University, Washington, DC.

Quantitative measurement of skin color is important for several reasons, including skin research and dermatologic treatment. It is difficult to obtain a precise description of skin color, particularly in darker-skinned races, because present criteria are subjective and give descriptions of a person's skin color according to the individual evaluator. Skin color is determined by levels of various components. The two most important are melanin and hemoglobin. This study quantified skin color in subjects based on objective evaluation using the Mexameter MX 16&#61666 to measure melanin and hemoglobin levels in skin of 466 volunteers of various ethnic groups in Washington, DC. Skin color was evaluated on four different anatomic sites, including the inner (anterior) forearm and the forehead. The inner forearm was measured to represent constitutive skin color. The forehead was measured to represent facultative skin color. Skin color was first determined for each subject using the Fitzpatrick classification system, sk in types I to VI. Within each Fitzpatrick skin type, the average melanin and erythema levels were determined for various ethnic groups by the Mexameter MX. The average melanin level for Fitzpatrick skin type II was 460.44 on the forehead 459.66 and on the anterior forearm; for skin type III, it was 482.56 on the forehead and 479.35 on the anterior forearm; for skin type IV, it was 517.10 on the forehead and 508.28 on the anterior forearm; for skin type V, it was 588.98 on the forehead and 570.20 on the anterior forearm; and for skin type VI, it was 701.20 on the forehead and 654.20 on the anterior forearm. From these data, a range of melanin levels was developed for each skin type. The average hemoglobin levels did not show significant variation among the different skin types, indicating similar cutaneous blood flow. Skin color is not a precise definition. It is difficult to classify shades of color. The traditional Fitzpatrick classification system provides subjective quantification of skin color. In our stu dy, the Mexameter MX 16&#61666 enabled the quick and accurate objective quantification of skin color in different skin types. We provide a more accurate method than the Fitzpatrick classification for skin color typing in darker-skinned ethnic groups. Data of this type are crucial in scientific studies of ethnic skin.

SUPERFICIAL ACRAL FIBROMYXOMA OF THE INDEX FINGER. CPT Jon H. Meyerle, MD, COL Richard A. Keller, MD, and LTC Stephen J. Krivda, MD. Dermatology Service, Department of Medicine, Walter Reed Army Medical Center, Washington, DC.

Superficial acral fibromyxoma is a newly characterized soft tissue tumor with a predilection for the nail region of the fingers and toes. We describe a man with a superficial acral fibromyxoma, the first such case reported in the dermatology literature, and review its clinical and histopathologic characteristics. Under local anesthesia, the well-circumscribed mass was completely excised revealing a conical tumor extending 1 to 2 mm beyond the nail matrix. The 5-mm wedge-shaped mass was fixed to the deeper structures of the index finger adjacent to the cuticle with its dorsal pole having a filiform appearance. Histologically, the overlying epidermis was acanthotic and hyperkeratotic. The tumor consisted of a proliferation of spindle-shaped and occasional stellate fibroblast-like cells in a myxocollagenous stroma. Focally, both myxoid and fascicular growth patterns were present. Mast cells were seen throughout the lesion, but other inflammatory cells were absent. Mitotic figures, multinucleate cells, and cellul ar atypia were not evident. The neoplastic cells showed immunoreactivity to epithelial membrane antigen, vimentin, CD-99, and CD-34, but not to actin, desmin, S100, cytokeratin, or HMB-45. Following excision, the lateral nail bed was reapproximated to the satisfaction of the patient. There has been no recurrence after 3 months of follow-up.

BENIGN CEPHALIC URTICARIA PIGMENTOSA. Eric J. Marsh, MD, and Mitchell E. Stashower, MD. National Naval Medical Center, Bethesda, MD.

We describe a 9-year-old girl with a 7-year history of urticaria pigmentosa without symptomatology other than cosmetic concerns. Urticaria pigmentosa lies on the benign end of a spectrum of proliferative mast cell disease ranging from a solitary mastocytoma to mast cell leukemia. Local and systemic manifestations of this rare, clinically heterogeneous group of disorders occur from mast cell mediator release. Recent mastocytosis research has led to diagnostic advances in the identification of specific immunohistochemical and biochemical markers, which are reviewed in this report.

AQUAGENIC URTICARIA PRECIPITATED BY MORPHINE. David Carey, MD. University of New Mexico Health Sciences Center/Department of Dermatology, Albuquerque, NM.

A 38-year-old man reported that exposure of his skin to water would rapidly result in a pruritic eruption that would then spontaneously resolve after several hours. The problem had started on the same day that he began taking morphine for migraine headaches. He noted that any exposure to water, irrespective of the temperature, would result in a pruritic eruption in the locations where water had contacted his skin. Sweating would result in a similar eruption in the axillae. He reported that morphine or water alone would not precipitate the eruption. He denied the eruption being related to emotional extremes, temperature changes, or handling cold objects. There was no associated lip swelling, dyspnea, or wheezing. Ingestion of antihistamines subsequent to the onset of the eruption did not help. Aside from the headaches, the patient was otherwise healthy. He took no other medications, and denied the use of aspirin or NSAIDs. Physical examination revealed no cutaneous abnormalities. A paper towel moistened with l ukewarm water was applied to the normal-appearing skin. Five minutes later the patient had numerous erythematous, urticarial papules in a distribution that mirrored that of the moist paper towel. There was no dermographism. Application of a plastic bag filled with ice water to the skin did not elicit an eruption. The diagnosis of aquagenic urticaria precipitated by morphine was rendered. Hydroxyzine taken 2 hours prior to water exposure completely ameliorated the problem. The patient's morphine has since been discontinued, and he is no longer afflicted with urticaria.

Section on Emergency Medicine

NEONATAL COMPLAINTS IN A PEDIATRIC EMERGENCY DEPARTMENT. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Visits to a pediatric emergency department by neonates can cause anxiety for parents and the emergency department staff. Many of the presenting complaints are unique to the neonate. Many medical conditions which traditionally have been managed in newborn nurseries are presenting to the emergency department. The present study reviews the epidemiology of neonatal visits to a pediatric emergency department. We did a prospective evaluation of all neonates <30 days old who presented to the pediatric emergency department from August 1998 to August 2001. There were 196 neonates. The median age was 14.1 days (range, 0-30 days). There were 105 males (53.6%), 121 (61.7%) African Americans, 40 Caucasians, 24 Hispanics, and 8 Asians. There were 38 different complaints, the most common being fever (41.3%), rhinorrhea (31.1%), and jaundice (8.1%). The most common diagnoses included viral illness (31.1%), physiologic jaundice (7%), delivery (5.1%), oral candidiasis (4%), urinary tract infection (4%), normal examination (4%) , acute life-threatening event (3.5%), crying (3.5%), and RSV (3%). There were 86 (43.8%) abnormal vital signs, with fever accounting for 77 (39.2%). Fortynine (25%) neonates arrived by emergency medical services. There were 124 (33.8%) admissions, the majority for fever evaluation. Of those with fever, significant infections included 8 urinary tract infections (UTI), 3 cases of bacteremia, 2 cases of chlamydia pneumonia, and 1 case of herpes encephalitis. Two of these neonates were classified as low risk and both had a UTI. Maternal age and race has a significant effect on the odds of presenting to the emergency department. Neonates that present to the emergency department have a 1 in 3 chance of being hospitalized, and therefore require a thorough evaluation of their presenting complaint

LYMPHOCYTIC VASCULITIS ASSOCIATED WITH THE ANTHRAX VACCINE. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Anthrax is caused by the spore-forming bacterium Bacillus anthracis. It has been manufactured for many years as a biological warfare agent and new strains resistant to antibiotics or with a more powerful virulence factor could be involved in the next batch of terrorist attacks. The anthrax vaccine is the only known effective prophylaxis for anthrax. A 53-year-old male Air Force Reserve officer presented with a rash 11 days after receiving his fourth anthrax vaccine. He developed a low-grade fever, chills, and a red rash on his leg and feet. The rash became more erythematous and edema developed. He had no medical illnesses and took acetaminophen for pain. He denied any recent bacterial infection, tattoos, blood transfusions, chemical exposures, or foreign travel. He had a temperature of 38.1[degrees]C, BP 115/71 mm Hg, heart rate 82 beats/min, and respiratory rate set at 16 breaths/min. His entire lower extremities had 3+ edema. There were numerous petechiae that became confluent as purpura. A 4-mm punch biops y showed leukocytic vasculitis. His condition resolved over the next few months. Anthrax causes three forms of disease: gastrointestinal, cutaneous, and inhalational. Inhalational anthrax presents with nonspecific symptoms that cannot be distinguished from more common viral illnesses. Once anthrax is diagnosed, it is almost always fatal despite appropriate antibiotic therapy. The anthrax vaccine contains the three virulence factors: lethal factor, edema factor, and protective factor. It is a non-live vaccine. There are no prospective trials evaluating its efficacy in humans. Because of the recent threats, it is the goal of the military to have all its members immunized. Reactions to the vaccine are usually mild, with systemic reactions occurring in only <0.06%. Lymphocytic vasculitis after the anthrax vaccine has never been reported. It is speculated that it occurred after an altered immune response to the bacterial antigen contained in the vaccine.

AORTIC DISSECTION IN A PATIENT RECEIVING FIBRINOLYTIC THERAPY FOR AN ACUTE STROKE: SHOULD WE OBTAIN A CHEST RADIOGRAPH PRIOR TO THERAPY? Antonio E. Muniz, MD, Marsh Cuttino, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Fibrinolytic therapy within the first 3 hours of onset of symptoms of an acute stroke has been successful in reversing neurologic deficits in carefully selected patients. Intracranial hemorrhage is the major life-threatening complication with the use of fibrinolytic therapy. However, the practice of obtaining a chest radiograph prior to fibrinolytic therapy has not been routinely advocated. Fibrinolytic therapy in the presence of a wide mediastinum is fraught with potentially devastating consequences. We present the case of a patient with an aortic dissection and a stroke who received fibrinolytic therapy. A 75-year-old woman presented with acute decrease in mental status and new right hemiplegia. She experienced 5 minutes of chest pains while having sexual intercourse and later became unresponsive. She denied trauma, fever, or previous episodes of chest pains or neurologic deficits. Her medical history included hypothyroidism. Her medications included levothyroxine. She had a temperature of 36.2[degrees]C; b lood pressure, 121/45 mm Hg; heart rate, 68 beats/mm; and respiratory rate, 22 breaths/mm. She was easily aroused but confused. Her lung and heart examinations were normal. Her neurologic examination was remarkable for nonfluent aphasia, but she was able to follow simple commands. She had a preferential left gaze, right facial droop, and right homonymous hemianopsia. She had 1/5 right upper extremity and 2/5 lower extremity strength. Her CBC count, basic metabolic profile, first set of cardiac enzyme values, PT, aPTT, and 12-lead ECG were normal except for a potassium level of 2.7 mEq/L. Her head CT showed no acute findings or hemorrhage. Her NIHSS score was 19. tPA was administered 2 hours and 30 minutes after onset of symptoms. Two hours later, bradycardia developed, followed by asystole. Resuscitation was not successful. A chest radiograph showed a widened mediastinum, and autopsy showed a ruptured dissecting aneurysm. Aortic dissection is an uncommon cause of chest pains. It is suspected when the chest pa in is acute, maximally intense, radiates to the back, and is knife-like or ripping. It must be considered in all patients with chest pains and especially if fibrinolytic therapy is to be considered. Fibrinolytic therapy cannot be given with impunity, as potentially life-threatening bleeding complicates the use of these medications. To prevent potential morbidity and mortality in patients, a chest radiograph should be obtained prior to fibrinolytic therapy in any acute stroke patient.

THE INFLUENCE OF EARLY ARTERIAL BLOOD GAS ANALYSIS ON PATIENT OUTCOME DURING CARDIOPULMONARY RESUSCITATION. M. Carmina Garcia, MD, Celso T. Ebeo, MD, Cheryl L. Fields, MD, Miguel A. Ossorio, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. The Division of Pulmonary Medicine and Critical Care, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

The significance of arterial blood gas (ABG) analysis during cardiopulmonary resuscitation (CPR) has been questioned for over a decade. The initial principles of CPR determined by the American Heart Association (AHA) included the acquisition of arterial specimens to assess acid-base status and to determine the adequacy of oxygenation and ventilation. Over time, however, the lack of close correlation of ABG parameters with actual tissue oxygenation has led many investigators to no longer advocate this test during resuscitation efforts. Nevertheless the phase-response format in the new AHA guidelines still advocates baseline ABG analysis in the phase II entry-level assessment. This study was undertaken to analyze the correlation of ABG parameters with the survival of patients undergoing CPR. A retrospective review of "Code Blue" critique forms for 206 consecutive patients at Quillen VAMC was performed. From these critiques, the following data were obtained: age, duration of resuscitation, whether ABG analysis w as performed, including results, and whether the patient survived resuscitation. Only those patients with in-hospital, nontraumatic, normothermic cardiopulmonary arrest were included in the study. Excluded from the study were those patients whose cardiopulmonary arrest occurred in critical care units. These patients were excluded because their therapy incorporated many of the therapeutic modalities contained in the ACLS algorithms. One hundred and seven patients were included in the study. Fifty-eight patients had arterial blood gas analysis performed during cardiopulmonary resuscitation. Comparison of survivors who had ABO analysis with nonsurvivors who had ABG analysis revealed no significant difference between the two patient populations with regard to age, duration of resuscitation, arterial blood gas results, or survival. Obtaining ABG during CPR had no significant impact on survival from CPR in our patient population. Resuscitation algorithms advocate the use of supplemental oxygen at an inspired concen tration of 100%. Since the fraction of inspired oxygen cannot be increased above 100%, determination of the partial pressure of arterial oxygenation during CPR adds no benefit to the patient in terms of treatment. In addition, since ventilation is maintained by external modes and since use of bicarbonate is not recommended during CPR, the utility of determining the partial pressure of carbon dioxide in patients in cardiopulmonary arrest is of limited value. The practice of obtaining ABG during CPR offers the physician little insight into the outcome of patients and does not guide therapeutic intervention. ABG analysis therefore should be reserved until the patient's condition is stabilized.

GABITRIL OVERDOSE CAUSES CONVULSIVE STATUS EPILEPTICUS THAT RESPONDS TO PROPOFOL. Bruce D. Adams, MD, and Susan T. Haney, MD. Department of Emergency Medicine, Medical College of Georgia, Augusta, GA.

Anticonvulsants are the fifth most common source of prescription drug overdose. However, there has been scant experience with the new second generation anticonvulsant agents. Tiagabine (TGB) was introduced recently as adjunctive therapy for epilepsy and mood stabilization. Most toxicology experience with TGB is limited to its long-term use. There are 11 cases in the medical literature of acute overdose with TGB. Only one of these manifested with convulsive status epilepticus (CSE). That patient, a known epileptic, responded to phenobarbital therapy. We present here the second case of acute TGB overdose presenting as CSE. A 31-year-old man presented to the Emergency Department after ingesting an unknown amount of TGB. He had no history of seizures. Physical examination revealed stupor, nystagmus, and generalized myoclonic and clonic activity. We tried aborting the seizure activity with lorazepam, midazolam, and phenobarbital, without success. The patient was intubated for airway protection. We then administere d escalating doses of propofol, which terminated the seizures. His TGB level was 910 ng/mL (therapeutic range, 5-70 ng/mL). He was extubated the next day and discharged in satisfactory condition on hospital day 4. There is little clinical experience with acute TGB overdose. We present the second documented case of acute TGB overdose presenting with CSE, the first in a nonepileptic patient. Our case was unique because these paradoxical seizures were refractory to both benzodiazepines and phenobarbital. When faced with a TGB overdose, clinicians should anticipate CSE and the need for airway intervention. If seizures prove refractory to first-line medical therapy, then consider treatment with high-dose propofol.

PERFORMANCE IMPROVEMENT BY A RADIOLOGY/EMERGENCY DEPARTMENT TEAM. W. Mel. Flowers, Jr., MD, Nancy C. Lawhon, MD, Renea Flays, Gina Habig, RHIA, Shawna Wallace, RHIA, Sheila Stephens, RN, James Thompson, MD, Robert D. Cox, MD, and James C. Kolb, MD. University of Mississippi Medical Center, Jackson, MS.

There are a significant number of problems that cannot be resolved by the independent actions of either the Department of Radiology or the Emergency Department. A formal performance improvement team was established to improve communications and to solve these problems. The interdisciplinary team includes physicians from the two departments, a registered nurse, and performance-improvement professionals. Business is conducted through scheduled and unscheduled meetings. The team has been helpful with three different types of activities: (1) development of strategies and procedures for improved patient care; (2) investigation of specific problems that develop during the interaction of the radiologists and emergency department physicians; and (3) documentation of performance improvement for the Joint Commission on Accreditation of Healthcare Organizations. A formal interdisciplinary performance improvement team can improve communications and resolve problems resistant to independent department action.

PREHOSPITAL NEEDLE THORACOSTOMY: PATIENT PRESENTATIONS AND OUTCOMES. Jason P. Stopyra, MD, and Roy A. Alson, MD, PhD. Wake Forest University, Winston-Salem, NC.

Tension pneumothorax (TP) is a rare but severe condition that can rapidly lead to cardiovascular collapse if not recognized and treated promptly. Needle thoracostomy (NT) for decompression of TP has been used in the prehospital setting for over 20 years, but there are few data showing the efficacy of this widely recommended intervention. Our study objective was to identify the characteristics of the patients who underwent NT in the prehospital setting and to determine final patient outcomes. A five-county, regional emergency medical service (EMS) database was queried to identify all patients who had NT performed over the past 2 years. The identified patient's medical record at the trauma center was then obtained and outcomes were recorded. From over 100,000 EMS cases, only 25 patients were identified who underwent field NT. Analysis of characteristics of patients receiving NT showed an average age of 48 years and 76% male patients. Ninety-six percent were trauma patients, and 75% of these cases involved a blu nt mechanism. Only 20% had a documented rush of air following the procedure while 24% had "no change" documented. Mortality in these cases was high, with 60% pronounced dead in the ED. Only 20% survived to hospital discharge. Characteristics of survivors included no loss of consciousness at the scene, an initial GCS>12, and no rush of air documented after NT. This small retrospective chart review suggests that prehospital NT did not change the outcome of patients who underwent the procedure. The lack of response to NT in survivors also suggests that these survivors may not have needed this intervention. Further animal and device-specific testing as well as protocol analysis must be undertaken in the future to determine whether NT truly has the benefits currently attributed to it.

THE EFFICACY OF TRANSARTERIAL EMBOLIZATION FOR BLUNT POLYTRAUMA PATIENTS. Akiyoshi Hagiwara, MD, Hideki Fukushima, MD, Atsuo Murata, MD, Kunitomo Minagawa, MD, Hiroharu Masuda, MD, and Syuji Shimazaki, MD. Department of Traumatology and Critical Care Medicine, Kyorin University, School of Medicine, Tokyo, Japan.

We applied transarterial embolization (TAE) to patients whose hemodynamics had been unstable but were stabilized by fluid resuscitation, and reported that TAE could be safely and effectively performed in patients whose hemodynamics were improved by fluid replacement <2,000 mL/hr. In the present study, we investigated whether TAE could be safely and effectively performed in patients with blunt polytrauma. Patients who were admitted to our hospital during a 2-year period and who received TAE for not less than 2 regions were retrospectively investigated. Angiography and TAE for splenic, hepatic, and renal injuries were performed according to the protocol established in our previous studies. Fifteen patients (9 males and 6 females aged 38.3 [+ or -] 16.6 years) received TAE for not less than 2 injured regions. Mean ISS was 39.0 [+ or -] 8.6. Among 11 patients who received TAE for 2 regions, 9 had pelvic fracture, 7 splenic injury, 4 hepatic injury, and 2 massive facial bleeding. Among 4 patients who received TAE for 3 regions, 4 had splenic injury, 3 hepatic injury, 2 renal injury, 2 pelvic fracture, and 1 massive facial bleeding. TAE was successfully performed in all patients. Two patients with complicated pelvic fracture died due to continuous bleeding from the retroperitoneum. According to the evaluation using the TRISS method, these 2 patients were classified as "non-preventable death" (P < .25). In the other 13 patients, mean arterial blood pressure after TAE (84.9 + or -] 11.7 mm Hg) was significantly higher than that before TAE (57.8 [+ or -] 17.5). The volume of fluid replacement per hour required during the 24 hours after TAE (154.8 [+ or -] 62.5 mL/hr) decreased significantly compared with that required during the period between admission and the completion of TAE (1145.5 [+ or -] 491.1 mL/hr; maximum, 1728.0 mL/hr). Nonsurgical management could be performed in patients with blunt polytrauma by utilizing TAE when their hemodynamics were improved by fluid replacement <2,000 mL/hr. TAE could be used as a mean s of "damage control" in patients with blunt polytrauma.

EMERGENCY DEPARTMENT TREATMENT OF SEA NETTLE ENVENOMATION. LCDR Timothy A. Coakley, LT Robin Marshall, LT Susan Letterle, LCDR Robert Trieff, and LCDR Kim Forman. Naval Medical Center, Portsmouth, VA.

This study serves to explore a randomized, placebo-controlled, double-blind experimental model for evaluating and comparing emergency department treatment of sea nettle (Chrysaora quinquecirrha) envenomation. The stinging apparatus of the sea nettle consists of a nematocyst filled with venoms (polypeptide mixtures of collagenase, hyaluronidase, nucleases, proteases, and phosphatases) located primarily on the fishing tentacles of the animal. Contact with sea nettles results in mild but painful stings that can be a significant nuisance to recreational, professional, and military personnel working or swimming in coastal waters. Various treatments are recommended in textbooks for sea nettle and otherjellyfish stings; however, none of these have been scientifically validated. Forty-one human volunteers were enrolled in the study. Live adolescent sea nettles were supplied by the Virginia Marine Science Museum. Trained investigators screened all volunteers and obtained informed consent. Subjects were exposed to sea nettle fishing tentacles on a 2 x 2-cm cleaned area on each forearm of each volunteer. Tentacles were left in contact with the skin until the subject reported pain. Subjects were block randomized to receive one of three interventions. Group 1 was treated with a paste of baking soda (100% sodium bicarbonate); group 2 was treated with a slurry of meat tenderizer (papain); and group 3 was treated with a vinegar dressing (5% acetic acid). The nonstudy forearm served as the control and was exposed to room temperature seawater. All treatments and controls were prepared on identical gauze dressings and then applied to the study and control areas. Subjects and evaluators were both blinded to which arm was the study and which was control as well as which treatment was applied. The treatments were left in contact with the study area for five minutes. Pain at time 0, 1, and 5 minutes was rated on a 10 cm visual analogue scale (VAS) and recorded by the evaluators. Average VAS scores for all groups at time 0 was 1.9, at t ime 1 minute 1.9, and at time 5 minutes 1.2. Average difference between control and treatment arms for every group was 0.4 mm or less. As the all VAS pain scores were low (as reflected in the averages above), further statistical analysis of the data was not undertaken. No trends were suggested by the data. While it is possible that none of treatments made significant improvements in the recovery from a jellyfish sting, the adolescent sea nettles available for the study did not deliver sufficiently painful stings to allow interpretation of the results. If a subject is essentially pain free before a treatment is applied, it is difficult to quantify whether a treatment is helping. However, this study does validate an experimental model for the study ofjellyfish envenomation. Current plans are to repeat the study with adult wild-caught animals that are anticipated to deliver more significant stings.

Section on Family Practice

SCREENING PRACTICES FOR CHLAMYDIA INFECTION AT A FAMILY HEALTH CENTER Donna Heffeman, MD, Ephraim Back, MD, and Gary Dunkerly, MD. St. Glare's Hospital Family Health Center, Schenectady, NY

The US Preventive Task Force (USPTF) recommends that all sexually active women aged 25 years and younger and all women with risk factors, regardless of age, be screened routinely for chiamydia infections. This is a Class A recommendation. Patient characteristics associated with a high prevalence of infection are single marital status, African American women, history of sexually transmitted disease, new or multiple partners, and cervical ectopy. The objective of this study was to determine compliance with the USPTF recommendations within a family residency health center and to determine screening practices. Computerized laboratory data, including Pap tests and chlamydia tests performed by polymerase chain reaction were collected from January 2000 through December 2001. Data were analyzed using Epilnfo 2000 (CDC) statistical package. The percentage of patients tested for chiamydia and also the incidence of chlamydia infection was determined along with evaluation of demographic factors of the population studied and training level of individual physicians. A total of 1,846 patients had Pap tests performed during the study period. Of all patients, 46% were tested for gonorrhea and chlamydia. Of patients aged 25 years or less, 66% were tested for gonorrhea and chlamydia. The incidence of chlamydia was 8.1% (69 positive tests of 849 tested for chlamydia) in the total population and 12.1% (53 positive tests of 439 tested for chlamydia) in the patients aged 25 years or less. The odds ratio for positive tests in women aged 25 years or less was 3.8 with a confidence interval of 1.9 to 6.0, P < .001. In the health center, only 66% of patients aged 25 years or less were tested for chlamydia as recommended by the USPTF, although the incidence of chlamydia was high at 12.1%. The serious sequelae of undiagnosed chlamydia infection include infertility, pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain. We have initiated an educational intervention to improve screening in this high-risk population. We will pr esent results from the initial data analysis as well as describing our intervention and the results of that intervention. All clinicians who perform Pap tests must recognize the danger to high-risk patients, and offer and encourage testing for gonorrhea and chlamydia to all patients at risk with their annual pelvic examination.

THE USEFULNESS OF HAND-HELD POINT-OF-CARE TECHNOLOGY IN THE EVALUATION AND TREATMENT OF HYPERCHOLESTEROLEMIA IN ADULTS AT A FAMILY PRACTICE RESIDENCY CENTER A PROSPECTiVE CLINICAL STUDY Andrew M. Ropp, MD, Ephraim Back, MD, and Gary Dunkerley, MD. St. Glare's Hospital Family Health Center, Schenectady, NY

We will present a prospective clinical study to assess the utility of a guideline tool using hand-held technology in the management of patients' cholesterol levels at a residency family practice center. Personal digital assistants (PDAs) are increasingly being used by physicians and physicians-intraining to assist in the management of patients. Some residency programs and medical schools are now even providing interns and medical students with PDAs to assist in their education and enhance patient care. The potential for the use of computer technology in clinical medicine is great. Optimal management of dyslipidemia in adults has repeatedly been shown to decrease the rate of morbidity and mortality from coronary artery disease (CAD). Despite this, multiple studies have shown that undertreatment and overtreatment of hyperlipidemia are common. With the release of new guidelines in May 2001, the Third Report on National Cholesterol Education Program (NCEP) Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Adult Treatment Panel III (ATP III), management of hyperlipidemia has become even more individualized based on cardiovascular risk profiles. This trend toward treating patients according to individual risk is also being recommended in the management of other conditions such as hypertension. The use of decision tools has been suggested as a way to assist clinicians in making treatment decisions about their patients. Our prospective clinical study has been designed to assess the usefulness of a computerized decision tool on the management of dyslipidemia in a residency-based family practice center. The Family practice office has a total of 33 providers, which includes 27 family practice residents, 2 physician's assistants, and 4 attending physicians. Based on interest and intent, providers were divided into two groups. One group is using the PDA-based ATP III Cholesterol Management Guidelines Interactive Guideline tool. The other group continues to manage cholesterol levels as they have previously. Chart reviews, questionnaires, and computerized laboratory data are being utilized to determine: (1) providers' cholesteroltesting patterns; (2) patterns of hyperlipidemia treatment; and (3) adherence to ATP III guidelines. Preliminary data analysis reveals an increased adherence to currently recommended guidelines by using the PDA technology. We will present and describe the final results of the study and its implications for the future practice of medicine.

THE WHITE LAND SIGN, A NEW SIMPLE MANEUVER USEFUL IN THE DIAGNOSIS OF THORACIC OUTLET SYNDROME Carlos A. Selmonosky, MD. North Georgia Medical Center, Ellijay, GA.

A simple objective test to assess the positional vascular obstruction at the thoracic outlet is the observation of the change of color of the hands when the patient elevates the hands above the shoulder girdle, with the fingers pointed to the ceiling and the palms of the hands facing the observer. The appearance of paleness, sometimes cadaveric, in one or both hands is called the white hand sign. Thoracic outlet syndrome is a group of symptoms arising not only from the upper extremity, but also from the chest, neck, shoulders, and head. The symptoms are produced by a positional intermittent compression of the brachial plexus and/or subclavian artery/vein, and the vertebral artery; the diagnosis is readily suspected by the physician who is aware of the symptoms. The white hand sign will objectively assess the postural vascular compression at the thoracic outlet. The absence of the color changes on elevation of the hands should not be construed that thoracic outlet syndrome is not present; severe nerve compress ion can exist without vascular compression. The use in the physical examination of a triad consisting of tenderness of the supraclavicular area, paleness and/or paresthesias on elevation of the hands, and weakness of the abductors and adductors of the 5th finger, will make the diagnosis of thoracic outlet syndrome consistent and reproducible. A new physical sign called the white hand sign is described. When used with the diagnostic triad in the routine physical examination it will standardize the diagnosis of thoracic outlet syndrome.

LISTERIA MENINGITIS IN AN ELDERLY, IMMUNOCOMPROMISED HOST. Donna Heffernan. MD, Gary Dunkerley, MD, Jack Parillo, MD, and Omar Mendez, MD. St. Clare's Hospital Family Health Center, Schenectady, NY.

Listeria monocytogenes is an important bacterial pathogen of pregnant women, the elderly, and the immunocompromised. We present the case of a 79-year-old white woman with a medical history significant for idiopathic thrombocytopenia treated with dexamethasone and azathioprine as an outpatient. She presented to the hospital with a two-week history of generalized weakness, a fall on the day of admission, fever to 130[degrees]F, tachypnea, and relative hypoxia (Sa[O.sub.2], 91%). Chest x-ray film was suspicious for right upper lobe pneumonia. A diagnosis of pneumonia with sepsis syndrome was considered likely. Cultures were done and treatment with ceftriaxone and vancomycin started. She continued methylprednisolone and gamma immunoglobulin therapy for low platelet count (7,000/[mm.sub.3]). The patient continued to be febrile and developed altered mental status by hospital day 2. CT scan was done at this time, but no acute process revealed. Presumed group B streptococci in the blood cultures prompted the addition of penicillin and gentamicin to her treatment regimen. The patient developed tachypnea and hypoxia by day 3 and, therefore, was intubated and mechanically ventilated. Chest x-ray films remained relatively clear with no progression of infiltrate. Because of her declining mental status continued fever, lumbar puncture was per-formed on day 3, after transfusion of platelets. CSF showed gram positive rods consistent with Listeria. To cover Listeria, ampicillin was added to gentamicin and penicillin was discontinued. Re-examination of the blood cultures revealed the correct diagnosis of Listeria. On day 5, an EEG was done and findings were consistent with electrical activity, although no physical evidence of overt seizures was noted. Despite optimal treatment with both phenytoin and midazolam, electrical seizure activity continued. Clinically, the patient remained comatose, febrile and showed no signs of improvement. On day 8, CT of the head was repeated and revealed marked hydrocephalus. Because of the patient's continued coma in the setting of new hydrocephalus, she was transferred to a local hospital for decompressive ventriculostomy. Normal CSF pressures were noted and no significant surgical bleeding was noted with platelet transfusion support. Supportive treatment and antibiotics were continued for six days. The patient continued to show no improvement. After discussion with the family, support was withdrawn and the patient died on the same day. Listeria is the most common cause of meningitis in patients receiving corticosteroids and patients with underlying neoplasm. Listeria also accounts for greater than 20% of cases of meningitis in the elderly and neonates. High mortality rates occur for patients with central nervous system infection. Literature review indicates that treatment in immunocompromised patients should continue for at least 3 to 6 weeks, and for central nervous system infection treatment should continue for 6 to 8 weeks. This case illustrates the need for clinicians to maintain a high index of s uspicion for Listeria when immunocompromised patients present with sepsis. Empiric treatment should include coverage for Listeria.

NOT ALL PANCREATITIS CASES ARE CREATED/TREATED EQUALLY Renata Mazzei, MD, Denise Lawrence, MD, Gary Dunkerley, MD, and Paul Brisson, MD. Department of Family Practice, St. Clare's Flospital, Schenectady, NY.

We present the case of a 72-year-old Caucasian woman admitted for pancreatitis due to a rare etiology. She was admitted through the ED with elevated amylase and lipase and epigastric pain, which resolved slowly. Ultrasonography, CT of the abdomen, and MRI were performed and were unremarkable. The patient clinically improved and was discharged to home with plans for her to have an ERCP on an outpatient basis. Before the ERCP could be performed, she was readmitted with clinical and chemical indicators of pancreatitis. The patient was admitted and prescribed IV fluids, pain medications, and an IV H2 blocker. GI service was consulted and was of the opinion that the recurrent abdominal pain and elevated amylase level were suggestive of pancreatitis with negative studies to date. They agreed with evaluating the patient further in the hospital, and also agreed with further evaluation with another CT scan. As soon as she improved clinically, ERCP evaluation to rule out ampullary disease, papillary stenosis, cholelith iasis, or pancreatitis could proceed. However, clinically she continued to have abdominal pain not relieved by medications. CT scan revealed findings suspicious for a volvulus or possible internal hernia. Exploratory laparotomy was performed revealing a paraduodenal hernia with the cecum traversing the foramen of Winslow, resulting in a bowel obstruction compressing the pancreas to simulate pancreatitis. We review the clinical, laboratory and radiographic criteria for pancreatitis. The differential diagnoses of etiologies for pancreatitis are reviewed. A literature review of etiologies causing pancreatitis are presented, including common etiologies such as alcoholism and biliary calculi. A paraduodenal hernia with cecal hemiation through the foramen of Winslow is a rare etiology of pancreatitis. Less common etiologies of pancreatitis, such as internal hernias, should be considered in recurrent pancreatitis without evident cause.