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The Journal of Emergency Medicine, Vol. 37, No. 2, pp. 244–248, 2009Copyright © 2009 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/09 $–see front matter

Abstracts

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KNOWLEDGE AND MANAGEMENT OF FEVERMONG LATINO PARENTS. Crocetti M, Sabath B, Cran-er L, Gubser S, Dooley D. Clin Pediatr (Phila) 2009;48:

83–9.This study used a cross-sectional survey of a convenience

ample of Spanish-speaking-only parents presenting to a hospital-ased urban pediatric clinic to assess understanding and man-gement of fever in their children. The administered question-aire elicited information regarding definition and cause ofever, concerns about fever, methods of temperature measure-ent, and treatment modalities used by the parents. The authors

onclude that Latino parents have numerous misconceptions aboutever and its role in illness. They found that owning a thermometeras associated with correct knowledge of temperature values

adjusted odds ratio 3.4 with 95% confidence interval 1.3–8.9).hey postulate that providing parents with a thermometer andducating them on its proper use may lead to an increase inppropriate monitoring and medical treatment of the febrile child.

[Erica Douglass, MD,

Denver Health Medical Center, Denver, CO]

Comment: This article confirms some of the misconceptionseld by Latino parents with regards to fever and its potentialeleterious effects on their children. By providing more edu-ation and training to parents we may help to prevent unnec-ssary or recurrent health care visits.

ACTIVE BED MANAGEMENT BY HOSPITALISTSND EMERGENCY DEPARTMENT THROUGHPUT.owell E, Bessman E, Kravet S, et al. Ann Intern Med 2008;49:804–10.

This study from Johns Hopkins Bayview Medical Centerompared emergency department (ED) throughput and ambu-ance diversion hours using a pre-post design to evaluate thenstitution of an active bed management protocol. The authorsssert that ambulance diversion, which occurs at a rate of onembulance every minute nationwide, results in prolonged timeo therapy, increased mortality rates, and financial losses for thenstitution on diversion. A major cause of ambulance diversions admitted patients who are physically located in the ED until

hospital bed becomes available. An active bed managementpproach was instituted consisting of a hospitalist whose onlylinical responsibility was to facilitate the transfer of patientsrom the ED to an inpatient bed. This active bed managementospitalist assessed real-time availability of beds, thereby iden-ifying possible shortages before they occurred, through col-aboration with other physicians, nursing supervisors, and

harge nurses in twice daily “prediversion” rounds. During the

244

tudy period, throughput for admitted patients decreased by 98in, the proportion of hours spent on yellow alert decreased bypercentage points, and hours spent on red alert decreased by

7 percentage points despite an increase in census during thetudy period. The authors concluded that active bed managementhrough collaboration with admitting services can lead to a signif-cant impact on throughput for admitted patients and hours spentn alert. The authors also asserted that the cost of additionalospitalists is offset by the savings of the intervention.

[Maggie DiGeronimo, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study provides a potential model for de-reasing ED overcrowding and time spent on ambulance diver-ion. However, there are several limitations. Although theuthors stated that the cost savings of the intervention out-eighed the cost of its implementation, only lost revenue

stimates were offered. There is no delineation of the cost ofhe intervention itself, therefore, actual cost savings cannot bestimated. The application of this method to other institutionsill depend upon the actual cost savings, non-physician staffingatterns and resources, and unidentified external forces thatould not be taken into account during this pre-post study.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AU-EUS AS A COMMON CAUSE OF VULVAR ABSCESSES.hurman AR, Satterfield TM, Soper DE. Obstet Gynecol 2008;12:538–44.

This retrospective chart review from San Antonio, Texaseports the incidence of methicillin-resistant Staphylococcusureus (MRSA) from vulvar abscesses in women presenting tohe emergency department in an urban, low income, primarilyispanic community. Sixty-four percent of 133 women withulvar abscess had MRSA isolated from abscess culture. Ninety-ix percent of isolated MRSA was sensitive to trimethoprim-ulfamethoxazole. The authors also report characteristics asso-iated with inpatient (40%) vs. outpatient treatment of abscessnd found that inpatients more often had diabetes, hyperten-ion, larger abscess, and higher white blood cell counts. Ninety-ix percent of inpatients received incision and drainage of thebscess in the operating room. The authors highlight the needo cover for MRSA when considering antibiotic treatment afterrainage of a vulvar abscess. They also mention several com-licated cases that required repeat debridement or prolongedospitalization.

[Michael Prendergast, MD,

Denver Health Medical Center, Denver, CO]

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The Journal of Emergency Medicine 245

Comments: This study was limited by its retrospective design.he results may also be less generalizable given the very high ratef inpatient management with operative incision and drainage.onetheless, it provides interesting data for considering what

ntibiotic treatment to use for patients with vulvar abscesses.

MECHANICAL SUPPORTS FOR ACUTE, SEVERENKLE SPRAIN: A PRAGMATIC, MULTICENTRE,ANDOMIZED CONTROLLED TRIAL. Lamb SE, Marsh

L, Hutton JL, et al. Lancet 2009;373:575–81.This study from the United Kingdom aimed to compare three

ifferent mechanical supports (Aircast Brace [DJO LLC, Vista,A], Bledsoe boot [Bledsoe Brace Systems, Grand Prairie, TX],0-day below-knee cast) to a double-layer tubular compressionandage in the treatment of severe ankle sprain. This multi-centerandomized trial enrolled 584 patients to one of the four treatmentrms. The mechanical support was placed within 3 days of injurynd functional outcomes were measured over 9 months, the pri-ary outcome being quality of ankle function at 3 months aseasured by the Foot and Ankle score. The most clinically im-

ortant benefit at 3 months was noted in the below-knee cast arm,9% mean difference in quality of ankle function as well as

mprovements in pain, symptoms, and activity. The Aircast bracerovided a similar improvement in ankle function (8%), althought lacked benefit in pain, symptoms, or activity. The Bledsoe bootsffered no advantage over the tubular compression bandage,hich was the least effective treatment. There was no differenceetween any of the treatment arms at 9 months. The authorsonclude that below-knee casts provide the widest range of benefitn the treatment of severe ankle sprain.

[Gary Witt, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study is strengthened by its randomizedesign and blinded measures of outcome, thereby limiting biasnd leading to increased internal validity. However, both inter-al and external validity were limited by the self-reportedature of compliance and frequent refusal of patients to enterhe study once randomized to the below-knee cast. The authorsheorize that patients may be more accepting of the below-kneeast if informed of its clinical benefit.

ONE-DAY COMPARED WITH 7-DAY NITROFURAN-OIN FOR ASYMPTOMATIC BACTERIURIA IN PREG-ANCY. Lumbiganon P, Villar J, Laopaiboon M, et al. Obstetynecol 2009;113:339–45.

This multi-center, double-blind, randomized, placebo-ontrolled international trial compared 14-day bacteriologicalure of asymptomatic bacteriuria in pregnant women receivingither a single- or 7-day course of 100 mg twice daily nitro-urantoin. Pregnant women seeking antenatal care in Thailand,he Philippines, Vietnam, and Argentina between March 2004nd March 2007 and who met inclusion and exclusion criteriaere invited to participate in the study. Asymptomatic bacte-

iuria had an overall prevalence of 5.1%, occurring in 1248 of

4,430 eligible women. Of these, 386 were randomized to receive D

1-day course of nitrofurantoin, and 392 received a 7-day course.acteriological cure rates at treatment day 14 were 75.7% and6.2% for the 1- and 7-day courses, respectively, which equateso a �10.5% cure rate difference between the two groups.dditionally, they found that mean birth weight and meanestational age at delivery were significantly lower in the 1-dayegimen group. There were fewer adverse events in this group;owever, this difference was not statistically significant. Theuthors concluded that the 7-day course of nitrofurantoin isore effective than the single-day regimen and should conse-

uently be the treatment regimen of choice in pregnant womenith asymptomatic bacteriuria.

[Erica Douglass, MD,

Denver Health Medical Center, Denver, CO]

Comment: In the current age of increasing bacterial resistance,t is important to continue questioning the need for, type of, anduration of administered antibiotics; however, this should not beone at the expense of adequate treatment. This article reinforceshe current practice of treating pregnant women with asymptom-tic bacteriuria with a full 7-day course of nitrofurantoin.

DIABETIC KETOACIDOSIS: A CURRENT APPRAISALF PATHOPHYSIOLOGY AND MANAGEMENT. Koul PB.lin Pediatr (Phila) 2009;48:135–44.

This is a current appraisal of new insights into the patho-hysiology and management of diabetic ketoacidosis (DKA),ncluding laboratory work-up, monitoring of insulin, and fluidanagement. This article also discussed the complications ofKA and its treatment, focusing on cerebral edema (CE). The

uthor recommends that fluid deficits be replaced at an evenate over 48 h, not to exceed 4/L/m2/24 h. Regular insulinhould be started at 0.1 units/kg/h (no bolus). In general, it isecommended that bicarbonate not be administered unless cor-ection of a pH � 6.9 is necessary. The major complication ofKA highlighted in this article is CE. Hypotheses for the causef CE include rising intracellular sodium leading to increasedell volume during dehydration, excess ketoacids, glucose-nduced hypertonicity producing osmotically active moleculesnd vasogenic edema. Risk factors for CE include age � 5ears, high blood urea nitrogen, PaCO2 � 22 mm Hg, andrterial pH � 7.00. CE usually presents 4–8 h into rehydrationherapy as sudden headache, vomiting, hypertension, and ob-undation. Finally, the management of CE includes elevation ofhe head of the bed, infusion of mannitol, intubation, hyperventi-ation, and reduction of fluid infusion to 75% of maintenance.

[Maggie DiGeronimo, MD,

Denver Health Medical Center, Denver, CO]

Comment: This article highlights new insights into the patho-hysiology and management of DKA as well as the pathophysi-logy and management of its most feared complication—erebral edema. Not only does it review the mechanisms behindhe common metabolic derangements of this disease process, itets forth a detailed timeline and management strategy for

KA. These strategies, as well as those for the management of