Trends in Encounters for Emergency Contraception in US Emergency Departments, 2006-2020

This cross-sectional study of female emergency contraception users examines emergency contraception–related emergency department use disparities and associations with policy changes.

Exploring Muslim Women's Reproductive Health Needs and Preferences in the Emergency Department

Objective: We explored individual Muslim women's reproductive healthcare experiences, preferences, beliefs, and behaviors in the emergency department (ED) and in general. Methods: This was a qualitative study conducted at a community ED using semi-structured interviews with a piloted interview guide. We interviewed participants awaiting care in the ED with the following criteria: female gender; English or Arabic speaking; aged ≥18 years; and self-identified as Muslim. We conducted interviews in both English and Arabic until thematic saturation was reached. Transcripts were coded using an iteratively developed codebook, maintaining intercoder agreement greater than 80%. We used an inductive thematic analysis to identify themes, and results were interpreted in the context of interview language and patient's age. Results: We interviewed 26 Muslim-identified female ED patients. We found that cultural representation and sensitivity among ED staff mitigated discrimination and promoted inclusion for Muslim ED patients. However, assumptions about Muslim identity also impacted the participants' healthcare. Most participants endorsed a preference for a female clinician for their reproductive healthcare in general, but not necessarily for other areas of medicine. Clinician cultural concordance was not always preferred for participants in the ED due to fears about the loss of confidentiality. Marital status impacted beliefs about reproductive and sexual health in the context of Muslim identity. Overall, family planning was acceptable and encouraged in this patient population. Conclusion: The themes elucidated in this study may guide clinicians in developing culturally sensitive practices when providing reproductive healthcare to the Muslim population.

Provider perspectives on patient-centered contraceptive counseling for Latinas in Baltimore, MD

OBJECTIVES

To explore: 1) provider narratives of their contraceptive counseling practices with Latina patients within the context of patient-centered care (PCC); and 2) provider perceptions about the barriers to the provision of patient-centered contraceptive counseling in general and more specifically, with Latina patients in Baltimore, MD.

STUDY DESIGN

We conducted 25 semistructured qualitative interviews with physicians  and nurse practitioners from four specialties who provide contraceptive care to Latinas in Baltimore, MD. We analyzed data using directed content analysis. We discuss findings with attention to major constructs of PCC, applying a reproductive justice framework.

RESULTS

Providers described a contraceptive counseling approach focused on pregnancy prevention as the primary goal. Most respondents used a tiered-effectiveness approach, even while noting the importance of PCC. Providers noted health system barriers to PCC, including time constraints and insurance status. Provider-reported patient-attributed barriers included low patient education/health literacy, culturally-attributed misconceptions about contraception, and language discordance.

CONCLUSION

Providers described knowledge of and intention to practice PCC but had limited integration of it in their own counseling with Latinas. Responses suggest tension between an expressed desire to provide PCC and paternalistic counseling paradigms that prioritize pregnancy prevention over patient preferences. Inequitable health system barriers also interfere with true implementation of contraceptive PCC.

IMPLICATIONS

Translating contraceptive PCC into practice, especially for marginalized communities, is paramount. Training should teach clinicians to recognize systems of structural inequity and discrimination that have informed approaches to counseling but are not reflective of PCC. Institutional policies must address health system barriers that also hamper PCC.

Trends in US Emergency Department Use After Sexual Assault, 2006-2019

IMPORTANCE

Adult sexual assault (SA) survivors experience numerous emergent health problems, yet few seek emergency medical care. Quantifying the number and types of survivors presenting to US emergency departments (EDs) after SA can inform health care delivery strategies to reduce survivor morbidity and mortality.

OBJECTIVE

To quantify ED use and factors that influenced seeking ED care for adult SA from 2006 through 2019.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used SA data from the Nationwide Emergency Department Sample from 2006 through 2019, which includes more than 35.8 million observations of US ED visits from 989 hospitals, a 20% stratified sample of hospital-based EDs. The study also used the Federal Bureau of Investigation's Uniform Crime Reporting Program, which includes annual crime data from more than 18 000 law enforcement agencies representing more than 300 million US inhabitants. The study sample included any adult aged 18 to 65 years with an ED visit in the Nationwide Emergency Department Sample coded as SA. The data were analyzed between January 2020 and June 2022.

MAIN OUTCOMES AND MEASURES

Annual SA-related ED visits, subsequent hospital admissions, and associated patient-related factors (age, sex, race and ethnicity, income quartile, and insurance) were analyzed using descriptive statistics.

RESULTS

Data were from 120 to 143 million weighted ED visits reported annually from 2006 through 2019. Sexual assault-related ED visits increased more than 1533.0% from 3607 in 2006 to 55 296 in 2019. Concurrently, admission rates for these visits declined from 12.6% to 4.3%. Female, younger, and lower-income individuals were more likely to present to the ED after SA. Older and Medicaid-insured patients were more likely to be admitted. Overall, the rate of ED visits for SA outpaced law enforcement reporting.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that US adult SA ED visits increased from 2006 through 2019 and highlighted the populations who access emergency care most frequently and who more likely need inpatient care. These data can inform policies and the programming needed to support this vulnerable population.

Patient perspectives of the climate of diversity, equity, and inclusion in the emergency department

Objective

Assessing the diversity, equity, and inclusion (DEI) climate of emergency departments (EDs) can inform organizational change to provide equitable, inclusive, and high‐quality care to their diverse patient populations. The purpose of this project was to investigate patient perspectives on the climate of DEI in an urban ED.

Methods

This was a cross‐sectional survey study conducted in a large‐volume, urban ED in Detroit, MI, from November 2018 to January 2019. The survey was developed by an experienced ED DEI committee via an iterative process and broad consensus.

Results

During their care in the ED, 849 patients completed an anonymous survey about their perspectives and experiences of DEI in that ED. Overall, the responses were favorable as most respondents reported that the ED staff treated patients from all races equally (75.8%) and made patients feel accepted (86%). However, some respondents felt that the ED staff's treatment of populations with greater complexity, such as patients who are mentally ill (16.8%) or lower income (14.3%), needs the most improvement.

Conclusions

This DEI climate assessment survey of ED patients’ perspectives revealed important insights that could guide strategic initiatives to advance DEI in the ED. This assessment may serve as a model for continuous evaluation of DEI over time and in multiple healthcare settings to help guide organizational change efforts.

Emergency Department Utilization for Substance Use Disorder During Pregnancy and Postpartum in the United States (2006-2016)

OBJECTIVES

We aimed to better understand emergency department (ED) use, admission patterns, and demographics for substance use disorder in pregnancy and postpartum (SUDPP).

METHODS

In this longitudinal study, the United States Nationwide Emergency Department Sample was queried for all ED visits by 15- to 50-year-old women with a primary diagnosis defined by International Classification of Diseases, 9th or 10th edition Clinical Modification, codes of SUDPP between 2006 and 2016. Patterns of ED visit counts, rates, admissions, and ED charges were analyzed.

RESULTS

Annual national estimated ED visits for SUDPP increased from 2,919 to 9,497 between 2006 and 2016 (a 12.4% annual average percentage change), whereas admission rates decreased (from 41.9% to 32.0%). ED visits were more frequent among women who were 20-29 years old, using Medicaid insurance, in the lowest income quartile, living in the South, and in metropolitan areas. Compared with the proportion of ED visits, 15- to 19-year-olds had significantly lower admission rates, whereas women with Medicaid and in the lowest income quartile had higher admission rates (p < .001). Opioid use, tobacco use, and mental health disorders were most commonly associated with SUDPP. The ED average inflation-adjusted charges for SUDPP increased from $1,486 to $3,085 between 2006 and 2016 (7.1% annual average percentage change; p < .001), yielding total annual charges of $4.02 million and $28.53 million.

CONCLUSIONS

Despite the decrease in admissions, the number and charges for ED visits for SUDPP increased substantially between 2006 and 2016. These increasing numbers suggest a continuous need to implement preventive public health measures and provide adequate outpatient care for this condition in this population specifically.

Facemasks: Perceptions and use in an ED population during COVID-19

Study objective

Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations.

Methods

This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them.

Results

Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks “all of the time” and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%).

Conclusions

Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.

"They're Doing Their Job": Women's Acceptance of Emergency Department Contraception Counseling

STUDY OBJECTIVE

We explore reproductive-aged women's acceptance of contraception counseling in the emergency department (ED).

METHODS

This study is phase 1 of an exploratory sequential mixed methods study. We purposively interviewed 31 participants with the following criteria: black, white, or Latina race/ethnicity; nonpregnant; aged 15 to 44 years; receiving nonemergency care; not using highly effective contraception; and did not intend to become pregnant. We conducted semistructured interviews with a piloted interview guide until reaching thematic saturation. We coded transcripts with an iteratively developed codebook, maintaining intercoder agreement greater than 80%. Qualitative acceptance of ED contraception counseling was grouped into 3 categories: acceptable, unacceptable, and equivocal. We conducted a thematic text analysis to assess themes expressing support and concern for ED contraception counseling. Qualitative findings were stratified by age, race, and frequency of ED use. Using components of grounded theory, we developed a conceptual model.

RESULTS

Most participants (81%) accepted ED contraception counseling. Themes expressing support and concern for ED contraception counseling included opportunity to address women's unmet contraception needs, contraception is within the scope of ED practice, the ED is a convenient setting with competent providers, contraception is a sensitive topic, and the ED may be an inappropriate setting for some women. Latina participants had lower acceptance of ED contraception counseling. Dominant subthemes varied slightly by race, age, and frequency of ED use.

CONCLUSION

Diverse women had high acceptance of contraception counseling in the ED. Perspectives expressing both support and concern in regard to ED contraception counseling were explored in detail.

Sexually Transmitted Infection History among Adolescents Presenting to the Emergency Department

BACKGROUND

Adolescents and young adults account for about half of the annual diagnoses of sexually transmitted infections (STI) in the United States. Screening and treatment for STIs, as well as prevention, are needed in health-care settings to help offset the costs of untreated STIs.

OBJECTIVE

Our aim was to evaluate the prevalence and correlates of self-reported STI history among adolescents presenting to an emergency department (ED).

METHODS

Over two and a half years, 4389 youth (aged 14-20 years) presenting to the ED completed screening measures for a randomized controlled trial. About half (56%) reported lifetime sexual intercourse and were included in analyses examining sexual risk behaviors (e.g., inconsistent condom use), and relationships of STI history with demographics (sex, age, race, school enrollment), reason for ED presentation (i.e., medical or injury), and substance use.

RESULTS

Among sexually active youth, 10% reported that a medical professional had ever told them they had an STI (212 females, 35 males). Using logistic regression, female sex, older age, non-Caucasian race, not being enrolled in school, medically related ED chief complaint, and inconsistent condom use were associated with increased odds of self-reported STI history.

CONCLUSIONS

One in 10 sexually active youth in the ED reported a prior diagnosed STI. Previous STI was significantly higher among females than males. ED providers inquiring about inconsistent condom use and previous STI among male and female adolescents may be one strategy to focus biological testing resources and improve screening for current STI.

Specialized intestinal metaplasia in patients with gastro-oesophageal reflux disease

BACKGROUND

There is an increasing awareness that short (less than 3 cm) segments of Barrett's epithelium and macroscopically normal cardia epithelium may harbour specialized intestinal metaplasia (SIM), a premalignant phenotype. The prevalence of SIM was studied prospectively in an unselected population of patients attending for endoscopy, and the association of SIM with symptoms, lifestyle, medication, endoscopic oesophagitis and carditis was investigated.

METHODS

Two hundred consecutive patients underwent endoscopy. Biopsies taken from just below the squamocolumnar junction were stained for SIM, and were analysed for carditis and Helicobacter pylori infection. A detailed questionnaire of symptoms, tobacco consumption and the use of proton pump inhibitors was completed.

RESULTS

Forty-two patients (21 per cent) had SIM: 19 (15 per cent) of 126 in an endoscopically normal oesophagus, 15 (24 per cent) of 63 in a short segment of Barrett's epithelium and eight of 11 in classical Barrett's oesophagus. There was a significant association between SIM and carditis (P < 0.0001) and endoscopic oesophagitis (P = 0.03).

CONCLUSION

SIM is prevalent in patients undergoing endoscopy, does not correlate with symptoms or H. pylori infection, but is significantly associated with endoscopic and pathological markers of gastro-oesophageal reflux.

Cardiac ischaemia induces vagally mediated lower oesophageal sphincter relaxation

Gastro-oesophageal reflux and coronary artery disease frequently coexist. Direct stimulation of myocardial vagal receptors impairs lower oesophageal sphincter (LOS) function but the effect of cardiac ischaemia has not been examined. Eight adult mongrel dogs were studied under general anaesthesia. Each underwent occlusion of the left circumflex coronary artery before and after bilateral cervical vagotomy. Blood pressure, heart rate and LOS responses were measured. Median (range) LOS tone was significantly reduced by coronary artery occlusion, from 9 (6-14) to 6 (3-8) sphinctometer units (P < 0.01). This was accompanied by a reduction in heart rate (P < 0.05) and blood pressure (P < 0.01). After bilateral cervical vagotomy the same ischaemic insult produced no significant alteration in LOS tone or heart rate. These data suggest a direct vagal reflex to explain the high incidence of gastro-oesophageal reflux in patients with coronary artery disease.

Hyper- and hypo-responsiveness to dietary fat and cholesterol among inbred mice: searching for level and variability genes

A concept proposed by Berg (Berg, K. 1989. Arteriosclerosis. 9: I-50-I-58) is that a combination of level and variability genes determine an individual's overall plasma lipid levels and atherosclerotic risk. Our goal was to determine which inbred mouse strains could be used to identify candidate level and variability genes controlling lipid levels and atherosclerosis susceptibility. Nine common inbred mouse strains were examined for responsiveness with respect to plasma lipoprotein and tissue lipid levels upon feeding diets rich in cholesterol and fat. Marked quantitative variations were observed in plasma cholesterol and triglyceride levels among mice fed rodent chow and the high fat test diets. Mice of strains DBA/2 and AKR appeared to be hyporesponsive to diets containing high levels of fat and cholesterol as compared to rodent chow. In contrast, several strains were primarily hyperresponsive to either dietary fat or cholesterol, or both ingredients. Determination of cholesterol absorption for selected strains fed test diets suggested that decreased cholesterol absorption, in part, contributes to hyporesponsiveness as seen in DBA/2 mice. Levels of mRNA for cholesterol 7 alpha-hydroxylase were estimated and shown to vary markedly among strains. An inverse correlation was seen among strains between cholesterol 7 alpha-hydroxylase mRNA, and plasma and hepatic cholesterol levels for some diets. Thus, genes controlling cholesterol absorption and bile acid synthesis are candidates for further study as level and variability genes affecting plasma cholesterol levels. Overall, inbred mouse strains will prove useful for identifying genes controlling level and variability traits.

Ambulatory oesophageal bile reflux monitoring in Barrett's oesophagus

Bile reflux has been implicated in the pathogenesis of Barrett's oesophagus but evaluation remains difficult. Bilitec 2000 is an ambulatory system that detects bilirubin based on its spectrophotometric properties. Oesophageal bile exposure was evaluated in three groups of patients. Group 1 (n = 11) were normal controls, group 2 (n = 13) were patients with uncomplicated gastro-oesophageal reflux and group 3 (n = 12) were patients with Barrett's oesophagus. Bile reflux was greater in patients with Barrett's mucosa than in controls or those with uncomplicated reflux. This difference was seen in the supine and interdigestive periods. The percentage of time at which gastric pH was greater than 4 and oesophageal pH was above 7 did not differ between the groups. Bilitec 2000 detects greater bile reflux in patients with Barrett's oesophagus. No corresponding gastric or oesophageal alkaline shift is found. This ambulatory bile reflux monitoring system may be a useful tool in clinical practice.

Gastric motility following oesophagectomy

The motility of the vagally denervated transposed stomach after oesophagectomy was examined by ambulatory gastric manometry and videofluoroscopy. Two groups of subjects were studied. Group 1 comprised ten patients who had undergone oesophagectomy 6-12 months previously and group 2 consisted of six normal control subjects. Studies were performed on fasting and fed subjects, and following injection of erythromycin 8 mg/kg. No distinguishable manometric wave activity was seen in either group while fasting. Feeding generated a measurable wave pattern in the patient group only. A significant increase in the mean (s.e.m.) distal wave amplitude was identified after infusion of erythromycin in both patients (34.0(15.1) versus 12.2(3.1) mmHg, P < 0.05) and controls (15.1(3.4) versus 5.0(0.0) mmHg, P = 0.05). The response to erythromycin was more rapid in patients than in controls (mean(s.e.m.) 113(16) versus 377(133) s, P < 0.05) and the effect persisted for longer (more than 1 h) in those who had undergone oesophagectomy. Videofluoroscopy confirmed purposeful motility in both the normal and vagally denervated stomach. It is concluded that the transposed stomach is a dynamic conduit. Enhancement of motility was greatest in the denervated stomach, indicative of denervation supersensitivity.

Helicobacter pylori infection increases following cholecystectomy

Cholecystectomy is frequently linked with duodenogastric reflux and gastritis but its effect on Helicobacter Pylori (H pylori) infection has not been examined. In a prospective study, twenty two patients with documented cholelithiasis underwent upper gastrointestinal endoscopy and biopsy and 24hr dual channel pH monitoring prior to cholecystectomy and again at 3-6 months post-operatively. The antral biopsies were histologically assessed for H pylori and gastritis and awarded an alkaline reflux score. The number of patients with H pylori infection increased from 7 (32%) preoperatively to 15 (68%) post-cholecystectomy (p < 0.05). Cholecystectomy was also associated with an increase in the incidence of gastritis from 7 to 15 (p < 0.05). The increase in H pylori infection rate occurred in association with an increase in the percentage time gastric pH > 4 in the supine position, from 9.6 (2.2) to 22.2 (4.8) percent, (p < 0.01). The median chemical gastritis score, however, did not change significantly following surgery [8(3-11) vs 7(3-11)]. Seven patients remained symptomatic following cholecystectomy all of whom were H pylori positive and had gastritis. H pylori can survive in the alkaline environment which follows cholecystectomy and may contribute to the post-cholecystectomy syndrome.

Myocardial vagal stimulation impairs lower esophageal sphincter function

BACKGROUND

Coronary artery disease and gastroesophageal reflux disease frequently coexist, but a direct pathophysiologic link has not been established.

METHODS

This study examines the effect of myocardial vagal receptor stimulation on lower esophageal sphincter (LES) tone in eight adult mongrel dogs, each acting as its own control. Pharmacologic stimulation was carried out by the application of 1 cm gauze patches soaked in nicotine (200 micrograms/ml) to the epicardium. Epicardial vagal receptors were stimulated mechanically by digital friction.

RESULTS

Pharmacologic stimulation produced a rapid fall in LES tone from a mean (SEM) of 12.6 (1.5) to 8.6 (0.9) sphinctometer units (p = 0.007). Mechanical stimulation also produced a rapid fall from 12.0 (1.5) sphinctometer units to 6.8 (0.7) (p = 0.007). Both were associated with a drop in mean arterial blood pressure and heart rate. Sham patches soaked in sterile water produced no effects.

CONCLUSIONS

These data suggest a direct vagal reflex linking the myocardium and the LES that may explain the high incidence of gastroesophageal reflux in patients with heart disease.

Hypotension induced by haemorrhage impairs lower oesophageal sphincter function

The effect of haemorrhage-induced hypotension on lower oesophageal sphincter (LOS) tone was studied in 11 adult mongrel dogs. Mean(s.e.m.) blood loss of 760(66) ml, corresponding to 42 per cent of estimated blood volume, was associated with a significant fall in LOS tone (14.2(1.0) versus 7.2(0.6) sphinctometer units, P < 0.002). This was associated with a reduction in mean(s.e.m.) arterial blood pressure (99(7) versus 53(3) mmHg, P < 0.002) and heart rate (113(6) versus 106(5) beats per min, P = 0.06). Group 1 animals (n = 6) received autotransfusion, restoring LOS tone to prehaemorrhage values. Dogs in group 2 (n = 5) were given intravenous erythromycin 4 mg/kg, which also restored LOS tone. This effect was transient, lasting a mean(s.e.m.) of only 67(7) min. Infusion of an equivalent volume of 0.9 per cent saline following cessation of the erythromycin effect restored LOS tone to control values although the animals remained hypotensive. Reduction in LOS tone with haemorrhage may be part of a vagal reflex mediated by myocardial afferent C fibres and may explain the high incidence of pulmonary aspiration in shocked patients.

Bradykinin, coronary artery disease and gastro-oesophageal reflux

Gastro-oesophageal reflux and coronary artery disease frequently coexist. Stimulation of myocardial vagal receptors impairs lower oesophageal sphincter (LOS) function and may explain this link. This study examined the role of bradykinin, produced in increased quantities by the ischaemic myocardium, in activating this reflex. Thirteen dogs had patches soaked in bradykinin 100 micrograms/ml and saline applied sequentially to the left ventricular epicardium. Eleven of these animals were further divided into two subgroups: group 1 animals (six dogs) had the above sequence repeated after obliteration of sympathetic afferent fibres with phenol and those in group 2 (five animals) underwent sequential intravenous and intra-atrial injection of bradykinin 0.2 micrograms/kg. Epicardial bradykinin produced a fall in mean(s.e.m.) LOS tone from 13.3(1.3) to 6.0(0.5) sphinctometer units (P < 0.002), accompanied by a reduction in mean(s.e.m.) arterial pressure from 95(4) to 83(5) mmHg (P < 0.002). Destruction of sympathetic afferent fibres did not alter the LOS effect. Intra-atrial, but not intravenous, bradykinin reproduced the LOS effect; this suggests a cardiac origin. Myocardial release of bradykinin may play a role in producing transient LOS relaxation, predisposing to gastro-oesophageal reflux.

Adhesions after laparoscopic inguinal hernia repair. A comparison of extra versus intra peritoneal placement of a polypropylene mesh in an animal model

Prosthetic mesh for laparoscopic inguinal hernia repair has become popular but the method of its placement is controversial. Mesh placed within the peritoneum may cause adhesion formation and further complications. The aim of this study was to examine the laparoscopic placement of a mesh, comparing intraperitoneal vs extraperitoneal insertion. In a porcine model (n = 15) a polypropylene mesh was placed laparoscopically over the anterior abdominal wall. On the left side the mesh was stapled on the parietal peritoneum. On the right side the peritoneum was incised, an extraperitoneal space was dissected, the mesh was inserted, and the peritoneum was closed over it. The animals were maintained for 2 weeks. At postmortem there were adhesions in two of those placed extraperitoneally and five of those placed intraperitoneally (P = 0.19, Fisher's exact test). The adhesions comprised fibrous peritoneal bands to loops of small intestine. Both methods of laparoscopic mesh placement were associated with a small but significant incidence of adhesion formation.

An ambulatory bile reflux monitoring system: an in vitro appraisal

Assessment of duodenogastric bile reflux has hitherto been unsatisfactory. An ambulatory system which utilizes the optical properties of bilirubin is examined. Test readings are correlated with the laboratory values for bilirubin in each of a number of physiological solutions. For dilutions of pure bile there was a linear correlation between absorbance and bilirubin concentration (r = 0.93, p < 0.001). In the more acidic environment of gastric juice there was also a linear correlation between absorbance and bilirubin concentration (r = 0.65, p < 0.001), but absorbance values were significantly higher than those of pure bile solutions (F ratio = 130, p < 0.0001). Normal gastric secretions and saliva give low absorbance values (0.02-0.04). Common foodstuffs such as soups, tea and coffee give higher readings and may interfere with bile reflux assessment in a clinical setting. Bilitec 2000 has potential for use as an ambulatory bile reflux monitoring system but consideration should be given to a standard diet or attention must focus on the fasting period.

Peritoneal aspiration cytology as a diagnostic aid in acute appendicitis

A total of 110 consecutive patients presenting to one surgical firm with suspected acute appendicitis underwent peritoneal aspiration cytology. Aspiration was successful in 108 patients and 44 were positive. Patients with a positive result underwent emergency surgery; 42 had histologically proven acute appendicitis and two peritonitis of other causes. Seven patients with a negative result underwent appendicectomy; four had acute appendicitis and three a normal appendix. Peritoneal aspiration cytology had a sensitivity for acute appendicitis of 91 per cent and a specificity of 94 per cent. The positive predictive value of the test was 95 per cent and the negative predictive value 94 per cent. The negative appendicectomy rate was 10 per cent overall and 11 per cent in women of reproductive age. Peritoneal aspiration cytology is a useful diagnostic test in the management of patients with suspected acute appendicitis.

Timing of extubation after oesophagectomy

Ventilatory support for 24 h after surgery is standard practice in many units after oesophagectomy, especially for patients in whom respiratory problems are anticipated. Weaning difficulties may occur, however, and there is increasing evidence that mechanical ventilation is associated with alveolar trauma. A deliberate change in policy was instituted in the authors' unit in January 1990 to make early extubation mandatory in all patients undergoing elective oesophagectomy, apart from those in whom serious perioperative problems were encountered. The present study compared two sets of patients: group 1 (n = 36) underwent oesophagectomy in the year before the policy change and group 2 (n = 45) oesophagectomy in the year after. The two groups were similar in age, sex and respiratory risk factors. Early extubation was carried out in 38 patients in group 2 compared with eight in group 1 (P < 0.001). Only two patients in group 2 required prolonged ventilation compared with ten in group 1 (P < 0.005). No patient in group 2 required reventilation compared with seven in group 1 (P < 0.005), and no patient in group 2 who had undergone early extubation required delayed ventilation. The mean ventilation time and length of stay in the intensive care unit were significantly reduced following the policy change. Early extubation after elective oesophagectomy is an attainable goal and results in a significant reduction in both the morbidity rate and cost of surgery.

Fatal trauma: a five year review in a Dublin hospital

The autopsy reports and clinical data of 96 patients presenting to St. James's Hospital with trauma of fatal outcome, between January 1, 1986 and December 31, 1990, were analysed. Eighty-one (84%) deaths were due to road traffic accidents and all were the result of blunt trauma. Ninety-five (99%) had an Abbreviated Injury Scale (AIS) score > or = 3 in at least one anatomical category. Cerebral trauma (41%) and shock and haemorrhage secondary to multiple injuries (40%) were the commonest causes of death. Sixty-eight (71%) patients were dead on arrival at the hospital. Of the twenty-eight deaths occurring after admission to hospital nine (32%) were potentially preventable. The mean (sem) Injury Severity Score (ISS) for those with preventable deaths was 24.1 (3.8). These data have implications for the development of trauma care facilities in Ireland.

Correlation of peritoneal aspiration cytology with acute appendicitis

Fifty-one patients in whom a clinical diagnosis of acute appendicitis had been made underwent peritoneal aspiration cytology (PAC). Thirty-six had a positive result, 11 had a negative result and aspiration failed in four cases. All patients had an appendicectomy and the histological findings were correlated with the PAC results. Thirty-five of the 36 patients with a positive PAC had histologically proven appendicitis. Seven of the 11 patients with a negative result had normal appendices. The sensitivity of PAC for acute appendicitis was 85% and the specificity was 70%. The positive predictive value was found to be 97% and the negative predictive value 60%. Peritoneal aspiration cytology is a useful aid in the diagnosis of acute appendicitis however, a negative result does not exclude this diagnosis.

Microvascular changes in experimental gastric stress ulceration: the influence of allopurinol, cimetidine, and misoprostol

The influence of stress on the structure of the gastric mucosal capillary network was investigated in an experimental model using scanning electron microscopy (SEM) to study corrosion casts of the gastric microvasculature. An index of microcirculatory patency was devised to improve the objectivity of SEM. Stress (mean score 42.4 +/- 4.7) severely disrupted the structure of the mucosal capillary network when compared with controls (mean 5.0 +/- 2.9) (P < 0.01). Disruption of the microvascular network was significantly reduced by pretreatment with allopurinol, cimetidine, and misoprostol, these groups having mean damage scores of 17.4 +/- 5.8, 21.2 +/- 7.9, and 28.6 +/- 9.3, respectively, when compared with untreated stressed controls in which the mean score was 42.4 +/- 4.7 (P < 0.02). Microvascular disruption is a significant factor in stress ulceration and the efficacy of allopurinol in minimizing the stress-induced disruption of the microvascular network provides further indirect evidence for the role of ischemia and oxygen-derived free radical generation in its etiology.