A B S T R A C T S

of myocardial infarction to receive either 50 mg tPA combined with 1.5 MUSK or 100 mg tPA alone. Patency was determined by angiography at 90 minutes and seven days after initiation of thrombolytic therapy. Of patients receiving thrombolytic ther- apy within three hours of symptom onset, tPA/SK resulted in a 90- minute patency rate of 89% com- pared with 58% in the tPA arm (P= .00005). In patients who were treat- ed between three and six hours from symptom onset, patency rates were found to be similar (67% after com- bination therapy and 73% after tPA alone) at 90 minutes. Reocclusion rates at seven days, in combination and full-dose tPA arms, were 3% and 10%, respectively (P= .06). Need for emergency bypass surgery, 1% ver- sus 6% (P= .05); and reinfarction rate, 0% versus 4% (P= .06) were less in the tPA/SK group. Infarct zone function measured by radionu- clide ventriculogram at seven days was superior in the tPA/SK group (P= .03). Marked depletion of fib- rinogen levels lasting 24 hours occurred in the combination group compared with tPA alone. Serious bleeding complications and in-hospi- tal mortality were similar in the two groups.

Mike Halperin, MD

Chlamydia trachomatis, clindamycin

Comparative efficacy of elindamyein versus erythromyein in eradieation of antenatal Chlamydia trachomatis Alger LS, Lovchik JC Am J Obstet Gynecol 165.375-381 Aug 1991

A prospective, randomized, double- blind, placebo-control led study was done in order to determine the efficacy of clindamycin versus erythromycin in eradicating chlamy-

dia from the lower genital tracts of pregnant women. The study was done because of poor compliance with erythromycin as a result of the frequent gastrointestinal side effects. Erythromycin is currently the only recommended drug for treat- ment of chlamydia during pregnancy. Data were obtained from 126 patients with a documented cervical chlamydia infection between 16 and 24 weeks' gestation. Patients received either erythromycin 333 mg orally four times daily, clindamycin 450 mg orally four times daily, or placebo. Patients were treated for 14 days. Members of the "control" group, who received no antibiotic, were participating in a different study to determine if chlamydia infections alter pregnancy outcome. There were no significant differ- ences in demographic factors or number of sexual partners between study groups. Follow-up cultures were obtained at 14 days after the first dose of medication and at four weeks. In all, 56 doses were to be taken during the study. In patients who took less than 28 doses, compli- ance was judged as poor. If they took more than 28, but less than 52, compliance was judged as moder- ate. Compliance was good if they took at least 52 doses. Compliance was moderate in 92% of the women. Twenty-three percent of the patients taking erythromycin developed vom- iting, diarrhea, or abdominal pain (compared with 10% of the patients taking clindamycin and 0.8% taking placebo). The cure rates for patients taking at least 28 doses were similar (94% for clindamycin vs 93% for erythromycin). The cure rates for all patients were 93% for clindamycin and 84% for erythromycin. Partner compliance significantly increased cure rates. The authors concluded that clindamycin is an effective, safe, and well-tolerated alternative to erythromycin for treatment of chlamydia in pregnant patients.

Eric Gilbert, MD

subungual hematoma

Treatment of subungual hematomas with nail trephination: A prospective study Seaberg DC, Angeles WG, Paris PM Am J Emerg Med 9.209-210 May 1991

Subungual hematoma is a commonly encountered problem in the emer- gency department. Some researchers advocate that any injury to the nail bed matrix must be repaired or per- manent deformity to the regenerat- ing nail will result. A prospective, observational study to determine if treatment of simple subungual hematomas (SUHs) by nail trephina- tion alone is without cosmetic or infectious complications was designed. Fifty-one patients with SUH were seen in the two-year study period. Three patients were excluded because of disruption of the nail or nail border, or because of pre-existing nail deformities, leaving. 48 study patients. Radiographs of all digits were taken to detect distal phalanx fractures (present in 14 of 48 patients), and SUH size was mea- sured. Nail trephination was per- formed using electrocautery, and all were splinted in extension for one week. Follow-up was achieved in 45 patients. No complications of infection, osteomyelitis, or major nail deformities occurred in any patients treated by nail trephination, regardless of SUH size or presence of fracture. This study supports the hypothesis that in simple SUH nail removal with suture repair of the nail bed is unnecessary. The study also suggests that radiographs may be unnecessary. [Editor's note: This study supports conservative treat- ment of subungual hematomas with a surrounding intact adherent nail. Unfortunately, the authors make no mention of the use of antibiotics. No patients, including those who had underlying fractures, developed infection. This seems to lend support to the fact that prophylactic anti-

biotics are rarely, if ever, indicated in the initial care and treatment of wounds and should never be used as a substitute for adequate wound cleansing, irrigation, and debride- ment.]

Mark Copeland, MD

peritoneal lavage enzyme

Peritoneal lavage enzyme determinations following blunt and penetrating trauma McAnena O J, Marx JA, Moore EE J Trauma 31:1161-1164 Aug 1991

Diagnostic peritoneal lavage (DPL) provides a rapid and sensitive means of evaluating the peritoneal cavity following blunt and penetrating trauma. However, its major limita- tion is early identification of isolated hollow viscous injury. Unfortunately, computed tomography has also been unreliable. Previous work had sug- gested that lavage amylase (LAM) and lavage alkaline phosphatase (LAP) might be useful in early detec- tion of isolated hollow viscous injury. This study retrospectively assessed the contribution of lavage enzyme analysis to the overall accu- racy of DPL Over a four-year period, 1,969 consecutive severely injured patients underwent DPL. 0nty those patients with grossly negative aspi- rates and lavage RBC counts below threshold for emergency laparotomy were included in the study. Of 28 patients with negative lavage by lavage RBC but LAM _> 20 lU/L, 13 (46%) had clinically significant injury requiring laparotomy, with 77% of these patients having small-bowel injury. In this group, LAM _> 20 IU/L had a sensitivity of 87%, specificity of 75%, and a positive predictive value of 46% for significant intra- abdominal injury. Among these 13, only three (23%) had lavage WBC count of more than 50O/mm, and in each case the DPL was performed four or more hours after •

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ABSTRACTS

injury. Of 13 patients with negative lavage by lavage RBC but LAP _> 3 IU/L, seven (54%) sustained signifi- cant intra-abdominal injury, and in six of these patients LAM was > 20 IU/L. LAP _> 3 IU/L had a sensitivity of 54%, a specificity of 98%, and a positive predictive value of 54% for significant intra-abdominal injury. LAM _> 20 IU/L and LAP _> 3 IU/L combined had sensitivity of 54%, specificity of 98%, and a positive predictive value of 88% for signifi- cant intra-abdominal injury. Ten patients in the study had an elevated LAM, LAP, or both as the only objec- tive laboratory evidence of signifi- cant intra-abdominal injury. The authors advocate routinely assaying LAM and LAP and suggest that lapa- rotomy is mandatory when these enzymes are elevated and the history is consistent with possible small-bowel injury.

Mark Copeland, M

herniation, transtentorial

Functional recovery after transtentorial herniation Andrews BT, Pitts LH Neurosurgery 29.227-231 Aug 1991

To evaluate the clinical characteris- tics, surgical findings, and treatment results among patients with trau- matic transtentorial herniation and to elucidate factors associated with functional outcome, a retrospective

review of 153 patients treated between 1981 and 1988 with clinical signs of upper brainstem dysfunction after a head injury was performed. Outcome was followed up to 37 months. One hundred four patients (68%) died, one patient was vegeta- tive, 15 patients (10%) were severe- ly disabled, 14 (9%) were moderate- ly disabled, and 14 (9%)had good recovery. Patients with good out- come were younger, had a mean age of 21 (half were of pediatric age), and had a higher initial Glasgow Coma Score (mean, 8). All 14 patients with good outcome had admission anisocoria with some preservation of pupillary responsive- ness compared with 54% of those who had a nonfunctional outcome. Surgical exploration revealed unilat- eral subdural or epidural in eight patients (57%) with good recovery, a frequency no different from that of other groups. Patients with moder- ate disability were also younger (mean age, 29) with higher initial Glasgow Coma Score (mean, 6). All patients with functional outcome recovered pupillary responsiveness soon after either hyperventilation and mannitol or the surgical evacua- tion of a hematoma. The authors concluded that a significant number of patients may recover from trau- matic transtentorial herniation and that aggressive early diagnosis and removal of intracranial hematomas and intensive supportive care for patients without mass lesions maxi- mizes the potential for functional recovery.

Juliana Karp, MD

overcrowding

Patients who leave a public hospital emergency department without being seen by a physician Baker DW, Stevens CD, Brook RH JAMA 266:1085-1090 Aug 1991

A follow-up study to address the causes and clinical consequences of patients leaving emergency depart- ments prior to being seen by a physi- cian was conducted. The study was set in an urban public hospital ED where approximately 90% of patients do not have private insur- ance, Medicaid, or Medicare. The study population consisted of 186 adult ambulatory patients who left without being seen; the comparison group (211) consisted of a random sample of 20% of those patients who waited until they saw a physi- cian. Two indicators of the urgency of a patient's problem were used, the triage nurse's assessment and a physician acuity rating. Seven days after the initial ED visit, a follow-up telephone interview was conducted to determine why patients left with- out being seen and whether they sought additional health care. Patients who left reported that they waited 6.4 hours before leaving; those who stayed reported a 6.2- hour wait before being seen. There were no significant differences between those who left and those

who stayed with regard to chief complaint, triage nurse assessment, or physician acuity ratings. Of the patients who left without being seen, 46% were judged to need attention within 24 to 48 hours. Patients who left cited frustration because of the long wait (57%), feeling toe ill to wait longer (53%), transportation difficulties (32%), work schedule conflicts (28%), and child care responsibilities (21%) as reasons for leaving. Eleven percent of those who left were hospitalized within the next week; 9% of patients who waited until they were seen by a physician were hospitalized. Forty- nine percent of patients who left did not see a physician during the one- week follow-up period; the main reason (61%) given for net seeking care was cost. The authors conclud- ed that overcrowding in this public hospital's ED restricts access to needed medical care for the poor and uninsured, and that if similar situations exist in other public hospi- tals, overcrowding in the ED may be an important barrier to health care access in the United States. •

David Magid, MD

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