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102


Update on emergin infections: news from the Centers for Disease Control and Prevention : Tularemia -- United States, 1990-2000

Levy PD; Chiang WK
ORIGINAL:0004656
ISSN: 0196-0644
CID: 42099

IV magnesium sulfate in the treatment of acute severe asthma: a multicenter randomized controlled trial

Silverman, Robert A; Osborn, Harold; Runge, Jeffrey; Gallagher, E John; Chiang, William; Feldman, James; Gaeta, Theodore; Freeman, Katherine; Levin, Bruce; Mancherje, Noel; Scharf, Steven
BACKGROUND: Studies of IV magnesium sulfate as a treatment for acute asthma have had mixed results, with some data suggesting a benefit for acute severe asthma, but not for mild-to-moderate asthma. In a multicenter cohort, this study tests the hypothesis that administration of magnesium sulfate improves pulmonary function in patients with acute severe asthma. DESIGN: Placebo-controlled, double-blind, randomized clinical trial. SETTING: Emergency departments (EDs) of eight hospitals. PATIENTS: Patients aged 18 to 60 years presenting with acute asthma and FEV1 < or = 30% predicted on arrival to the ED. INTERVENTION: All patients received nebulized albuterol at regular intervals and IV methylprednisolone. Two grams of IV magnesium sulfate or placebo were administered 30 min after ED arrival. The primary efficacy end point was FEV1 at 240 min, and the data analysis was intent to treat. RESULTS: Two hundred forty-eight patients were included, and the mean FEV1 on ED arrival was 22.9% predicted. At 240 min, patients receiving magnesium had a mean FEV1 of 48.2% predicted, compared to 43.5% predicted in the placebo-treated group (mean difference, 4.7%; 95% confidence interval [CI], 0.29 to 9.3%; p = 0.045). A regression model confirmed the effect of magnesium compared to placebo was greater in patients with a lower initial FEV1 (p < 0.05). If the initial FEV1 was < 25% predicted, the final FEV1 was 45.3% predicted in the magnesium-treated group and 35.6% predicted in the placebo-treated group (mean difference, 9.7%; 95% CI, 4.0 to 15.3%; p = 0.001). If the initial FEV was > or = 25% predicted, magnesium administration was not beneficial; the final FEV1 was 51.1% predicted in the magnesium-treated group and 53.9% predicted in the placebo-treated group (mean difference, - 2.9%, 95% CI, - 9.4 to 3.7; p = not significant). Overall, the use of magnesium sulfate did not improve hospital admission rates. CONCLUSION: Administration of 2 g of IV magnesium sulfate improves pulmonary function when used as an adjunct to standard therapy in patients with very severe, acute asthma
PMID: 12171821
ISSN: 0012-3692
CID: 42091

Utility of acetaminophen screening in unsuspected suicidal ingestions

Lucanie, Ralph; Chiang, William K; Reilly, Rosemary
Acetaminophen (APAP) is a common overdosed medication. Because of the lack of specific symptoms associated with initial toxicity, potential unsuspected APAP toxicity is a concern in suicidal ingestions. To identify the likelihood of unsuspected APAP toxicity in suicidal ingestions, we performed a retrospective study of all suicidal ingestions without a history of APAP exposure reported to a poison control center over a 6-mo period. History, symptoms, and APAP levels to assessed the incidence of unsuspected APAP ingestions. In a total of 471 cases, 151 had APAP levels requested but not documented in our records. Of the remaining 320 cases, 23 (7.2%) had APAP levels > 10 microg/mL. Twelve patients were treated with Nacetylcysteine, 7 patients (2.2 %) had potentially toxic levels, and 5 patients had non-toxic or uninterpretable levels. Although the overall risk of unsuspected acetaminophen toxicity in suicidal ingestions is small, the definite risk in this treatable entity warrants universal APAP screening in all suicidal ingestions
PMID: 12046974
ISSN: 0145-6296
CID: 42080

Behavioral risk factor and preventive health care practice survey of immigrants in the emergency department

Jacobs, David H; Tovar, Juan M; Hung, Oliver L; Kim, Mimi; Ye, Philip; Chiang, William K; Goldfrank, Lewis R
OBJECTIVE: To compare the demographic profiles, behavioral risk factors, and preventive health care practices of adult immigrant and non-immigrant patients while considering the effects of various socioeconomic variables. METHODS: This was a prospective survey administered at a large urban emergency department in New York City. Study subjects were adult immigrant patients presenting in an eight-week period in 1998. One non-immigrant control patient was recruited concurrently with every two immigrant patients. Differences between immigrants and non-immigrants were evaluated using the chi-square test. Multivariate logistic regression models were used to adjust for confounding variables. RESULTS: Eight hundred sixty-nine immigrant patients from 80 countries and 354 non-immigrant patients completed surveys. Immigrants were more likely not to have reached high school (28.9% vs 8.5%; p < 0.001), to have annual family incomes less than $20,000 (73.8% vs 64.5%; p < 0.01), and to have no health coverage (51.7% vs 30.8%; p < 0.001). Immigrant women were more likely never to have had a Papanicolaou test (16.1% vs 1.4%; OR 11.24, 95% CI = 2.70 to 46.8) and never to have performed a self-breast examination (20.8% vs 7.5%; OR 2.03, 95% CI = 1.29 to 3.20). Immigrants were more likely not to use condoms (63.4% vs 42.8%; OR 1.61, 95% CI = 1.20 to 2.15) and never to have visited a dentist (21.2% vs 7.8; OR 2.54, 95% CI = 1.60 to 4.04). Immigrants were more likely never to have received a purified protein derivative (PPD) skin test (30.3% vs 9.1%; OR 3.85, 95% CI = 2.56 to 5.80) and never to have received a tetanus immunization (48.1% vs 13.5%; OR 3.09, 95% CI = 2.17 to 4.42). These differences were independent of age, gender, marital status, employment, education, income, and health insurance status. When analyzing the immigrant group alone, region of origin, length of time in the United States, and English ability were significant independent predictors of higher-risk behavioral profiles and poor preventive health care practices. CONCLUSIONS: Differences exist between the socioeconomic profiles, behavioral risk profiles, and preventive health care practices of immigrant and non-immigrant patients presenting to a large inner-city municipal emergency department. Different populations within a heterogeneous group of immigrants have distinct health risks and public health needs
PMID: 12045073
ISSN: 1069-6563
CID: 42081

Neurocysticercosis in radiographically imaged seizure patients in U.S. emergency departments

Ong, Samuel; Talan, David A; Moran, Gregory J; Mower, William; Newdow, Michael; Tsang, Victor C W; Pinner, Robert W
Neurocysticercosis appears to be on the rise in the United States, based on immigration patterns and published cases series, including reports of domestic acquisition. We used a collaborative network of U.S. emergency departments to characterize the epidemiology of neurocysticercosis in seizure patients. Data were collected prospectively at 11 university-affiliated, geographically diverse, urban U.S. emergency departments from July 1996 to September 1998. Patients with a seizure who underwent neuroimaging were included. Of the 1,801 patients enrolled in the study, 38 (2.1%) had seizures attributable to neurocysticercosis. The disease was detected in 9 of the 11 sites and was associated with Hispanic ethnicity, immigrant status, and exposure to areas where neurocysticercosis is endemic. This disease appears to be widely distributed and highly prevalent in certain populations (e.g., Hispanic patients) and areas (e.g., Southwest)
PMCID:2738481
PMID: 12023918
ISSN: 1080-6040
CID: 42098

Malaria deaths following inappropriate malaria chemoprophylaxis--United States, 2001 [Case Report]

Hexdall, Aaron H; Chiang, William K
PMID: 11782737
ISSN: 0196-0644
CID: 42082

Selective tomographic imaging of patients with new-onset seizure disorders

Mower, William R; Biros, Michelle H; Talan, David A; Moran, Greg J; Ong, Sam; [Chiang, William K; et al]
OBJECTIVE:Significant benefit could be realized by developing a clinical decision rule for new-onset seizure victims that would be capable of discriminating between patients having relevant structural lesions visible on computed tomographic (CT) imaging and those who do not. This study sought to determine whether a reliable decision rule could be developed using a limited number of clinical and demographic characteristics. METHODS:Chi-squared recursive partitioning was applied in a secondary analysis of the EMERGEncy ID NET database of new-onset seizure victims. Variables in this database (age, sex, race, ethnicity, seizure type, history of HIV or cysticercosis, and presence or absence of lateralizing neurologic findings or altered mentation) provided the partitioning variables, while CT imaging results provided outcome measures. The study sought to develop a decision rule with 100% sensitivity for detecting any intracranial lesions, and a separate rule with 100% sensitivity for detecting lesions of emergent concern. RESULTS:A decision rule using age > or = 65 years, lateralizing neurologic findings, altered mentation, high risk or known HIV infection, history of cysticercosis, and Hispanic ethnicity showed a sensitivity of 91.9% [95% confidence interval (95% CI) = 88.8% to 94.9%] in detecting individuals who had any tomographic finding. This rule had a sensitivity of 90.1% (95% CI = 83.4% to 96.7%) in detecting individuals with emergent tomographic findings. CONCLUSIONS:Recursive partitioning failed to produce a decision rule capable of reliably identifying new-onset seizure patients who have important lesions identified on CT. Future attempts to formulate such an instrument may need to include additional variables. In the interim, physicians should use liberal tomographic imaging in evaluating patients who present with new-onset seizures.
PMID: 11772668
ISSN: 1069-6563
CID: 2944512

Otolaryngologic principles

Chapter by: Chiang, William K
in: Goldfrank's toxicologic emergencies by Goldfrank LR [Eds]
New York : McGraw-Hill, 2002
pp. 420-431
ISBN: 0071360018
CID: 3146282

Amphetamines

Chapter by: Chiang, William K
in: Goldfrank's toxicologic emergencies by Goldfrank LR [Eds]
New York : McGraw-Hill, 2002
pp. 1020-1033
ISBN: 0071360018
CID: 3146292

The epidemiology of the homeless population and its impact on an urban emergency department

D'Amore J; Hung O; Chiang W; Goldfrank L
OBJECTIVES: To characterize the homeless adult population of an urban emergency department (ED) and study the medical, psychiatric, and social factors that contribute to homelessness. METHODS: A prospective, case-control survey of all homeless adult patients presenting to an urban, tertiary care ED and a random set of non-homeless controls over an eight-week period during summer 1999. Research assistants administered a 50-item questionnaire and were trained in assessing dentition and triceps skin-fold thickness. Inclusion criteria: all homeless adults who consented to participate. Homelessness was defined as being present for any person not residing at a private address, group home, or drug treatment program. Randomly selected controls were concurrently enrolled with a 3:1 homeless:control rate. Exclusion criteria: critically ill, injured, or incapacitated patients, or patients <21 years of age. Univariate analysis with appropriate statistical tests was used. The Mantel-Haenszel test was used to adjust for population differences. RESULTS: Two hundred fifty-two homeless subjects and 88 controls were enrolled. Data are presented for homeless vs control patients, and all p-values were <0.01. Odds ratios (ORs) with 95% confidence intervals (95% CIs) are given where appropriate: mean age (+/-SD) = 42 +/- 10 vs 48 +/- 13; male gender 95% vs 54% (OR = 17; 95% CI = 8 to 37); history of (hx) tuberculosis 49% vs 15% (OR = 2.5; 95% CI = 1.2 to 3); hx HIV infection 35% vs 13% (OR = 3.8; 95% CI = 1.8 to 8); hx penetrating trauma 62% vs 16% (OR = 8.62; 95% CI = 4.4 to 17.1); hx depression 70% vs 15% (OR = 13.4; 95% CI = 6.7 to 27); hx schizophrenia 27% vs 7% (OR = 5.1; 95% CI = 2.0 to 14); hx alcoholism 81% vs 15% (OR = 24; 95% CI = 12 to 49); significant tooth loss (>3) 43% vs 18% (OR = 3.3; 95% CI = 1.8 to 6.4); percentage of body fat 16.5% vs 19.7%; hx social isolation (no weekly social contacts) 81% vs 11% (OR = 33.3; 95% CI = 14 to 100); mean number of ED visits/year 6.0 vs 1.6. CONCLUSIONS: In the study population homelessness was associated with a history of significantly higher rates of infectious disease, ethanol and substance use, psychiatric illness, social isolation, and rates of ED utilization
PMID: 11691667
ISSN: 1069-6563
CID: 26583