NEJM â Collection Updates for Emergency Medicine

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 41-2009 â A 16-Year-Old Boy with Hypothermia and Frostbite

Thu, 31Â DecÂ 2009 00:00:00 -05:00

Dr. Benjamin Sandefur (Emergency Medicine): A 16-year-old boy was admitted to the hospital after being found unconscious in a snow bank at 6 a.m. on New Year's Day. He had...

IMAGES IN CLINICAL MEDICINE: Frostbite

Habib Rehman, M.B., B.S. and Aimee Seguin, M.D. — Thu, 17Â DecÂ 2009 00:00:00 -05:00

A 39-year-old man was found in a snowbank, with the ambient temperature â35Â°C. He had been reported missing the previous evening, after an argument with his girlfriend. The emergency services...

IMAGES IN CLINICAL MEDICINE: Air in the Portal and Mesenteric Veins

Diego de Mendoza-Asensi, M.D. and Kenneth Planas, M.D. — Thu, 19Â NovÂ 2009 00:00:00 -05:00

A 73-year-old man with history of smoking, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes mellitus presented with respiratory distress. The trachea was intubated, and the patient was admitted...

IMAGES IN CLINICAL MEDICINE: Extensive Bowel Infarction

Janice Cheng, M.B., B.S. and Girish Pande, M.B., B.S. — Thu, 12Â NovÂ 2009 00:00:00 -05:00

A 45-year-old man presented to the emergency room with abdominal pain that had been increasing over the previous week and hematemesis and melena that had begun in the preceding 12...

IMAGES IN CLINICAL MEDICINE: Central Nervous System Hemorrhage

Joshua P. Klein, M.D., Ph.D. and Robin C. Ryther, M.D., Ph.D. — Thu, 29Â OctÂ 2009 00:00:00 -05:00

A 68-year-old man who had hypertension, diabetes, and atrial fibrillation and was being treated with warfarin was discovered snoring and unarousable at home. He had been in his usual state...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 33-2009 â A 35-Year-Old Woman with Fever, Abdominal Pain, and Hypotension after Cesarean Section

Thu, 22Â OctÂ 2009 00:00:00 -05:00

Dr. Claudius H.O. Conrad (Surgery): A 35-year-old woman was transferred to this hospital because of abdominal pain, fever, and hypotension.

Three days earlier, an elective cesarean section was performed at another...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 31-2009 â A 26-Year-Old Man with Abdominal Distention and Shock

Thu, 08Â OctÂ 2009 00:00:00 -05:00

Dr. Jeffrey S. Ustin (Trauma, Emergency Surgery, and Surgical Critical Care): A 26-year-old man was admitted to this hospital because of abdominal distention and shock.

The patient had been well until...

IMAGES IN CLINICAL MEDICINE: Esophageal Foreign Body

Thu, 13Â AugÂ 2009 00:00:00 -05:00

A 50-year-old man presented to the emergency department with marked dysphagia, dyspnea, and paroxysmal cough. He had swallowed a spoon while trying to extract a fish bone that was stuck...

CLINICAL PRACTICE: Neurologic Prognosis after Cardiac Arrest

G. Bryan Young, M.D. — Thu, 06Â AugÂ 2009 00:00:00 -05:00

A 55-year-old man collapses while jogging through the park. A bystander finds him unconscious and without a pulse and initiates cardiopulmonary resuscitation (CPR) while an ambulance is summoned. On arrival...

EDITORIAL: Protecting against Future Shock â Inhalational Anthrax

Gary J. Nabel, M.D., Ph.D. — Thu, 09Â JulÂ 2009 00:00:00 -05:00

In a world filled with pressing unmet medical needs, why would a physician want to protect against a disease that is rarely seen? Part of the answer can be deduced...

IMAGES IN CLINICAL MEDICINE: Telltale Triangle of Pneumoperitoneum

Ming-Yuan Huang, M.D. and Wen-Han Chang, M.D., Ph.D. — Thu, 02Â JulÂ 2009 00:00:00 -05:00

A 56-year-old man presented to the emergency department with a 3-day history of diarrhea and dull epigastric pain. The diarrhea had responded to antidiarrheal agents. However, the epigastric pain had...

ORIGINAL ARTICLE: Epidemiologic Study of In-Hospital Cardiopulmonary Resuscitation in the Elderly

Thu, 02Â JulÂ 2009 00:00:00 -05:00

Background: It is unknown whether the rate of survival after in-hospital cardiopulmonary resuscitation (CPR) is improving and which characteristics of patients and hospitals predict survival.

Methods: We examined fee-for-service Medicare data...

IMAGES IN CLINICAL MEDICINE: Ingested Magnets

Luigi Avolio, M.D. and Giuseppe Martucciello, M.D. — Thu, 25Â JunÂ 2009 00:00:00 -05:00

A 9-year-old boy ingested 23 magnets (Panel A). Four days later, he had clinical and surgical evidence of intestinal perforation and peritonitis due to pressure necrosis of the bowel. In...

CLINICAL THERAPEUTICS: Fomepizole for Ethylene Glycol and Methanol Poisoning

Jeffrey Brent, M.D., Ph.D. — Thu, 21Â MayÂ 2009 00:00:00 -05:00

A 35-year-old man is brought to the emergency department by his wife after ingesting automobile antifreeze in an attempt at self-harm. On presentation, the patient is somnolent. He is afebrile...

BOOK REVIEW:

Thu, 14Â MayÂ 2009 00:00:00 -05:00

Expedition and wilderness medicine becomes more important to public health each year, as professional and recreational travel to remote environments grows. Travel companies increasingly ask physicians to screen potential clients...

IMAGES IN CLINICAL MEDICINE: Bilateral Subacute Subdural Hematomas

Joshua J. Wind, M.D. and James W. Leiphart, M.D., Ph.D. — Thu, 23Â AprÂ 2009 00:00:00 -05:00

A 43-year-old man presented to the emergency department with a 2-day history of headache; he reported being otherwise healthy. Four weeks earlier, he had been an unrestrained driver involved in...

CLINICAL PRACTICE: Carbon Monoxide Poisoning

Lindell K. Weaver, M.D. — Thu, 19Â MarÂ 2009 00:00:00 -05:00

A 39-year-old female executive has a several-month history of fatigue, headache, and memory lapse. Multiple specialists have performed evaluations, but no diagnosis has been established. During a period of feeling...

CLINICAL PRACTICE: Epistaxis

Rodney J. Schlosser, M.D. — Thu, 19Â FebÂ 2009 00:00:00 -05:00

A 61-year-old man presents to the emergency room with left-sided epistaxis that has continued for 1 hour. He estimates having lost approximately 1/2 cup of blood and reports no history...

IMAGES IN CLINICAL MEDICINE: Traumatic Epidural Hematoma

Gary L. Gallia, M.D., Ph.D. and Michael H. Sobotta, M.B., B.S. — Thu, 05Â FebÂ 2009 00:00:00 -05:00

An 18-year-old intoxicated man was assaulted with a glass bottle on the left parietal region of his head and had a 5-minute loss of consciousness. The patient went home, but...

IMAGES IN CLINICAL MEDICINE: Traumatic Diaphragmatic Rupture with Intrathoracic Liver Herniation

Stephen H. McKellar, M.D. and L. Ray Matthews, M.D. — Thu, 29Â JanÂ 2009 00:00:00 -05:00

A 24-year-old man who had been wearing a seatbelt while driving a car involved in a high-speed motor vehicle crash was taken by ambulance to a local hospital, where his...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2009 â A 25-Year-Old Man with Pain and Swelling of the Right Hand and Hypotension

Thu, 15Â JanÂ 2009 00:00:00 -05:00

Dr. William D. Binder (Emergency Services): A 25-year-old man was transferred to the emergency department of this hospital because of pain and swelling of the right hand and hypotension.

The patient...

IMAGES IN CLINICAL MEDICINE: Diagnosis of Uterine Rupture on CT

Alexandra Grosvenor Eller, M.D. and Barbra Fisher, M.D., Ph.D. — Thu, 08Â JanÂ 2009 00:00:00 -05:00

A 34-year-old woman with seven previous cesarean deliveries and a history of scant prenatal care presented at 32 weeks' gestation with constant, vague lower abdominal pain that had worsened over...

VIDEOS IN CLINICAL MEDICINE: Basic Splinting Techniques

Thu, 25Â DecÂ 2008 00:00:00 -05:00

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ORIGINAL ARTICLE: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest

Thu, 18Â DecÂ 2008 00:00:00 -05:00

Background: Approximately 70% of persons who have an out-of-hospital cardiac arrest have underlying acute myocardial infarction or pulmonary embolism. Therefore, thrombolysis during cardiopulmonary resuscitation may improve survival.

Methods: In a double-blind,...

IMAGES IN CLINICAL MEDICINE: Acute Calcific Tendinitis

Jonathan D. Wiper, M.B., Ch.B. and Anselmo Garrido, M.D. — Thu, 04Â DecÂ 2008 00:00:00 -05:00

A 56-year-old woman presented to the emergency department with a 3-day history of severe pain in and loss of movement of her right index finger. She reported that for the...

VIDEOS IN CLINICAL MEDICINE: Peripheral Intravenous Cannulation

Thu, 20Â NovÂ 2008 00:00:00 -05:00

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IMAGES IN CLINICAL MEDICINE: Reversal of Traumatic Quadriplegia after Closed Reduction

John A. Cowan, Jr., M.D. and John E. McGillicuddy, M.D. — Thu, 13Â NovÂ 2008 00:00:00 -05:00

A 39-year-old woman was struck by a truck traveling at high speed. Cervical computed tomography showed a dislocation between the C5 and C6 vertebrae (Panel A, sagittal reconstruction). Physical examination...

IMAGES IN CLINICAL MEDICINE: A Medical Mystery â A 71-Year-Old Man with Pancytopenia

Julia M. Braza, M.D. and Parul Bhargava, M.D. — Thu, 30Â OctÂ 2008 00:00:00 -05:00

A 71-year-old-man presented to the emergency department with dizziness, progressive lethargy, and confusion, which he reported having had for the past 10 days. A complete blood count showed pancytopenia. A...

REVIEW ARTICLE: Blunt Aortic Injury

Thu, 16Â OctÂ 2008 00:00:00 -05:00

Blunt aortic injury occurs in less than 1% of motor vehicle crashes but is responsible for 16% of the deaths.1 This injury is second only to head injury as the...

CLINICAL DECISIONS: Management of Skin and Soft-Tissue Infection â Polling Results

Sarah P. Hammond, M.D., and Lindsey R. Baden, M.D. — Thu, 09Â OctÂ 2008 00:00:00 -05:00

In early September, we presented a case of a college athlete with a skin and soft-tissue infection in Clinical Decisions,1 an interactive feature designed to assess how readers would manage...

IMAGES IN CLINICAL MEDICINE: Pneumopericardium

Mehdi Karoui, M.D., Ph.D. and Petru Octav Bucur, M.D. — Thu, 02Â OctÂ 2008 00:00:00 -05:00

A 47-year-old homeless man presented to the emergency department 1 week after the onset of chest pain. He was hemodynamically stable. The physical examination was unremarkable. A routine complete blood...

CLINICAL DECISIONS: Management of Skin and Soft-Tissue Infection

Thu, 04Â SepÂ 2008 00:00:00 -05:00

A 20-year-old college basketball player presents to the emergency department with a 2-day history of a red, painful area on his right buttock. He reports that there was no specific...

REVIEW ARTICLE: Current Management of Acute Cutaneous Wounds

Adam J. Singer, M.D., and Alexander B. Dagum, M.D. — Thu, 04Â SepÂ 2008 00:00:00 -05:00

In 2005, 11.8 million wounds were treated in emergency departments in the United States.1 More than half a million burns and 7.3 million lacerations are treated annually,2 and wounds caused...

REVIEW ARTICLE: Management of Acute Bleeding from a Peptic Ulcer

Thu, 28Â AugÂ 2008 00:00:00 -05:00

Acute upper gastrointestinal hemorrhage, which is defined as bleeding proximal to the ligament of Treitz, is a prevalent and clinically significant condition with important implications for health care costs worldwide....

CLINICAL THERAPEUTICS: Acetylcysteine for Acetaminophen Poisoning

Kennon J. Heard, M.D. — Thu, 17Â JulÂ 2008 00:00:00 -05:00

A 25-year-old man presents to the emergency department with a toothache. During the evaluation, the physician determines that the patient has been taking large doses of over-the-counter acetaminophen along with...

ORIGINAL ARTICLE: Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation

Thu, 03Â JulÂ 2008 00:00:00 -05:00

Background: During the administration of advanced cardiac life support for resuscitation from cardiac arrest, a combination of vasopressin and epinephrine may be more effective than epinephrine or vasopressin alone, but...

VIDEOS IN CLINICAL MEDICINE: Placement of a Femoral Venous Catheter

Thu, 26Â JunÂ 2008 00:00:00 -05:00

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IMAGES IN CLINICAL MEDICINE: Bladder Foreign Body

William E. Corcoran, M.D. and Nancy Phifer, M.D. — Thu, 19Â JunÂ 2008 00:00:00 -05:00

A 35-year-old woman with bipolar disorder was found wandering on a highway screaming and crying, with disorganized speech. She was evaluated in the emergency department, and computed tomography of the...

IMAGES IN CLINICAL MEDICINE: Rupture of a Calcified Achilles' Tendon

Marius C. Wick, M.D. and Michael Rieger, M.D. — Thu, 12Â JunÂ 2008 00:00:00 -05:00

A 69-year-old man presented at the emergency room with stabbing pain and swelling of the right lower leg on standing up from a seated position. On clinical examination, rupture of...

IMAGES IN CLINICAL MEDICINE: Bilateral Peritonsillar Abscesses

James F. Fiechtl, M.D. and Lawrence B. Stack, M.D. — Thu, 05Â JunÂ 2008 00:00:00 -05:00

A 19-year-old woman presented to the emergency department with a 10-day history of intermittent odynophagia, voice changes, and fever. Before her visit to the emergency department, she was treated with...

ORIGINAL ARTICLE: Hypothermia Therapy after Traumatic Brain Injury in Children

Thu, 05Â JunÂ 2008 00:00:00 -05:00

Background: Hypothermia therapy improves survival and the neurologic outcome in animal models of traumatic brain injury. However, the effect of hypothermia therapy on the neurologic outcome and mortality among children...

VIDEOS IN CLINICAL MEDICINE: Cricothyroidotomy

James Hsiao, M.D., and Victor Pacheco-Fowler, M.D. — Thu, 29Â MayÂ 2008 00:00:00 -05:00

...

IMAGES IN CLINICAL MEDICINE: Ocular Trauma Due to a Water-Bottle Cap

Shiyoung Roh, M.D. and Mark E. Patron, M.D. — Thu, 22Â MayÂ 2008 00:00:00 -05:00

A 14-year-old girl presented with a traumatic injury to the right eye from a water-bottle cap, caused by the increasingly popular adolescent activity of twisting and crushing an empty plastic...

ORIGINAL ARTICLE: Cardiac Troponin and Outcome in Acute Heart Failure

Thu, 15Â MayÂ 2008 00:00:00 -05:00

Background: Cardiac troponin provides diagnostic and prognostic information in acute coronary syndromes, but its role in acute decompensated heart failure is unclear. The purpose of our study was to describe...

IMAGES IN CLINICAL MEDICINE: Changes in the Brain Stem and Fundus in Malignant Hypertension

Michael S. Lee, M.D. and Brian J. Tienor, B.S. — Thu, 01Â MayÂ 2008 00:00:00 -05:00

A 53-year-old man presented with a 4-week history of bilateral retrobulbar headache and blurred vision. His blood pressure was 220/135 mm Hg; his neurologic examination was unremarkable. He had no...

VIDEOS IN CLINICAL MEDICINE: Female Urethral Catheterization

Rafael Ortega, M.D., Linda Ng, M.D., Pavan Sekhar, B.S., and Michael Song, M.A. — Thu, 03Â AprÂ 2008 00:00:00 -05:00

...

IMAGES IN CLINICAL MEDICINE: Crystalluria from Acyclovir Use

William J. Mason, M.D. and Hilary H. Nickols, M.D., Ph.D. — Thu, 27Â MarÂ 2008 00:00:00 -05:00

A 60-year-old man infected with the human immunodeficiency virus (HIV) (CD4 count of 450 per cubic millimeter and HIV viral load of <50 copies per milliliter) who had HIV-associated dementia...

REVIEW ARTICLE: Acute Pulmonary Embolism

Victor F. Tapson, M.D. — Thu, 06Â MarÂ 2008 00:00:00 -05:00

Pulmonary embolism, most commonly originating from deep venous thrombosis of the legs, ranges from asymptomatic, incidentally discovered emboli to massive embolism causing immediate death. Chronic sequelae of venous thromboembolism (deep...

IMAGES IN CLINICAL MEDICINE: Calcified Hematoma of the Skull

Ali-Reza Fathi, M.D. and Dominique Erni, M.D. — Thu, 31Â JanÂ 2008 00:00:00 -05:00

A 46-year-old man presented with a hard subcutaneous mass in the left side of the forehead (Panel A). He reported that the lesion had developed rapidly after a head trauma...

IMAGES IN CLINICAL MEDICINE: Open Mandibular Fracture with Malocclusion

Joseph R. Shiber, M.D. and Kelly Carter, M.D. — Thu, 31Â JanÂ 2008 00:00:00 -05:00

A 21-year-old healthy man presented to the emergency department with mouth pain and bleeding, after being struck with a gun on his right lower jaw. Physical examination revealed upward displacement...

IMAGES IN CLINICAL MEDICINE: Penetrating Orbital Trauma

Harsha S. Reddy, M.D. and Eli Chang, M.D. — Thu, 17Â JanÂ 2008 00:00:00 -05:00

A 15-year-old boy presented with an inability to open his left eye after being assaulted with a pencil. A small laceration was noted on the left eyebrow (Panel A). An...

ORIGINAL ARTICLE: A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction

Thu, 17Â JanÂ 2008 00:00:00 -05:00

Background: If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction....

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 1-2008 â A 45-Year-Old Man with Sudden Onset of Abdominal Pain and Hypotension

Thu, 10Â JanÂ 2008 00:00:00 -05:00

Dr. Megan Fix (Emergency Medicine): A 45-year-old man was transferred on an emergency basis to this hospital from a community health center because of abdominal pain and hypotension.

On the day...

EDITORIAL: Factoring PAF in Anaphylaxis

A. Wesley Burks, M.D. — Thu, 03Â JanÂ 2008 00:00:00 -05:00

Anaphylaxis has been recognized for more than 100 years, but it remains a condition that is difficult to predict, diagnose, and treat. Generally defined as a serious allergic reaction that...

ORIGINAL ARTICLE: Platelet-Activating Factor, PAF Acetylhydrolase, and Severe Anaphylaxis

Thu, 03Â JanÂ 2008 00:00:00 -05:00

Background: Platelet-activating factor (PAF) is an important mediator of anaphylaxis in animals, and interventions that block PAF prevent fatal anaphylaxis. The roles of PAF and PAF acetylhydrolase, the enzyme that...

VIDEOS IN CLINICAL MEDICINE: Central Venous Catheterization â Subclavian Vein

Thu, 13Â DecÂ 2007 00:00:00 -05:00

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CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 36-2007 â A 31-Year-Old Woman with Rash, Fever, and Hypotension

Thu, 22Â NovÂ 2007 00:00:00 -05:00

Dr. Jeffrey O. Greenberg (Medicine): A 31-year-old woman was admitted to this hospital because of facial swelling, fever, and hypotension.

The patient had relapsing and remitting multiple sclerosis, associated with severe...

IMAGES IN CLINICAL MEDICINE: Cerebral Tuberculoma

Juan Carlos CataÃ±o, M.D. — Thu, 22Â NovÂ 2007 00:00:00 -05:00

A 29-year-old homeless man was admitted to the hospital after being stabbed in the chest. A hemothorax was diagnosed, and a chest tube was placed. One day after admission, he...

VIDEOS IN CLINICAL MEDICINE: Abscess Incision and Drainage

Thu, 08Â NovÂ 2007 00:00:00 -05:00

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CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 34-2007 â A 77-Year-Old Man with Ear Pain, Difficulty Speaking, and Altered Mental Status

Thu, 08Â NovÂ 2007 00:00:00 -05:00

A 77-year-old right-handed man was admitted to the hospital because of the recent onset of pain in the ear, difficulty speaking, and altered mental status. The patient had been well...

IMAGES IN CLINICAL MEDICINE: Herpes Labialis

Julian W. Tang, M.D. and Paul K.S. Chan, M.D. — Thu, 01Â NovÂ 2007 00:00:00 -05:00

A 68-year-old man with a history of asthma and chronic obstructive pulmonary disease was admitted to our hospital with a 1-day history of dyspnea, fever, and epigastric and chest pain....

EDITORIAL: Bell's Palsy â Is Glucocorticoid Treatment Enough?

Donald H. Gilden, M.D., and Kenneth L. Tyler, M.D. — Thu, 18Â OctÂ 2007 00:00:00 -05:00

Approximately a third of cases of acute peripheral facial weakness are caused by trauma, diabetes mellitus, hypertension, eclampsia, the Ramsay Hunt syndrome (facial palsy with zoster oticus caused by varicellaâzoster...

REVIEW ARTICLE: Time to Treatment in Primary Percutaneous Coronary Intervention

Thu, 18Â OctÂ 2007 00:00:00 -05:00

Early administration of reperfusion therapy improves survival in patients with ST-elevation myocardial infarction by reestablishing coronary blood flow within the occluded infarct-related artery.1 Primary percutaneous coronary intervention (PCI) is superior...

ORIGINAL ARTICLE: Early Treatment with Prednisolone or Acyclovir in Bell's Palsy

Thu, 18Â OctÂ 2007 00:00:00 -05:00

Background: Corticosteroids and antiviral agents are widely used to treat the early stages of idiopathic facial paralysis (i.e., Bell's palsy), but their effectiveness is uncertain.

Methods: We conducted a double-blind, placebo-controlled,...

VIDEOS IN CLINICAL MEDICINE: Chest-Tube Insertion

Thu, 11Â OctÂ 2007 00:00:00 -05:00

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IMAGES IN CLINICAL MEDICINE: White Phosphorus Dermal Burns

Johnathan C. Conner, M.D. and Vikhyat S. Bebarta, M.D. — Thu, 11Â OctÂ 2007 00:00:00 -05:00

A 19-year-old man presented with painful burns on his posterior scalp after exposure to an incendiary agent. Smoke emanated from the wounds on removal of the dressing that had been...

IMAGES IN CLINICAL MEDICINE: Pneumocephalus Associated with Pneumosinus Dilatans Frontalis

Neil Bhattacharyya, M.D. and Robert M. Friedlander, M.D. — Thu, 13Â SepÂ 2007 00:00:00 -05:00

An 87-year-old woman presented to the emergency department with an acute-onset severe global headache of 36 hours' duration, with greater occipital involvement than frontal involvement. She reported no recent trauma,...

IMAGES IN CLINICAL MEDICINE: An Intraabdominal Cyst

Cornelis H. van der Vlies, M.D. and Olivier R.C. Busch, M.D., Ph.D. — Thu, 02Â AugÂ 2007 00:00:00 -05:00

A 50-year-old woman presented with abdominal tenderness, fever, and vaginal bleeding. Physical examination showed a periumbilical mass and necrosis of the upper wall of the vagina. Laboratory data were notable...

IMAGES IN CLINICAL MEDICINE: Ascending Aortic Aneurysm in a Young Adult

Paul D. Harris, M.B., Ch.B. and Chris Cokis, F.A.N.Z.C.A. — Thu, 26Â JulÂ 2007 00:00:00 -05:00

A 37-year-old man presented to the emergency department with chest pain of 2 days' duration. The pain was heavy in character, intermittent, and made worse by deep inspiration and lying...

VIDEOS IN CLINICAL MEDICINE: Positive-Pressure Ventilation with a Face Mask and a Bag-Valve Device

Thu, 26Â JulÂ 2007 00:00:00 -05:00

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CLINICAL PRACTICE: Skin and Soft-Tissue Infections Caused by Methicillin-Resistant

Robert S. Daum, M.D., C.M. — Thu, 26Â JulÂ 2007 00:00:00 -05:00

A 37-year-old man presents for the evaluation of localized swelling and tenderness of the left leg just below the knee. He suspects this lesion developed after a spider bite, although...

VIDEOS IN CLINICAL MEDICINE: Central Venous Catheterization

Thu, 24Â MayÂ 2007 00:00:00 -05:00

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ORIGINAL ARTICLE: Advanced Life Support for Out-of-Hospital Respiratory Distress

Thu, 24Â MayÂ 2007 00:00:00 -05:00

Background: Respiratory distress is a common symptom of patients transported to hospitals by emergency medical services (EMS) personnel. The benefit of advanced life support for such patients has not been...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 15-2007 â A 20-Year-Old Woman with Asthma and Cardiorespiratory Arrest

Thu, 17Â MayÂ 2007 00:00:00 -05:00

A 20-year-old woman with asthma was taken to the emergency room of another hospital because of cardiorespiratory arrest. The patient had had severe asthma since childhood. She was born after...

VIDEOS IN CLINICAL MEDICINE: Orotracheal Intubation

Thu, 26Â AprÂ 2007 00:00:00 -05:00

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CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 10-2007 â A 55-Year-Old Man Impaled in a Rowing Accident

Thu, 29Â MarÂ 2007 00:00:00 -05:00

A 55-year-old man was admitted to this hospital after being impaled by the prow of a racing shell in a rowing accident.

The patient, who was in excellent health, was sculling...

IMAGES IN CLINICAL MEDICINE: Hydrofluoric Acid Burn

Martin W. DÃ¼nser, M.D. and Josef Rieder, M.D. — Thu, 08Â FebÂ 2007 00:00:00 -05:00

A 45-year-old healthy man was involved in demolishing an industrial plant in which glass had been etched. He was exposed to a reservoir of 70% hydrofluoric acid while repairing a...

IMAGES IN CLINICAL MEDICINE: Urine Fluorescence in Ethylene Glycol Poisoning

Christopher M. McStay, M.D. and Peter E. Gordon, M.D. — Thu, 08Â FebÂ 2007 00:00:00 -05:00

A 38-year-old man presented to the emergency department after reportedly ingesting antifreeze. He appeared to be intoxicated and was agitated and combative; chemical sedation was induced. Initial laboratory studies revealed...

IMAGES IN CLINICAL MEDICINE: Contraceptive Failure

Fred C. Cobey, M.D., M.P.H. and Hiroo Takayama, M.D. — Thu, 25Â JanÂ 2007 00:00:00 -05:00

A 60-year-old Somalian woman presented to the emergency department with pain in the upper abdomen. Her medical history was notable for the placement of an intrauterine device (IUD) while she...

REVIEW ARTICLE: International Aeromedical Evacuation

Peter G. Teichman, M.D., M.P.A., Yoel Donchin, M.D., and Raphael J. Kot, M.D. — Thu, 18Â JanÂ 2007 00:00:00 -05:00

Worldwide, when the needs of injured or ill patients exceed what local clinics and hospitals can provide, urgent evacuation by air to the nearest well-equipped medical facility becomes the key...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 1-2007 â A 40-Year-Old Woman with Epistaxis, Hematemesis, and Altered Mental Status

Thu, 11Â JanÂ 2007 00:00:00 -05:00

Dr. Amy Jo Chien (Medicine): A 40-year-old woman was admitted to the emergency department of this hospital because of the sudden onset of headache, loss of consciousness, and coagulopathy.

The patient...

IMAGES IN CLINICAL MEDICINE: Prevertebral Emphysema after a Dental Procedure

Kumar Sujeet, M.D. and Stuti Shankar, M.D. — Thu, 11Â JanÂ 2007 00:00:00 -05:00

A 47-year-old woman with diabetes was seen in the emergency room with difficulty swallowing, bilateral chest pain, and a foreign-body sensation in her throat. Earlier that day, she had undergone...

CLINICAL PRACTICE: Concussion

Allan H. Ropper, M.D., and Kenneth C. Gorson, M.D. — Thu, 11Â JanÂ 2007 00:00:00 -05:00

A 64-year-old woman slipped on an icy walk, falling forward and striking her forehead. She had a brief convulsion immediately after the fall, was unresponsive for less than 1 minute,...

CLINICAL THERAPEUTICS: Primary PCI for Myocardial Infarction with ST-Segment Elevation

Ellen C. Keeley, M.D., and L. David Hillis, M.D. — Thu, 04Â JanÂ 2007 00:00:00 -05:00

A 58-year-old man has chest pain at 9:30 a.m.; 3 hours later, he calls for an ambulance. Paramedics arrive, provide standard treatment, and transport him to the nearest emergency department....

CLINICAL PROBLEM-SOLVING: Sum of the Parts

Thu, 07Â DecÂ 2006 00:00:00 -05:00

A 36-year-old Pakistani woman presented to the emergency room with a 10-day history of a nonproductive cough, dyspnea, and fever. She reported having no night sweats and no contact with...

IMAGES IN CLINICAL MEDICINE: Medical Mystery â Abnormal Abdominal Radiograph

Kumiko Tajima, M.D., Ph.D. and Masahiko Kurabayashi, M.D., Ph.D. — Thu, 07Â DecÂ 2006 00:00:00 -05:00

A 50-year-old woman presented to the emergency department with obtundation and hypotension. She had a 1-month history of slight fever, before which she had been well. On abdominal examination, an...

EDITORIAL: Reducing the Door-to-Balloon Time for Myocardial Infarction with ST-Segment Elevation

Mauro Moscucci, M.D., and Kim A. Eagle, M.D. — Thu, 30Â NovÂ 2006 00:00:00 -05:00

It has been 27 years since the initial report of successful reperfusion of occluded coronary arteries with thrombolytic therapy in patients with acute myocardial infarction,1 and 20 years since the...

SPECIAL ARTICLE: Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction

Thu, 30Â NovÂ 2006 00:00:00 -05:00

Background: Prompt reperfusion treatment is essential for patients who have myocardial infarction with ST-segment elevation. Guidelines recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon...

PERSPECTIVE: Murder or Mercy? Hurricane Katrina and the Need for Disaster Training

Thu, 16Â NovÂ 2006 00:00:00 -05:00

In July 2006, a New Orleans physician, Anna Pou, and two nurses, Lori Budo and Cheri Landry, were arrested and accused of the second-degree murder of four patients at Memorial...

IMAGES IN CLINICAL MEDICINE: Crohn's Disease and an Olive

Susan Shedda, F.R.A.C.S. and Frank Frizelle, F.R.A.C.S. — Thu, 09Â NovÂ 2006 00:00:00 -05:00

An otherwise healthy 45-year-old man presented with a 3-day history of colicky central abdominal pain associated with nausea and vomiting. His bowel habits had not changed, and he had no...

VIDEOS IN CLINICAL MEDICINE: Paracentesis

Thu, 09Â NovÂ 2006 00:00:00 -05:00

...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 34-2006 â A 72-Year-Old Woman with Nausea Followed by Hypotension and Respiratory Failure

Thu, 09Â NovÂ 2006 00:00:00 -05:00

Dr. David S. Frankel (Medicine): A 72-year-old woman was admitted to this hospital because of respiratory failure and hypotension.

During the week before admission, the patient and other members of her...

IMAGES IN CLINICAL MEDICINE: Vascular Occlusion after Intraarterial Cocaine Injection

Mark C. Stover, M.D. and Jeanmarie Perrone, M.D. — Thu, 09Â NovÂ 2006 00:00:00 -05:00

A 54-year-old man with a history of parenteral substance abuse, hepatitis C virus infection, and poor peripheral venous access presented to the emergency department with a history of progressive pain,...

CLINICAL PROBLEM-SOLVING: The Missing Piece

Thu, 02Â NovÂ 2006 00:00:00 -05:00

A 21-year-old man presented to the emergency department after a 2-day history of increasing pain in the right lower quadrant. The pain was dull and nonradiating, was not exacerbated by...

VIDEOS IN CLINICAL MEDICINE: Basic Laceration Repair

Todd W. Thomsen, M.D., Derek A. Barclay, M.D., and Gary S. Setnik, M.D. — Thu, 26Â OctÂ 2006 00:00:00 -05:00

...

PERSPECTIVE: Surviving Sepsis â Practice Guidelines, Marketing Campaigns, and Eli Lilly

Thu, 19Â OctÂ 2006 00:00:00 -05:00

Practice guidelines approved by expert panels are intended to standardize care in such a way as to improve health outcomes. In recent years, the developers of such standards have started...

VIDEOS IN CLINICAL MEDICINE: Thoracentesis

Todd W. Thomsen, M.D., Jennifer DeLaPena, M.D., and Gary S. Setnik, M.D. — Thu, 12Â OctÂ 2006 00:00:00 -05:00

...

VIDEOS IN CLINICAL MEDICINE: Lumbar Puncture

Thu, 28Â SepÂ 2006 00:00:00 -05:00

...

PERSPECTIVE: Crisis in the Emergency Department

Thu, 28Â SepÂ 2006 00:00:00 -05:00

At 2 a.m. on July 27, 1996, I stood in the ambulance bay of Grady Memorial Hospital, awaiting the first of 35 severely injured bombing victims who would be brought...

CLINICAL PRACTICE: Acute Vulvovaginitis

Linda O. Eckert, M.D. — Thu, 21Â SepÂ 2006 00:00:00 -05:00

A 24-year-old sexually active woman presents with a 3-day history of vaginal pruritus and increased vaginal discharge. One year before presentation, she had the same symptoms, which resolved with use...

IMAGES IN CLINICAL MEDICINE: Elevated Jugular Venous Pressure

SÃ¡ndor GyÃ¶rik, M.D. and Andrea Menafoglio, M.D. — Thu, 14Â SepÂ 2006 00:00:00 -05:00

A 43-year-old man presented to the emergency room in respiratory distress after a 3-week illness. He had a history of alcoholism but no other serious illness. He had a respiratory...

ORIGINAL ARTICLE: Methicillin-Resistant Infections among Patients in the Emergency Department

Thu, 17Â AugÂ 2006 00:00:00 -05:00

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly recognized in infections among persons in the community without established risk factors for MRSA.

Methods: We enrolled adult patients with acute, purulent skin and...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 24-2006 â A 40-Year-Old Woman with Hypotension after an Overdose of Amlodipine

N. Stuart Harris, M.D., M.F.A. — Thu, 10Â AugÂ 2006 00:00:00 -05:00

Dr. Murray McLachlan (Emergency Medicine): A 40-year-old woman was transferred to the emergency department of this hospital because of hypotension. She had been well until the early afternoon of the...

EDITORIAL: Cardiac Resuscitation â When Is Enough Enough?

Gordon A. Ewy, M.D. — Thu, 03Â AugÂ 2006 00:00:00 -05:00

Cardiac arrest is a leading cause of death in the United States.1 In spite of periodic updates of the Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of the American...

CLINICAL PROBLEM-SOLVING: A Sharp Right Turn

Thu, 03Â AugÂ 2006 00:00:00 -05:00

A 60-year-old man presented to the emergency department for evaluation of rectal bleeding, syncope, and pain in the right leg. Five days earlier, diffuse abdominal pain that worsened with movement...

ORIGINAL ARTICLE: Validation of a Rule for Termination of Resuscitation in Out-of-Hospital Cardiac Arrest

Thu, 03Â AugÂ 2006 00:00:00 -05:00

Background: We prospectively evaluated a clinical prediction rule to be used by emergency medical technicians (EMTs) trained in the use of an automated external defibrillator for the termination of basic...

ORIGINAL ARTICLE: Postexposure Treatment with Doxycycline for the Prevention of Tick-Borne Relapsing Fever

Thu, 13Â JulÂ 2006 00:00:00 -05:00

Background: Tick-borne relapsing fever (TBRF) is an acute febrile illness. In Israel, TBRF is caused by Borrelia persica and is transmitted by Ornithodoros tholozani ticks. We examined the safety and...

IMAGES IN CLINICAL MEDICINE: Venous Air Embolism

Antoine Cuvelier, M.D., Ph.D. and Jean-Francois Muir, M.D. — Thu, 22Â JunÂ 2006 00:00:00 -05:00

An 82-year-old man was transferred to our hospital for the treatment of respiratory distress after computed tomography (CT) of the thorax. He had undergone a follow-up evaluation seven years after...

IMAGES IN CLINICAL MEDICINE: Tooth Aspiration

Yevgeniy Ostrinsky, M.D. and Zaza Cohen, M.D. — Thu, 15Â JunÂ 2006 00:00:00 -05:00

A 77-year-old man with a history of hypertension was found on the sidewalk, face down and unresponsive. He had tonicâclonic movements and was brought to the hospital. The initial chest...

EDITORIAL: Fluid-Management Strategies in Acute Lung Injury â Liberal, Conservative, or Both?

Emanuel P. Rivers, M.D., M.P.H. — Thu, 15Â JunÂ 2006 00:00:00 -05:00

One of the factorial assessments carried out in the Fluids and Catheters Treatment Trial (FACTT) conducted by the National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical...

ORIGINAL ARTICLE: Comparison of Two Fluid-Management Strategies in Acute Lung Injury

Thu, 15Â JunÂ 2006 00:00:00 -05:00

Background: Optimal fluid management in patients with acute lung injury is unknown. Diuresis or fluid restriction may improve lung function but could jeopardize extrapulmonary-organ perfusion.

Methods: In a randomized study, we...

EDITORIAL: Accuracy or Outcome in Suspected Pulmonary Embolism

Arnaud Perrier, M.D., and Henri Bounameaux, M.D. — Thu, 01Â JunÂ 2006 00:00:00 -05:00

Sixteen years ago, the results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study1 were published. That large-scale, multicenter trial definitively established the diagnostic characteristics of ventilationâperfusion scintigraphy of...

CLINICAL PROBLEM-SOLVING: Thinking outside the Box

Ramin Farzaneh-Far, M.D., Talya Schwarzberg, M.D., and Stuart B. Mushlin, M.D. — Thu, 01Â JunÂ 2006 00:00:00 -05:00

A 35-year-old man with advanced acquired immunodefiency syndrome (AIDS) presented to the emergency department after a witnessed syncopal event. He had noted light-headedness after walking from the bathroom to his...

ORIGINAL ARTICLE: Outcomes of In-Hospital Ventricular Fibrillation in Children

Thu, 01Â JunÂ 2006 00:00:00 -05:00

Background: Ventricular fibrillation and ventricular tachycardia are less common causes of cardiac arrest in children than in adults. These tachyarrhythmias can also begin during cardiopulmonary resuscitation (CPR), presumably as reperfusion...

ORIGINAL ARTICLE: Multidetector Computed Tomography for Acute Pulmonary Embolism

Thu, 01Â JunÂ 2006 00:00:00 -05:00

Background: The accuracy of multidetector computed tomographic angiography (CTA) for the diagnosis of acute pulmonary embolism has not been determined conclusively.

Methods: The Prospective Investigation of Pulmonary Embolism Diagnosis II trial...

VIDEOS IN CLINICAL MEDICINE: Male Urethral Catheterization

Todd W. Thomsen, M.D., and Gary S. Setnik, M.D. — Thu, 25Â MayÂ 2006 00:00:00 -05:00

...

EDITORIAL: Pulmonary-Artery Catheters â Peace at Last?

Deborah Shure, M.D. — Thu, 25Â MayÂ 2006 00:00:00 -05:00

The history of the use of the pulmonary-artery catheter (PAC) illustrates a great deal about physicians' often uncritical acceptance of technology in clinical applications. In 1956, Forssmann, Cournand, and Richards...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 16-2006 â A 72-Year-Old Woman Admitted to the Emergency Department because of a Sudden Change in Mental Status

Stephen H. Thomas, M.D., M.P.H., Lee H. Schwamm, M.D., and Michael H. Lev, M.D. — Thu, 25Â MayÂ 2006 00:00:00 -05:00

Dr. Emily Senecal (Emergency Medicine): A 72-year-old left-handed woman was transported by helicopter from her home to the emergency department of this hospital because of a sudden change in mental...

ORIGINAL ARTICLE: Pulmonary-Artery versus Central Venous Catheter to Guide Treatment of Acute Lung Injury

Thu, 25Â MayÂ 2006 00:00:00 -05:00

Background: The balance between the benefits and the risks of pulmonary-artery catheters (PACs) has not been established.

Methods: We evaluated the relationship of benefits and risks of PACs in 1000 patients...

IMAGES IN CLINICAL MEDICINE: Rotator-Cuff Tear

Paranee Auethavekiat, M.D. and Clement J. Michet, Jr., M.D. — Thu, 11Â MayÂ 2006 00:00:00 -05:00

A 72-year-old man with advanced glenohumeral and acromioclavicular arthritis presented with a painless mass over his left shoulder that had become progressively larger over a period of about a year...

VIDEOS IN CLINICAL MEDICINE: Arthrocentesis of the Knee

Thu, 11Â MayÂ 2006 00:00:00 -05:00

...

IMAGES IN CLINICAL MEDICINE: Reexpansion Pulmonary Edema after Treatment of Pneumothorax

Syed Mohammad Tariq, F.R.C.P. and Tabinda Sadaf, M.B., B.S. — Thu, 11Â MayÂ 2006 00:00:00 -05:00

A 50-year-old smoker presented with acute-onset breathlessness and right-sided chest pain of four days' duration. There was no history of chest trauma. A posteroanterior chest radiograph (Panel A) demonstrated a...

IMAGES IN CLINICAL MEDICINE: Spurious Platelet Count

Michele Siegenthaler, M.D. and Olivier Spertini, M.D. — Thu, 04Â MayÂ 2006 00:00:00 -05:00

A previously healthy 48-year-old man was admitted for severe burns involving his face, thorax, and upper and lower limbs (45 percent of body-surface area) associated with an inhalation injury. The...

VIDEOS IN CLINICAL MEDICINE: Nasogastric Intubation

Todd W. Thomsen, M.D., Robert W. Shaffer, M.D., and Gary S. Setnik, M.D. — Thu, 27Â AprÂ 2006 00:00:00 -05:00

...

PERSPECTIVE: The South Asian Earthquake Six Months Later â An Ongoing Crisis

Thu, 27Â AprÂ 2006 00:00:00 -05:00

The magnitude 7.6 earthquake that struck northern Pakistan and India on October 8, 2005, was the world's third-deadliest natural disaster of the past 25 years, surpassed only by the 2004...

ORIGINAL ARTICLE: Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department

Thu, 20Â AprÂ 2006 00:00:00 -05:00

Background: Vomiting limits the success of oral rehydration in children with gastroenteritis. We conducted a double-blind trial to determine whether a single oral dose of ondansetron, an antiemetic, would improve...

PERSPECTIVE: Adaptations

Thu, 13Â AprÂ 2006 00:00:00 -05:00

Two outpatient clinics serving the disenfranchised have adapted in creative ways to deliver community-based care to New Orleans. Charity Hospital's HIV Outpatient (HOP) Clinic, funded under the Ryan White Comprehensive...

PERSPECTIVE: After the Storm â Health Care Infrastructure in Post-Katrina New Orleans

Thu, 13Â AprÂ 2006 00:00:00 -05:00

On September 2, 2005, when Wildlife and Fisheries boats finally evacuated patients and staff from Charity Hospital in New Orleans, we could not fully comprehend the devastation of our health...

IMAGES IN CLINICAL MEDICINE: Talc Retinopathy

Fayssal El-Jabali, B.S. and Steven Cohen, M.D. — Thu, 23Â MarÂ 2006 00:00:00 -05:00

A 37-year-old woman with chronic hepatitis C presented with blurred vision after losing her eyeglasses. Her corrected visual acuity was 20/30 in both eyes. On questioning, she reported intravenous use...

IMAGES IN CLINICAL MEDICINE: Pneumomediastinum

Kuo-Hsien Chiang, M.D. and Andy Shau-Bin Chou, M.D. — Thu, 16Â MarÂ 2006 00:00:00 -05:00

A 15-year-old boy had the sudden onset of sharp, piercing, centralized chest pain while at rest. He had no important medical history. He also reported a sore throat and said...

IMAGES IN CLINICAL MEDICINE: Veiled Right Kidney Sign in a Patient with Valentino's Syndrome

Hsiu-Po Wang, M.D. and Wei-Chih Su, M.D. — Thu, 09Â MarÂ 2006 00:00:00 -05:00

A 72-year-old man presented to the emergency department with severe abdominal pain of two days' duration in the right lower quadrant. He reported recent use of nonsteroidal antiinflammatory drugs for...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 7-2006 â A 47-Year-Old Man with Altered Mental Status and Acute Renal Failure

J. Kimo Takayesu, M.D., M.Sc., Hasan Bazari, M.D., and Michael Linshaw, M.D. — Thu, 09Â MarÂ 2006 00:00:00 -05:00

A 47-year-old man was transferred to the emergency department of this hospital at 10 a.m. on a day in early June because of altered mental status and acute renal failure....

REVIEW ARTICLE: Management of Crush-Related Injuries after Disasters

Thu, 09Â MarÂ 2006 00:00:00 -05:00

Disasters can rarely be anticipated, much less prevented. After both natural disasters (e.g., earthquakes, hurricanes, tornadoes, and landslides) and man-made catastrophes (e.g., wars, mining accidents, and terrorist attacks), injuries to...

CLINICAL PRACTICE: Supraventricular Tachycardia

Etienne DelacrÃ©taz, M.D. — Thu, 09Â MarÂ 2006 00:00:00 -05:00

A 28-year-old woman suddenly has rapid palpitations accompanied by chest pain and dizziness while playing her cello. She is brought to an emergency department. She has a faint regular pulse...

IMAGES IN CLINICAL MEDICINE: Colonic Ileus

Senator Hazelwood, M.D. and Denise Burton, Ph.D. — Thu, 16Â FebÂ 2006 00:00:00 -05:00

A 77-year-old man with a history of hypertension, diabetes mellitus, and seizure disorder presented to the emergency room with abdominal pain and distention of approximately two to three days' duration....

IMAGES IN CLINICAL MEDICINE: Subacute Urinary Retention

Sameer Kassem, M.D. and Gideon Friedman, M.D. — Thu, 09Â FebÂ 2006 00:00:00 -05:00

An 88-year-old man with benign prostate hypertrophy and ischemic heart disease who had undergone an anterior peritoneal resection due to adenocarcinoma of the rectum presented with a three-month history of...

ORIGINAL ARTICLE: Human Botulism Immune Globulin for the Treatment of Infant Botulism

Thu, 02Â FebÂ 2006 00:00:00 -05:00

Background: We created the orphan drug Human Botulism Immune Globulin Intravenous (Human) (BIG-IV), which neutralizes botulinum toxin, and evaluated its safety and efficacy in treating infant botulism, the intestinal-toxemia form...

IMAGES IN CLINICAL MEDICINE: The Importance of Early Cervical-Spine Radiography

Morgan P. McMonagle, M.B. — Thu, 26Â JanÂ 2006 00:00:00 -05:00

A 19-year-old man was brought to the emergency department after a high-speed motorbike collision. The patient had a score of 3 on the Glasgow Coma Scale, (possible scores range from...

REVIEW ARTICLE: Aneurysmal Subarachnoid Hemorrhage

Jose I. Suarez, M.D., Robert W. Tarr, M.D., and Warren R. Selman, M.D. — Thu, 26Â JanÂ 2006 00:00:00 -05:00

Nontraumatic subarachnoid hemorrhage is a neurologic emergency characterized by the extravasation of blood into the spaces covering the central nervous system that are filled with cerebrospinal fluid. The leading cause...

CLINICAL PRACTICE: Preventing Nephropathy Induced by Contrast Medium

Brendan J. Barrett, M.B., and Patrick S. Parfrey, M.D. — Thu, 26Â JanÂ 2006 00:00:00 -05:00

A 71-year-old man with type 2 diabetes and hypertension is referred for coronary angiography. His medications include metformin and a thiazide. Before the angiogram, his serum creatinine level is 1.8...

SPECIAL ARTICLE: A National Evaluation of the Effect of Trauma-Center Care on Mortality

Thu, 26Â JanÂ 2006 00:00:00 -05:00

Background: Hospitals have difficulty justifying the expense of maintaining trauma centers without strong evidence of their effectiveness. To address this gap, we examined differences in mortality between level 1 trauma...

IMAGES IN CLINICAL MEDICINE: Heavy-Metal Meals of Mercury

Jon K.C. Yoong, M.R.C.P. — Thu, 19Â JanÂ 2006 00:00:00 -05:00

A 28-year-old flight engineer from Singapore presented with nausea, lethargy, and tremor. He had been defecating an increasingly large quantity of silver droplets, which were identified on laboratory analysis as...

REVIEW ARTICLE: Community-Acquired Bacterial Meningitis in Adults

Thu, 05Â JanÂ 2006 00:00:00 -05:00

Bacterial meningitis is a medical, neurologic, and sometimes neurosurgical emergency that requires a multidisciplinary approach. Bacterial meningitis has an annual incidence of 4 to 6 cases per 100,000 adults (defined...

IMAGES IN CLINICAL MEDICINE: Urinary Calcium Oxalate Crystals in Ethylene Glycol Intoxication

Jose Morfin, M.D. and Andrew Chin, M.D. — Thu, 15Â DecÂ 2005 00:00:00 -05:00

A 73-year-old man presented with a self-inflicted stab wound to the abdomen. A plasma ethanol level of 27 mg per deciliter was found on preliminary toxicologic screening; the results of...

ORIGINAL ARTICLE: Fatal Toxic Shock Syndrome Associated with after Medical Abortion

Thu, 01Â DecÂ 2005 00:00:00 -05:00

Endometritis and toxic shock syndrome associated with Clostridium sordellii have previously been reported after childbirth and, in one case, after medical abortion. We describe four deaths due to endometritis and...

PERSPECTIVE: Fatal Infections Associated with Mifepristone-Induced Abortion

Michael F. Greene, M.D. — Thu, 01Â DecÂ 2005 00:00:00 -05:00

The Population Council submitted a new drug application to the Food and Drug Administration (FDA) on March 14, 1996, for the progesterone antagonist mifepristone (also known as RU 486) to...

IMAGES IN CLINICAL MEDICINE: Unfortunate Ingestion

M.C. Ruiz, M.D. and J. Soler-Gonzalez, M.D. — Thu, 24Â NovÂ 2005 00:00:00 -05:00

A 37-year-old woman had an eating disorder characterized by frequent episodes of self-induced vomiting. She presented after accidentally swallowing a kitchen fork while attempting to induce emesis. Radiographs of the...

IMAGES IN CLINICAL MEDICINE: Renal Colic

Gauthier Raynal, M.D. and Kamal Achkar, M.D. — Thu, 10Â NovÂ 2005 00:00:00 -05:00

A 57-year-old man was referred to our hospital because of an acute onset of right flank pain. An intravenous urogram showed normal excretion from the left kidney, a calculus in...

IMAGES IN CLINICAL MEDICINE: Traumatic Cranial Nerve Palsy

Christopher Baker, M.D. and Jeremy Cannon, M.D. — Thu, 03Â NovÂ 2005 00:00:00 -05:00

A 19-year-old man sustained a crush injury to his skull from a piece of heavy machinery. Although on initial assessment he readily followed commands, his mental status deteriorated and he...

REVIEW ARTICLE: Bacterial Infections in Drug Users

Rachel J. Gordon, M.D., M.P.H., and Franklin D. Lowy, M.D. — Thu, 03Â NovÂ 2005 00:00:00 -05:00

Illicit drug use is a worldwide health problem. Annually, Approximately 5 percent of the global population, or 200 million people, use illicit drugs.1 In a U.S. survey, 19.5 million people...

IMAGES IN CLINICAL MEDICINE: Angioedema of the Arytenoids

Joseph R. Shiber, M.D. — Thu, 27Â OctÂ 2005 00:00:00 -05:00

A 42-year-old woman reported feeling as if something were stuck in her throat (pointing to her thyroid cartilage) since eating a steak dinner two hours earlier. She had a hoarse,...

IMAGES IN CLINICAL MEDICINE: Left Sixth Cranial Nerve Palsy with Herpes Zoster Ophthalmicus

Edward Jude, M.D., M.R.C.P. and Amiya Chakraborty, M.R.C.P. — Thu, 20Â OctÂ 2005 00:00:00 -05:00

A 62-year-old man reported acute left retro-orbital pain of one week's duration. Physical examination revealed no abnormalities. Three days later, double vision developed, and the next day a rash appeared...

ORIGINAL ARTICLE: Incidence and Outcomes of Acute Lung Injury

Thu, 20Â OctÂ 2005 00:00:00 -05:00

Background: Acute lung injury is a critical illness syndrome consisting of acute hypoxemic respiratory failure with bilateral pulmonary infiltrates that are not attributed to left atrial hypertension. Despite recent advances...

PERSPECTIVE: Triaging Tragedy

Gregory S. Henderson, M.D., Ph.D., Ochsner Clinic Foundation, New Orleans — Thu, 13Â OctÂ 2005 00:00:00 -05:00

There is nothing that I had ever witnessed in the United States to which I could compare the scene outside the New Orleans Convention Center. Thousands upon thousands of people...

PERSPECTIVE: Unexpected Necessities â Inside Charity Hospital

Ruth Berggren, M.D. — Thu, 13Â OctÂ 2005 00:00:00 -05:00

The skyscraper housing the oldest continuously operating hospital in the country, New Orleans' Charity Hospital, was erected in 1936, to replace a centuries-old complex that had grown rapidly to keep...

PERSPECTIVE: Lethal Levels

Andrew J. Cohen, M.D., Ochsner Clinic Foundation, New Orleans — Thu, 13Â OctÂ 2005 00:00:00 -05:00

On Tuesday, August 31, in the wake of Hurricane Katrina, Sylvester Donaldson (not his real name) landed at the emergency room of the Ochsner Clinic Foundation in New Orleans, desperately...

PERSPECTIVE: Evacuated Populations â Lessons from Foreign Refugee Crises

Thu, 13Â OctÂ 2005 00:00:00 -05:00

The terms âmalfeasanceâ and ânegligenceâ have been bandied about by many who are frustrated by the official response to Hurricane Katrina. Beginning with the evacuation orders before the hurricane's landfall,...

PERSPECTIVE: Aftershocks

Edward D. Frohlich, M.D., Ochsner Clinic Foundation, New Orleans — Thu, 13Â OctÂ 2005 00:00:00 -05:00

When Hurricane Katrina hit, my wife and I responded in a fashion common to many New Orleans residents: we âvertically evacuatedâ to the lower floors of one of the city's...

PERSPECTIVE: Public Health Response â Assessing Needs

P. Gregg Greenough, M.D., M.P.H., and Thomas D. Kirsch, M.D., M.P.H. — Thu, 13Â OctÂ 2005 00:00:00 -05:00

Never before Hurricane Katrina has a disaster caused such a massive displacement of a U.S. population. Never before has the country seen so vividly the exposure and vulnerability of displaced...

PERSPECTIVE: Finding Supplies

Gregory S. Henderson, M.D., Ph.D., Ochsner Clinic Foundation, New Orleans — Thu, 13Â OctÂ 2005 00:00:00 -05:00

When dawn broke on Tuesday, August 30, it was clear that everything was completely different. I looked out the window to discover that the hotel was surrounded by three to...

PERSPECTIVE: Volunteer Work â Logistics First

Hilarie H. Cranmer, M.D., M.P.H. — Thu, 13Â OctÂ 2005 00:00:00 -05:00

âWhat can I do to help?â The voice was clear and assertive, almost authoritative, and it captured my attention immediately. I looked up from the chaotic mosaic of maps, lists,...

IMAGES IN CLINICAL MEDICINE: Infarction Due to Myocardial Bridging

Karam Souibri, M.D. and Gilles Grollier, M.D. — Thu, 15Â SepÂ 2005 00:00:00 -05:00

A 45-year-old man with dyslipidemia had a sudden onset of retrosternal chest pain and presented to the emergency department. Findings on the physical examination were unremarkable. His electrocardiogram showed ST-segment...

IMAGES IN CLINICAL MEDICINE: Air-Pressure Injury of the Eye and Intracranial Structures

Stefan Mennel, M.D. and Silvia Peter, M.D. — Thu, 01Â SepÂ 2005 00:00:00 -05:00

A 5-year-old boy activated an air-pressure pistol from a distance of about 10 cm, pointing directly toward his right eye. Examination revealed downward vertical deviation of the right eye and...

CLINICAL PROBLEM-SOLVING: A Sailor's Heartbreak

Thu, 01Â SepÂ 2005 00:00:00 -05:00

A 24-year-old sailor presented to the emergency department describing a seven-day history of shortness of breath, occasional substernal chest pain, increasing abdominal girth, and nausea and vomiting. He reported that...

PERSPECTIVE: Prehospital and Hospital Care

Thu, 11Â AugÂ 2005 00:00:00 -05:00

On the morning of July 7, 2005, when four bombs were detonated on the London public transportation system, doctors were mobilized from all over the city to report to work...

PERSPECTIVE: Terrorism and the Medical Response

Jim Ryan, M.Ch., D.M.C.C., and Hugh Montgomery, M.B., B.S., M.D. — Thu, 11Â AugÂ 2005 00:00:00 -05:00

Although Britain is no stranger to terrorist attacks, the pattern of activity has changed in recent years. Irish bombers first attacked London in 1867, but bombings peaked between 1969 and...

PERSPECTIVE: Improvising in an Emergency

Peter J.P. Holden, M.B., Ch.B., F.I.M.C.R.C.S.Ed. — Thu, 11Â AugÂ 2005 00:00:00 -05:00

Thursday, July 7, 2005. A hot, humid day for London, and all the windows on the third floor of the British Medical Association (BMA) building are open. A last-minute change...

IMAGES IN CLINICAL MEDICINE: Transcatheter Treatment of Thromboembolism in the Superior Mesenteric Artery

Akifumi Nishida, M.D. and Kenichiro Fukui, M.D. — Thu, 28Â JulÂ 2005 00:00:00 -05:00

An 88-year-old woman with a history of hypertension and atrial fibrillation presented with an acute onset of severe abdominal pain, vomiting, and diarrhea. She had been taking warfarin for the...

CLINICAL PRACTICE: Cervical Radiculopathy

Simon Carette, M.D., M.Phil., and Michael G. Fehlings, M.D., Ph.D. — Thu, 28Â JulÂ 2005 00:00:00 -05:00

A 37-year-old woman presents with a two-week history of severe neck pain radiating to her left shoulder girdle and extending to the arm, forearm, and dorsum of the hand. She...

IMAGES IN CLINICAL MEDICINE: Pseudomonas Cellulitis

Thomas P. Habif, M.D. — Thu, 14Â JulÂ 2005 00:00:00 -05:00

A healthy 42-year-old man presented with a broad eroded, ulcerated lesion on the left foot, which had developed over the previous month. His new job required that he wear boots,...

IMAGES IN CLINICAL MEDICINE: Small-Bowel Prolapse through a Persistent Omphalomesenteric Duct

Daniel F. Saad, M.D. and Kenneth W. Gow, M.D. — Thu, 07Â JulÂ 2005 00:00:00 -05:00

A 23-day-old term male infant presented to the emergency room with acute small-bowel evisceration through the umbilicus (Panel A). His parents had noted periumbilical erythema and mucus-containing umbilical drainage before...

CLINICAL PROBLEM-SOLVING: Double Jeopardy

Thu, 07Â JulÂ 2005 00:00:00 -05:00

A 36-year-old woman in her 34th week of pregnancy presented to the emergency department after the onset of severe substernal chest pain. The chest pain was sudden in onset and...

IMAGES IN CLINICAL MEDICINE: Ruptured Ectopic Pregnancy

Sandra D. Lyden, M.D. and Lillian Nojadera, M.D. — Thu, 07Â JulÂ 2005 00:00:00 -05:00

A 33-year-old woman, para 2, presented to the emergency department with a report of vaginal bleeding and abdominal pain of several days' duration. She had no history of pelvic inflammatory...

PERSPECTIVE: Close Calls with Club Drugs

Cynthia G. McGinn, M.D. — Thu, 30Â JunÂ 2005 00:00:00 -05:00

Around midnight one night in 1999, I was radioed by the EMTs: they were bringing in two âdrunkâ college students. This was hardly an uncommon occurrence. Many a college student...

IMAGES IN CLINICAL MEDICINE: Tsunami Sinusitis

Kamonporn Limchawalit, M.D. and Chirotchana Suchato, M.D. — Thu, 23Â JunÂ 2005 00:00:00 -05:00

A 35-year-old man was brought to the hospital after sustaining injuries associated with the tsunami in Southeast Asia on December 26, 2004. The patient had inhaled seawater when he nearly...

ORIGINAL ARTICLE: Survival after Treatment of Rabies with Induction of Coma

Thu, 16Â JunÂ 2005 00:00:00 -05:00

We report the survival of a 15-year-old girl in whom clinical rabies developed one month after she was bitten by a bat. Treatment included induction of coma while a native...

IMAGES IN CLINICAL MEDICINE: Myiasis Due to (Human Botfly)

Francisco M. Marty, M.D. and Kristen R. Whiteside, B.S. — Thu, 09Â JunÂ 2005 00:00:00 -05:00

A 65-year-old man presented with skin lesions on his chest and left arm and shoulder six weeks after returning from a vacation in Belize at the beach and in the...

EDITORIAL: Using Every Resource to Care for Our Casualties

Jeffrey M. Drazen, M.D. — Thu, 19Â MayÂ 2005 00:00:00 -05:00

The war in Iraq has resulted in an unprecedented number of traumatic brain injuries to U.S. soldiers. As described by Okie in this issue of the Journal,1 these soldiers have...

IMAGES IN CLINICAL MEDICINE: Asphyxia Due to an Inhaled Foreign Body

Neda Zarrin-Khameh, M.D., M.P.H. and Robert E. Lyon, D.O. — Thu, 19Â MayÂ 2005 00:00:00 -05:00

A three-year-old boy was playing with a small plastic ball while riding in the backseat of a motor vehicle driven by his father. The father heard a gasp, saw that...

PERSPECTIVE: Traumatic Brain Injury in the War Zone

Susan Okie, M.D. — Thu, 19Â MayÂ 2005 00:00:00 -05:00

Sergeant David Emme, a supply officer with a U.S. Army Stryker Brigade, was stationed at a submachine gun on a truck rolling through northern Iraq last November, in a convoy...

ORIGINAL ARTICLE: Heart-Rate Profile during Exercise as a Predictor of Sudden Death

Thu, 12Â MayÂ 2005 00:00:00 -05:00

Background: Changes in heart rate during exercise and recovery from exercise are mediated by the balance between sympathetic and vagal activity. Since alterations in the neural control of cardiac function...

CLINICAL PRACTICE: Persistent Low Back Pain

Eugene J. Carragee, M.D. — Thu, 05Â MayÂ 2005 00:00:00 -05:00

A 49-year-old maintenance worker with a history of depression and previous reports of minor back pain is seen after four months of continuing low back pain. He has remained out...

EDITORIAL: Multislice Computed Tomography for Pulmonary Embolism â A Technological Marvel

Samuel Z. Goldhaber, M.D. — Thu, 28Â AprÂ 2005 00:00:00 -05:00

Rapid and accurate diagnosis of pulmonary embolism will improve survival and quality of life because treatment decreases mortality and the likelihood that thromboembolic pulmonary hypertension or the post-thrombotic syndrome will...

ORIGINAL ARTICLE: Multidetector-Row Computed Tomography in Suspected Pulmonary Embolism

Thu, 28Â AprÂ 2005 00:00:00 -05:00

Background: Single-detectorârow computed tomography (CT) has a low sensitivity for pulmonary embolism and must be combined with venous-compression ultrasonography of the lower limbs. We evaluated whether the use of D-dimer...

ORIGINAL ARTICLE: Necrotizing Fasciitis Caused by Community-Associated Methicillin-Resistant in Los Angeles

Thu, 07Â AprÂ 2005 00:00:00 -05:00

Background: Necrotizing fasciitis is a life-threatening infection requiring urgent surgical and medical therapy. Staphylococcus aureus has been a very uncommon cause of necrotizing fasciitis, but we have recently noted an...

IMAGES IN CLINICAL MEDICINE: Benign Subcutaneous Emphysema of the Upper Extremity

James S. Winshall, M.D. and Barbara N. Weissman, M.D. — Thu, 31Â MarÂ 2005 00:00:00 -05:00

A 59-year-old woman fell from a horse and injured her left elbow. Four days later she sought evaluation for persistent swelling of her arm. On examination, the patient had a...

REVIEW ARTICLE: Blast Injuries

Thu, 31Â MarÂ 2005 00:00:00 -05:00

Although information about terrorism has emphasized chemical, biologic, and radiation events,12345 most terrorist attacks have involved explosive devices. To date, the number of lives lost, the number of people injured,...

ORIGINAL ARTICLE: Addition of Clopidogrel to Aspirin and Fibrinolytic Therapy for Myocardial Infarction with ST-Segment Elevation

Thu, 24Â MarÂ 2005 00:00:00 -05:00

Background: A substantial proportion of patients receiving fibrinolytic therapy for myocardial infarction with ST-segment elevation have inadequate reperfusion or reocclusion of the infarct-related artery, leading to an increased risk of...

REVIEW ARTICLE: The Serotonin Syndrome

Edward W. Boyer, M.D., Ph.D., and Michael Shannon, M.D., M.P.H. — Thu, 17Â MarÂ 2005 00:00:00 -05:00

The serotonin syndrome is a potentially life-threatening adverse drug reaction that results from therapeutic drug use, intentional self-poisoning, or inadvertent interactions between drugs. Three features of the serotonin syndrome are...

IMAGES IN CLINICAL MEDICINE: Malposition of a SengstakenâBlakemore Tube

Jung-Yien Chien, M.D. and Chong-Jen Yu, M.D., Ph.D. — Thu, 24Â FebÂ 2005 00:00:00 -05:00

An 86-year-old woman had a history of cirrhosis associated with chronic hepatitis B infection lasting more than 16 years; she had had five episodes of esophageal variceal bleeding that had...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 5-2005 â A 53-Year-Old Man with Depression and Sudden Shortness of Breath

Thu, 17Â FebÂ 2005 00:00:00 -05:00

Dr. Daniel Egan (Emergency Medicine, Massachusetts General Hospital and Brigham and Women's Hospital): A 53-year-old man came to the emergency department because of symptoms of depression.

The patient had been in...

REVIEW ARTICLE: Bites of Brown Recluse Spiders and Suspected Necrotic Arachnidism

David L. Swanson, M.D., and Richard S. Vetter, M.S. — Thu, 17Â FebÂ 2005 00:00:00 -05:00

Cutaneous injury caused by spider venom has been recognized by physicians in the United States only since the late 1950s, with recluse spiders (genus loxosceles) most frequently implicated. During the...

IMAGES IN CLINICAL MEDICINE: Finger Avulsion with Pulled-Out Flexor Tendon

Georg M. Huemer, M.D. and Karin M. Dunst, M.D. — Thu, 10Â FebÂ 2005 00:00:00 -05:00

A 17-year-old boy jumped over a fence and sustained an avulsion injury to the fifth finger of his right hand when the ring he was wearing caught on the fence....

PERSPECTIVE: Beyond the Purple Heart â Continuity of Care for the Wounded in Iraq

James B. Peake, M.D. — Thu, 20Â JanÂ 2005 00:00:00 -05:00

You can hear the usual hum of the emergency room, and all the familiar beeps of monitors in the operating room provide a backdrop for medical teams boasting the usual...

IMAGES IN CLINICAL MEDICINE: Fatal Free-Floating Left Atrial Thrombus

TamÃ¡s TornÃ³czky, M.D., Ph.D. and Zeno Ajtay, M.D. — Thu, 30Â DecÂ 2004 00:00:00 -05:00

A 68-year-old woman who had been resuscitated after cardiac arrest was admitted because of chest pain. The electrocardiogram showed atrial fibrillation and ST-segment elevation in leads II, III, and aVF,...

ORIGINAL ARTICLE: Codeine Intoxication Associated with Ultrarapid CYP2D6 Metabolism

Thu, 30Â DecÂ 2004 00:00:00 -05:00

Life-threatening opioid intoxication developed in a patient after he was given small doses of codeine for the treatment of a cough associated with bilateral pneumonia. Codeine is bioactivated by CYP2D6...

PERSPECTIVE: Caring for the Wounded in Iraq â A Photo Essay

George E. Peoples, M.D., James R. Jezior, M.D., and Craig D. Shriver, M.D. — Thu, 09Â DecÂ 2004 00:00:00 -05:00

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PERSPECTIVE: Casualties of War â Military Care for the Wounded from Iraq and Afghanistan

Atul Gawande, M.D., M.P.H. — Thu, 09Â DecÂ 2004 00:00:00 -05:00

Each Tuesday, the U.S. Department of Defense provides an online update of American military casualties (the number of wounded or dead) from Operation Iraqi Freedom and Operation Enduring Freedom.1 According...

IMAGES IN CLINICAL MEDICINE: The Tale of Phineas Gage, Digitally Remastered

Peter Ratiu, M.D. and Ion-Florin Talos, M.D. — Thu, 02Â DecÂ 2004 00:00:00 -05:00

On September 13, 1848, while using a tamping iron to pack explosive into a rock, Phineas Gage, a 25-year-old construction foreman, triggered an uncontrolled explosion that propelled the tool (which...

IMAGES IN CLINICAL MEDICINE: Backscatter from Lead

Rutger J. Hassink, M.D., Ph.D. and Pieter A. Doevendans, M.D., Ph.D. — Thu, 04Â NovÂ 2004 00:00:00 -05:00

A 65-year-old man underwent routine chest radiography before undergoing cardiac catheterization. The images (Panels A and B) revealed the presence of many little spheres in the posterior thoracic wall. On...

IMAGES IN CLINICAL MEDICINE: Getting the Lead Out

Joy Shen, M.D. and Robert Hirschtick, M.D. — Thu, 04Â NovÂ 2004 00:00:00 -05:00

A 32-year-old man reported having had back and abdominal pain, nausea, and constipation for several weeks. The results of laboratory studies were notable for normocytic anemia, a hemoglobin level of...

EDITORIAL: Awake and Informed

Jeffrey M. Drazen, M.D. — Thu, 28Â OctÂ 2004 00:00:00 -05:00

I grew up with the one-doctorâone-patient paradigm. When I admitted a patient, I took the case as my personal responsibility. I did my best to get to know the patient...

ORIGINAL ARTICLE: Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units

Thu, 28Â OctÂ 2004 00:00:00 -05:00

Background: Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors.

Methods: We conducted a prospective, randomized study comparing the rates of...

ORIGINAL ARTICLE: Effect of Reducing Interns' Weekly Work Hours on Sleep and Attentional Failures

Thu, 28Â OctÂ 2004 00:00:00 -05:00

Background: Knowledge of the physiological effects of extended (24 hours or more) work shifts in postgraduate medical training is limited. We aimed to quantify work hours, sleep, and attentional failures...

PERSPECTIVE: A Precarious Exchange

Siddhartha Mukherjee, M.D., Ph.D. — Thu, 28Â OctÂ 2004 00:00:00 -05:00

If an anthropologist were to stumble into this room between 6 and 8 p.m. this evening, he might find the telltale signs of a ritual: a group of residents and...

IMAGES IN CLINICAL MEDICINE: Nontraumatic Myonecrosis

Rafael Arteta-Bulos, M.D. and Syed Mustafa Karim, M.D. — Thu, 21Â OctÂ 2004 00:00:00 -05:00

A 73-year-old man with a history of colon cancer presented to the emergency department with a three-day history of pain in the right hip, without a history of trauma. He...

CLINICAL PRACTICE: Bell's Palsy

Donald H. Gilden, M.D. — Thu, 23Â SepÂ 2004 00:00:00 -05:00

A healthy 50-year-old man notices that his face is drooping on the right side. On examination, facial asymmetry is evident, and some saliva has accumulated on the right side of...

ORIGINAL ARTICLE: A Randomized Trial of a Single Dose of Oral Dexamethasone for Mild Croup

Thu, 23Â SepÂ 2004 00:00:00 -05:00

Background: The benefits of dexamethasone treatment for moderate-to-severe croup are well established. However, most children with croup have mild symptoms, and it is unknown whether they would derive the same...

IMAGES IN CLINICAL MEDICINE: Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm

W. Anthony Lee, M.D. — Thu, 16Â SepÂ 2004 00:00:00 -05:00

A 62-year-old man presented with an acute onset of severe lower back pain, hypotension, and nausea and vomiting. He had a history of hypertension and hypertriglyceridemia. On arrival, the patient...

IMAGES IN CLINICAL MEDICINE: Traumatic Laceration of the Aorta

Frederick B. Rogers, M.D. — Thu, 16Â SepÂ 2004 00:00:00 -05:00

A 37-year-old man was involved in a motor vehicle collision. On examination in the emergency department, the patient was hemodynamically stable but had a steering-wheel imprint on the anterior chest...

IMAGES IN CLINICAL MEDICINE: Inhaled Foreign Body

Syed Mohammad Tariq, M.R.C.P. and Jojy George, M.R.C.P. — Thu, 26Â AugÂ 2004 00:00:00 -05:00

Many Arab women wear a head scarf, termed the lahaaf or hejaab. It is usually secured around the head and neck with one or two pins. A 20-year-old Arab woman...

CLINICAL PRACTICE: Acute Bacterial Sinusitis

Jay F. Piccirillo, M.D. — Thu, 26Â AugÂ 2004 00:00:00 -05:00

A 43-year-old man has a two-week history of nasal congestion, postnasal drip, and fatigue. He has used an over-the-counter nasal decongestant and acetaminophen, without relief. During the past few days,...

IMAGES IN CLINICAL MEDICINE: Lung Herniation after Cardiopulmonary Resuscitation

Laura D. Sprague, D.O. and Filippo J. Ferrigni, M.D. — Thu, 12Â AugÂ 2004 00:00:00 -05:00

A 63-year-old man collapsed, unresponsive and pulseless, at his workplace. Security guards, using an automated external defibrillator, delivered two shocks to his chest and performed cardiopulmonary resuscitation (CPR) until paramedics...

ORIGINAL ARTICLE: Outcomes of Allergy to Insect Stings in Children, with and without Venom Immunotherapy

Thu, 12Â AugÂ 2004 00:00:00 -05:00

Background: Children are thought to âoutgrowâ the allergy to insect stings, but there are no reports documenting the natural history of this reaction. We studied the outcome of allergic reactions...

ORIGINAL ARTICLE: Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest

Thu, 12Â AugÂ 2004 00:00:00 -05:00

Background: The Ontario Prehospital Advanced Life Support (OPALS) Study tested the incremental effect on the rate of survival after out-of-hospital cardiac arrest of adding a program of advanced life support...

ORIGINAL ARTICLE: Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest

The Public Access Defibrillation Trial Investigators — Thu, 12Â AugÂ 2004 00:00:00 -05:00

Background: The rate of survival after out-of-hospital cardiac arrest is low. It is not known whether this rate will increase if laypersons are trained to attempt defibrillation with the use...

PERSPECTIVE: Out-of-Hospital Cardiac Arrest â The Solution Is Shocking

David J. Callans, M.D. — Thu, 12Â AugÂ 2004 00:00:00 -05:00

Sudden cardiac arrest claims 350,000 to 450,000 lives per year in the United States alone and is responsible for more than half of all deaths that are due to cardiovascular...

IMAGES IN CLINICAL MEDICINE: Gastrothorax Simulating Acute Tension Pneumothorax

Cornelis P.C. de Jager, M.D. and Ronald J. Trof, M.D. — Thu, 05Â AugÂ 2004 00:00:00 -05:00

A 27-year-old man was admitted to the emergency department because of respiratory failure. Three years earlier, he had undergone surgery to repair a traumatic rupture of the left side of...

CLINICAL PROBLEM-SOLVING: A Bitter Tale

Lori S. Newman, M.D., Ph.D., Mark W. Feinberg, M.D., and Howard E. LeWine, M.D. — Thu, 05Â AugÂ 2004 00:00:00 -05:00

A 53-year-old woman presented to an outpatient urgent care clinic with persistent nausea and vomiting. On the previous evening, she had had an acute onset of nausea that was followed...

IMAGES IN CLINICAL MEDICINE: âPseudoinfarctionâ Pattern Due to Hyperkalemia

Kyuhyun Wang, M.D. — Thu, 05Â AugÂ 2004 00:00:00 -05:00

A 38-year-old man presented to the emergency department with nausea, vomiting, and epigastric pain. The patient had type 1 diabetes mellitus and was being treated with insulin. He was also...

IMAGES IN CLINICAL MEDICINE: Electrocardiographic Changes in Extreme Hypothermia

Haval Saadlla, M.D. — Thu, 29Â JulÂ 2004 00:00:00 -05:00

A 39-year-old man was brought to the emergency department with altered mental status and a core temperature of 27.6Â°C. The patient appeared to have had exposure to cold temperatures. He...

CLINICAL PRACTICE: Treatment of Deep-Vein Thrombosis

Shannon M. Bates, M.D.C.M., and Jeffrey S. Ginsberg, M.D. — Thu, 15Â JulÂ 2004 00:00:00 -05:00

A 52-year-old-woman with no history of venous thromboembolism presents with a four-day history of discomfort in her left calf. Proximal deep-vein thrombosis is diagnosed by compression ultrasonography. How should her...

CLINICAL PROBLEM-SOLVING: A Twist of Fate?

Michael D. Christian, M.D., and Allan S. Detsky, M.D., Ph.D. — Thu, 01Â JulÂ 2004 00:00:00 -05:00

A 39-year-old Sri Lankan male physiotherapist presented to an emergency department in Toronto with a three-day history of headache, chills, diarrhea, nausea, vomiting, and neck stiffness. He reported having had...

PERSPECTIVE: Semper Fi

Pamela Grim, M.D. — Thu, 01Â JulÂ 2004 00:00:00 -05:00

A while ago, before more recent geopolitical disasters, I saw on the news that a ârapid response teamâ of Marines had landed in Port-au-Prince, Haiti, and I wondered whether any...

IMAGES IN CLINICAL MEDICINE: Cicatricial Pemphigoid

Conleth A. Egan, M.R.C.P.I. and Scott R. Florell, M.D. — Thu, 10Â JunÂ 2004 00:00:00 -05:00

A 26-year-old man presented with blisters and erosions that had developed on his tongue over a 48-hour period (Panel A). The blisters had appeared primarily in his mouth, but several...

IMAGES IN CLINICAL MEDICINE: Unusual Cystitis

Keyvan Ravakhah, M.D., M.B.A. and Ramona Simionescu, M.D. — Thu, 27Â MayÂ 2004 00:00:00 -05:00

A 68-year-old woman with diabetes mellitus that was treated with insulin was hospitalized because of abdominal pain and vomiting. She had been treated empirically for a urinary tract infection with...

IMAGES IN CLINICAL MEDICINE: Acquired Arteriovenous Fistula

Oren K. Steinmetz, M.D. and L.P. Palerme, M.D. — Thu, 20Â MayÂ 2004 00:00:00 -05:00

A 35-year-old man presented with high-output congestive heart failure. Fourteen years earlier, he had received a shrapnel wound to the left thigh in a car-bomb attack in Lebanon. As a...

IMAGES IN CLINICAL MEDICINE: Papilledema and Spinal Cord Tumor

Seyed F.A. Amlashi, M.D. and Laurent Riffaud, M.D. — Thu, 13Â MayÂ 2004 00:00:00 -05:00

A 49-year-old man presented with a three-week history of progressive visual loss and headaches. Funduscopic examination revealed bilateral papilledema. Computed tomographic examination of the cerebrum showed a moderate-sized, communicating hydrocephalus....

IMAGES IN CLINICAL MEDICINE: Air Embolism after the Insertion of a Central Venous Catheter

Ulf K.M. TeichgrÃ¤ber, M.D. and Thomas Benter, M.D. — Thu, 06Â MayÂ 2004 00:00:00 -05:00

A 17-year-old girl was involved in a car accident as a passenger. Before she was transported by helicopter to a hospital, a central venous catheter was inserted. She was admitted...

CLINICAL PRACTICE: Genital Herpes

David W. Kimberlin, M.D., and Dwight J. Rouse, M.D., M.S.P.H. — Thu, 06Â MayÂ 2004 00:00:00 -05:00

A 22-year-old woman presents to her gynecologist with genital lesions. Examination reveals bilateral labial ulcerations (Figure 1), cervical ulcerations, and mildly tender inguinal lymphadenopathy. To her knowledge, neither she nor...

ORIGINAL ARTICLE: A Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest

Thu, 22Â AprÂ 2004 00:00:00 -05:00

Background: When efforts to resuscitate a child after cardiac arrest are unsuccessful despite the administration of an initial dose of epinephrine, it is unclear whether the next dose of epinephrine...

PERSPECTIVE: Can Resuscitation Jeopardize Survival?

George Lister, M.D., and J. Julio PÃ©rez FontÃ¡n, M.D. — Thu, 22Â AprÂ 2004 00:00:00 -05:00

Resuscitations are events that are often clouded by desperation and frenzy and directed by persons with limited experience, who may feel a great burden of responsibility for the circumstances precipitating...

PERSPECTIVE: Earthquake Relief â The U.S. Medical Response in Bam, Iran

Jay J. Schnitzer, M.D., Ph.D., and Susan M. Briggs, M.D., M.P.H. — Thu, 18Â MarÂ 2004 00:00:00 -05:00

The magnitude-6.6 earthquake in Bam, Iran, struck at 5:26 a.m. local time on December 26, 2003, while most people were asleep in their homes. It destroyed much of the city....

IMAGES IN CLINICAL MEDICINE: Interdigital Pilonidal Sinus

Peter J. Stern, M.D. and Charles A. Goldfarb, M.D. — Thu, 11Â MarÂ 2004 00:00:00 -05:00

A healthy 39-year-old woman who was employed as an animal groomer presented with a chronic draining cyst in the web between the middle and ring fingers of one hand. The...

IMAGES IN CLINICAL MEDICINE: Meckel's Diverticulum in Action

See-Ching Chan, M.D. and Chung-Yau Lo, F.R.C.S., F.A.C.S. — Thu, 19Â FebÂ 2004 00:00:00 -05:00

A 26-year-old man presented with massive gastrointestinal hemorrhage and hypovolemic shock. His hemoglobin level dropped by 4 g per deciliter over a six-hour period. Emergency upper endoscopy to the second...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 6-2004 â A 35-Year-Old Woman with Extensive, Deep Burns from a Nightclub Fire

Thu, 19Â FebÂ 2004 00:00:00 -05:00

A 35-year-old woman sustained extensive burns and was possibly trampled in a nightclub after a pyrotechnics display set fire to the building. At the scene, she was responsive but confused...

REVIEW ARTICLE: Acute Chemical Emergencies

Stefanos N. Kales, M.D., M.P.H., and David C. Christiani, M.D., M.P.H. — Thu, 19Â FebÂ 2004 00:00:00 -05:00

Acute chemical emergencies can occur as a result of an industrial disaster,12 occupational exposure,34 recreational mishap,5 natural catastrophe,6 chemical warfare,78 and acts of terrorism.910 This article reviews the health effects...

EDITORIAL: B-Type Natriuretic Peptide â A Biomarker for All Seasons?

Daniel B. Mark, M.D., M.P.H., and G. Michael Felker, M.D. — Thu, 12Â FebÂ 2004 00:00:00 -05:00

Despite more than two decades of research that has shown the value and cost effectiveness of information from the medical history and physical examination for management decisions, physicians are increasingly...

CLINICAL PRACTICE: Acute Renal Colic from Ureteral Calculus

Joel M.H. Teichman, M.D. — Thu, 12Â FebÂ 2004 00:00:00 -05:00

A 39-year-old man reports an eight-hour history of colicky pain in the right lower quadrant radiating to the tip of his penis. He had previously had a kidney stone, which...

ORIGINAL ARTICLE: Use of B-Type Natriuretic Peptide in the Evaluation and Management of Acute Dyspnea

Thu, 12Â FebÂ 2004 00:00:00 -05:00

Background: B-type natriuretic peptide levels are higher in patients with congestive heart failure than in patients with dyspnea from other causes.

Methods: We conducted a prospective, randomized, controlled study of 452...

IMAGES IN CLINICAL MEDICINE: Hypoglossal-Nerve Palsy

Dimitrios I. Zafeiriou,, M.D., Ph.D. and Evangelos Pavlou, M.D. — Thu, 29Â JanÂ 2004 00:00:00 -05:00

A six-year-old boy was brought to the emergency department because of acute speech difficulties. Five days previously, a low-grade fever, sore throat, and malaise had developed. The day before presentation,...

ORIGINAL ARTICLE: EffusiveâConstrictive Pericarditis

Thu, 29Â JanÂ 2004 00:00:00 -05:00

Background: Effusiveâconstrictive pericarditis is an uncommon pericardial syndrome characterized by concomitant tamponade, caused by tense pericardial effusion, and constriction, caused by the visceral pericardium. We conducted a prospective study of...

IMAGES IN CLINICAL MEDICINE: Intussusception

Duyen Dang, M.D. and David Cromwell, M.D. — Thu, 15Â JanÂ 2004 00:00:00 -05:00

An 80-year-old woman presented with a three-day history of passage of bright red blood from the rectum. She was afebrile and had a blood pressure of 70/52 mm Hg. The...

EDITORIAL: Vasopressin in Asystolic Cardiac Arrest

Kevin M. McIntyre, M.D., J.D. — Thu, 08Â JanÂ 2004 00:00:00 -05:00

Cardiac arrest remains a major health problem in the United States and other Western nations. Of the approximately 1000 sudden deaths that occur each day in the United States, it...

ORIGINAL ARTICLE: A Comparison of Vasopressin and Epinephrine for Out-of-Hospital Cardiopulmonary Resuscitation

Thu, 08Â JanÂ 2004 00:00:00 -05:00

Background: Vasopressin is an alternative to epinephrine for vasopressor therapy during cardiopulmonary resuscitation, but clinical experience with this treatment has been limited.

Methods: We randomly assigned adults who had had an...

CLINICAL PRACTICE: Acute Infectious Diarrhea

Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. — Thu, 01Â JanÂ 2004 00:00:00 -05:00

An otherwise healthy 23-year-old man presents after the acute onset of watery diarrhea that has persisted for two days. He reports associated nausea and cramping but no emesis and is...

EDITORIAL: Choosing between Clinical Prediction Rules

Donald M. Yealy, M.D., and Thomas E. Auble, Ph.D. — Thu, 25Â DecÂ 2003 00:00:00 -05:00

Clinicians currently order imaging studies for most patients with blunt head or neck trauma if there is even a remote possibility of cervical-spine injury, in order to avoid missing a...

REVIEW ARTICLE: Body Packing â The Internal Concealment of Illicit Drugs

Stephen J. Traub, M.D., Robert S. Hoffman, M.D., and Lewis S. Nelson, M.D. — Thu, 25Â DecÂ 2003 00:00:00 -05:00

In 1973, two physicians from Toronto admitted a patient in whom a small-bowel obstruction developed 13 days after he had swallowed a condom filled with hashish.1 The condom was surgically...

ORIGINAL ARTICLE: The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma

Thu, 25Â DecÂ 2003 00:00:00 -05:00

Background: The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients...

IMAGES IN CLINICAL MEDICINE: Bleeding Colonic Diverticulum

Sripathi R. Kethu, M.D. and Harlan G. Rich, M.D. — Thu, 18Â DecÂ 2003 00:00:00 -05:00

A 73-year-old man presented with acute lower gastrointestinal bleeding. He was hemodynamically stable, and nasogastric-tube lavage revealed bile with no blood, suggesting a lower gastrointestinal source for the bleeding. Urgent...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 38-2003 â A 12-Year-Old Girl with Fever and Coma

H. Shaw Warren, Jr., M.D., R. Gilberto Gonzalez, M.D., and Di Tian, M.D., Ph.D. — Thu, 11Â DecÂ 2003 00:00:00 -05:00

A 12-year-old girl was admitted to the hospital because of fever, vomiting, and an abrupt onset of unresponsiveness.

She had been well until one week earlier, when a cough, sore throat,...

IMAGES IN CLINICAL MEDICINE: Hypokalemia

Adam Nosworthy, M.B., B.Ch. — Thu, 27Â NovÂ 2003 00:00:00 -05:00

A 42-year-old man was hospitalized because he had had confusion, weakness, and lethargy for approximately a week. Hypertension had recently been diagnosed, and the patient had begun therapy with a...

PERSPECTIVE: Tragedy and Response â The Rhode Island Nightclub Fire

Michael J. Dacey, M.D. — Thu, 20Â NovÂ 2003 00:00:00 -05:00

Just before midnight on February 20, 2003, a terrible fire broke out in a crowded Rhode Island nightclub. It killed almost 100 people immediately and left more than 200 injured,...

REVIEW ARTICLE: Implantable CardioverterâDefibrillators

John P. DiMarco, M.D., Ph.D. — Thu, 06Â NovÂ 2003 00:00:00 -05:00

Despite advances in emergency medical systems and in techniques of resuscitation, sudden death from cardiac arrest remains a major public health problem. Most persons who have an out-of-hospital cardiac arrest...

CLINICAL PRACTICE: Emergency Contraception

Carolyn Westhoff, M.D. — Thu, 06Â NovÂ 2003 00:00:00 -05:00

A healthy 19-year-old woman comes in for a routine appointment. She is sexually active in a monogamous relationship. Pregnancy is not currently desired. Her partner uses condoms most of the...

IMAGES IN CLINICAL MEDICINE: Isolated Right Ventricular Infarction

Aloke V. Finn, M.D. and Elliott M. Antman, M.D. — Thu, 23Â OctÂ 2003 00:00:00 -05:00

A 47-year-old man with no history of cardiac disease presented to a hospital, reporting severe substernal chest pressure associated with bilateral arm weakness. A standard 12-lead electrocardiogram (Panel A) showed...

IMAGES IN CLINICAL MEDICINE: âT-U-Pâ Syndrome, or Pseudoatrial Flutter

Gregory M. Marcus, M.D. and J. Edwin Atwood, M.D. — Thu, 16Â OctÂ 2003 00:00:00 -05:00

A 77-year-old man with a remote history of atrial fibrillation presented to the emergency department reporting fatigue and weakness. The patient said he had not made any recent changes in...

IMAGES IN CLINICAL MEDICINE: Epidural Lipomatosis Causing Spinal Cord Compression

Moahad Saeed Dar, M.D. and Shadi Daoud, M.D. — Thu, 09Â OctÂ 2003 00:00:00 -05:00

A 68-year-old woman with corticosteroid-dependent chronic obstructive pulmonary disease was admitted to the hospital for worsening respiratory symptoms and for new-onset weakness in both legs. Physical examination revealed poor air...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 30-2003 â A 21-Year-Old Man with Sudden Alteration of Mental Status

David N. Tancredi, M.D., and Michael W. Shannon, M.D. — Thu, 25Â SepÂ 2003 00:00:00 -05:00

Dr. Joshua N. Goldstein (Emergency Medicine): A 21-year-old man was brought to the emergency department because of a sudden change in mental status.

On the evening of admission, the patient...

IMAGES IN CLINICAL MEDICINE: Human Bites versus Dog Bites

Howard Fischer, M.D., Pamela W. Hammel, D.D.S., and L.J. Dragovic, M.D. — Thu, 11Â SepÂ 2003 00:00:00 -05:00

A six-year-old boy was admitted to the hospital with an acute abdomen. He had a rectal perforation and two groups of lesions on his right leg. Neither he nor his...

REVIEW ARTICLE: Sudden Death in Young Athletes

Barry J. Maron, M.D. — Thu, 11Â SepÂ 2003 00:00:00 -05:00

Young athletes have come to be regarded as a special part of society, owing to their unique lifestyle and the widely held perception that they epitomize health and invulnerability, capable...

IMAGES IN CLINICAL MEDICINE: Uvular Angioedema (Quincke's Disease)

Andrew Kestler, M.D. and Linda Keyes, M.D. — Thu, 28Â AugÂ 2003 00:00:00 -05:00

A 19-year-old man without a history of asthma or allergies presented to the emergency department with difficulty in breathing. He had snorted and smoked cocaine three hours before presentation, after...

IMAGES IN CLINICAL MEDICINE: Calcified Splenic Cyst

Ton-Ho Young, M.D. and Hung-Shang Tang, M.D. — Thu, 21Â AugÂ 2003 00:00:00 -05:00

A 45-year-old man presented with a two-month history of discomfort in the left upper quadrant. Twenty years earlier, he had been involved in a motor vehicle accident. Physical examination confirmed...

IMAGES IN CLINICAL MEDICINE: Electrocardiographic Changes in Intracranial Hemorrhage Mimicking Myocardial Infarction

W. Brian Bailey, M.D. and Bernard R. Chaitman, M.D. — Thu, 07Â AugÂ 2003 00:00:00 -05:00

A 19-year-old man was admitted to the trauma unit after being struck in the left temple by a brick. Surgery to evacuate an intracranial hemorrhage was performed, and an electrocardiogram...

IMAGES IN CLINICAL MEDICINE: Carotid-Artery Thrombosis Secondary to Basal Skull Fracture

Thomas Santarius, M.R.C.S. and David K. Menon, Ph.D. — Thu, 31Â JulÂ 2003 00:00:00 -05:00

A 17-year-old boy dove to catch a cricket ball and struck his head on a teammate's knee. On initial assessment, the score on the Glasgow Coma Scale was 7 and...

IMAGES IN CLINICAL MEDICINE: Shot to the Heart

Lance E. Sullenberger, M.D. and Mary Jo Rohrer, M.D. — Thu, 26Â JunÂ 2003 00:00:00 -05:00

A 29-year-old soldier on active duty in the Army who was involved in the forward combat zone of Afghanistan required emergency evaluation for a shrapnel wound to the chest. Chest...

ORIGINAL ARTICLE: Long-Term Outcomes of Out-of-Hospital Cardiac Arrest after Successful Early Defibrillation

Thu, 26Â JunÂ 2003 00:00:00 -05:00

Background: Mortality after out-of-hospital cardiac arrest from ventricular fibrillation is high. Programs focusing on early defibrillation have improved the rate of survival to hospital discharge. We conducted a population-based analysis...

ORIGINAL ARTICLE: Outpatient Oral Prednisone after Emergency Treatment of Chronic Obstructive Pulmonary Disease

Thu, 26Â JunÂ 2003 00:00:00 -05:00

Background: In this randomized, double-blind, placebo-controlled trial, we studied the effectiveness of prednisone in reducing the risk of relapse after outpatient exacerbations of chronic obstructive pulmonary disease (COPD).

Methods: We enrolled...

IMAGES IN CLINICAL MEDICINE: Abdominal Aortic Aneurysm as an Incidental Finding

Peter H. Lin, M.D. and Alan B. Lumsden, M.D. — Thu, 08Â MayÂ 2003 00:00:00 -05:00

A 56-year-old man was involved in a minor bicycle accident in which the handlebars of the bicycle struck his abdomen. He came to the emergency room with swelling and pain...

REVIEW ARTICLE: Management of Drug and Alcohol Withdrawal

Thomas R. Kosten, M.D., and Patrick G. O'Connor, M.D., M.P.H. — Thu, 01Â MayÂ 2003 00:00:00 -05:00

Each year in the United States, approximately 8.2 million persons are dependent on alcohol and 3.5 million are dependent on illicit drugs, including stimulants (1 million) and heroin (750,000).1 In...

IMAGES IN CLINICAL MEDICINE: Cardiac Compression by a Ruptured Aneurysm of the Descending Thoracic Aorta

Jurg Schmidli, M.D. and Thierry Carrel, M.D. — Thu, 01Â MayÂ 2003 00:00:00 -05:00

A 68-year-old man presented with acute thoracic, abdominal, and back pain and progressive shock. In the past, he had undergone repair of an abdominal aortic aneurysm, bilobar wedge resection, and...

IMAGES IN CLINICAL MEDICINE: Hematoma of the Rectus Sheath

David R. Gutknecht, M.D. — Thu, 10Â AprÂ 2003 00:00:00 -05:00

A 79-year-old woman who was taking warfarin and enoxaparin because of deep venous thrombosis reported abdominal pain after coughing. On physical examination, a mass was felt in the left side...

SPECIAL ARTICLE: Implications of Hospital Evacuation after the Northridge, California, Earthquake

Carl H. Schultz, M.D., Kristi L. Koenig, M.D., and Roger J. Lewis, M.D., Ph.D. — Thu, 03Â AprÂ 2003 00:00:00 -05:00

Background: On January 17, 1994, an earthquake with a moment magnitude (total energy release) of 6.7 occurred in Northridge, California, leading to the evacuation of patients from several hospitals. We...

PERSPECTIVE: Hospital Emergency Preparedness â Lessons Learned since Northridge

Michael A. Berman, M.D., and Eliot J. Lazar, M.D. — Thu, 03Â AprÂ 2003 00:00:00 -05:00

The events of September 11, 2001, served to crystallize a decade-long evolution of the role of hospitals in emergency preparedness and disaster management. The article by Schultz et al. in...

IMAGES IN CLINICAL MEDICINE: Appearance of Intraocular Silicone Oil on Computed Tomography

Gavin J. Stringfellow, M.B., B.S. and Ian C. Francis, F.A.S.O.P.R.S. — Thu, 20Â MarÂ 2003 00:00:00 -05:00

A 60-year-old man presented with epiphora, or an abnormal overflow of tears, caused by bilateral primary acquired nasolacrimal-duct obstruction. Computed tomography (CT) of the orbits and sinuses performed as part...

ORIGINAL ARTICLE: An Outbreak of Conjunctivitis Due to Atypical

Thu, 20Â MarÂ 2003 00:00:00 -05:00

Background: In February 2002, clinicians at the Dartmouth College Health Service recognized an outbreak of conjunctivitis; cultures of conjunctival swabs implicated Streptococcus pneumoniae. An investigation was begun to determine the...

ORIGINAL ARTICLE: Effect of Anti-IgE Therapy in Patients with Peanut Allergy

Thu, 13Â MarÂ 2003 00:00:00 -05:00

Background: Peanut-induced anaphylaxis is an IgE-mediated condition that is estimated to affect 1.5 million people and cause 50 to 100 deaths per year in the United States. TNX-901 is a...

PERSPECTIVE: Studying Peanut Anaphylaxis

Beverly Merz — Thu, 13Â MarÂ 2003 00:00:00 -05:00

In this issue of the Journal, Leung et al. (pages 986â993) report results with a new drug to reduce the risk of anaphylactic reactions to food. In a multicenter, phase...

CLINICAL PRACTICE: Vestibular Neuritis

Robert W. Baloh, M.D. — Thu, 13Â MarÂ 2003 00:00:00 -05:00

A 53-year-old man awoke in the morning with acute dizziness. He staggered to the bathroom, where he vomited repeatedly. When he was seen at a local emergency room 12 hours...

IMAGES IN CLINICAL MEDICINE: A Deadly Examination

Oren Fruchter, M.D. and Robert Dragu, M.D. — Thu, 13Â MarÂ 2003 00:00:00 -05:00

An 80-year-old man underwent esophagogastroduodenography with barium contrast medium to investigate long-standing dysphagia. During the examination, the patient aspirated contrast material into his lungs. Forty-eight hours later, he presented with...

REVIEW ARTICLE: Use of the Electrocardiogram in Acute Myocardial Infarction

Peter J. Zimetbaum, M.D., and Mark E. Josephson, M.D. — Thu, 06Â MarÂ 2003 00:00:00 -05:00

The electrocardiogram remains a crucial tool in the identification and management of acute myocardial infarction. A detailed analysis of patterns of ST-segment elevation may influence decisions regarding the use of...

IMAGES IN CLINICAL MEDICINE: Fatal Cerebral Hypoxemia after Cardiac Arrest

Jesper Kelsen, M.D. and Annette Obel, M.D. — Thu, 27Â FebÂ 2003 00:00:00 -05:00

A 50-year-old woman suddenly became unconscious during her birthday celebration; there was no measurable pulse or blood pressure. Breathing and circulation returned spontaneously within a few minutes, but the exact...

IMAGES IN CLINICAL MEDICINE: Cardiac Rupture

Andrew Redfern, F.R.C.S., F.R.C.R. and James Smart, F.R.C.R. — Thu, 13Â FebÂ 2003 00:00:00 -05:00

A 79-year-old man was admitted with atypical chest pain and electrocardiographic changes characteristic of an anterior myocardial infarction. The chest radiograph showed a widened mediastinum, raising the possibility of a...

ORIGINAL ARTICLE: Validation of a Brief Observation Period for Patients with Cocaine-Associated Chest Pain

Thu, 06Â FebÂ 2003 00:00:00 -05:00

Background: Retrospective studies of patients with cocaine-associated chest pain suggest that a strategy of discharging patients from the emergency department after a 12-hour observation period if they do not have...

PERSPECTIVE: Cocaine and the Heart

Robert A. Kloner, M.D., Ph.D., and Shereif H. Rezkalla, M.D. — Thu, 06Â FebÂ 2003 00:00:00 -05:00

Cocaine use has been associated with both acute and chronic cardiovascular diseases. These include acute myocardial infarction, myocardial ischemia (both silent ischemia and ischemia associated with angina), acceleration of the...

CLINICAL PRACTICE: Suspected Appendicitis

Erik K. Paulson, M.D., Matthew F. Kalady, M.D., and Theodore N. Pappas, M.D. — Thu, 16Â JanÂ 2003 00:00:00 -05:00

An otherwise healthy 22-year-old woman comes to the emergency department with acute abdominal pain of 18 hours' duration in the right lower quadrant. On physical examination, she is afebrile, with...

ORIGINAL ARTICLE: An Analysis of Outcomes of Reconstruction or Amputation after Leg-Threatening Injuries

Thu, 12Â DecÂ 2002 00:00:00 -05:00

Background: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated.

Methods:...

PERSPECTIVE: To Reconstruct or Not to Reconstruct?

Thu, 12Â DecÂ 2002 00:00:00 -05:00

In the opening scene of the movie âDances with Wolves,â dazed Union Army soldiers with mangled limbs are laid out, resigned to their turn at the surgeon's cleaver. This scene...

IMAGES IN CLINICAL MEDICINE: Commotio Cordis

Janette F. Strasburger, M.D. and Barry J. Maron, M.D. — Thu, 17Â OctÂ 2002 00:00:00 -05:00

Figure 1. A 13-year-old boy in good health was a batter in a Little League baseball game. He pivoted his body toward the field to avoid an inside pitch, was...

ORIGINAL ARTICLE: Public Use of Automated External Defibrillators

Thu, 17Â OctÂ 2002 00:00:00 -05:00

Background: Automated external defibrillators save lives when they are used by designated personnel in certain public settings. We performed a two-year prospective study at three Chicago airports to assess whether...

PERSPECTIVE: Defibrillators in Public Places â One Step Closer to Home

Thu, 17Â OctÂ 2002 00:00:00 -05:00

At least 450,000 cases of unexpected cardiac arrest occur annually in the United States (Figure 1). The majority occur in places other than hospitals in people with recognized heart disease....

EDITORIAL: Hyperbaric-Oxygen Therapy for Acute Carbon Monoxide Poisoning

Thu, 03Â OctÂ 2002 00:00:00 -05:00

Carbon monoxide appears to be the leading cause of injury and death due to poisoning worldwide.1 A colorless, odorless, tasteless gas, carbon monoxide is produced by the incomplete combustion of...

ORIGINAL ARTICLE: Hyperbaric Oxygen for Acute Carbon Monoxide Poisoning

Thu, 03Â OctÂ 2002 00:00:00 -05:00

Background: Patients with acute carbon monoxide poisoning commonly have cognitive sequelae. We conducted a double-blind, randomized trial to evaluate the effect of hyperbaric-oxygen treatment on such cognitive sequelae.

Methods: We randomly...

PERSPECTIVE: Carbon Monoxide Poisoning

Thu, 03Â OctÂ 2002 00:00:00 -05:00

Carbon monoxide poisoning is the most common type of accidental poisoning in the United States, accounting for thousands of emergency department visits and some 800 deaths annually. Carbon monoxide, an...

PERSPECTIVE: Treating Sepsis

Thu, 26Â SepÂ 2002 00:00:00 -05:00

Sepsis, a leading cause of death in the United States, is now viewed physiologically as a proinflammatory and procoagulant response to invading pathogens. There are three recognized stages in the...

EDITORIAL: Syncope â Getting to the Heart of the Matter

Thu, 19Â SepÂ 2002 00:00:00 -05:00

Syncope is the sudden and transient loss of consciousness accompanied by a loss of postural tone. The term derives from the Greek word synkoptein, meaning âto cut short,â and purportedly,...

ORIGINAL ARTICLE: Incidence and Prognosis of Syncope

Thu, 19Â SepÂ 2002 00:00:00 -05:00

Background: Little is known about the epidemiology and prognosis of syncope in the general population.

Methods: We evaluated the incidence, specific causes, and prognosis of syncope among women and men participating...

EDITORIAL: World Trade Center Cough â A Lingering Legacy and a Cautionary Tale

Thu, 12Â SepÂ 2002 00:00:00 -05:00

One year has passed since the terrorist attacks in New York and at the Pentagon. As we struggle to address important issues related to the health consequences of warfare and...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 28-2002 â A 35-Year-Old Long-Term Traveler with a Rapidly Progressive Soft-Tissue Infection

Deborah J. Hoadley and Eugene J. Mark — Thu, 12Â SepÂ 2002 00:00:00 -05:00

A 35-year-old woman was admitted to the hospital because of pain and swelling of the right thigh.

The patient had been in excellent health until the morning before admission, when she...

REVIEW ARTICLE: Respiratory Protection

John Martyny, Ph.D., Craig S. Glazer, M.D., and Lee S. Newman, M.D. — Thu, 12Â SepÂ 2002 00:00:00 -05:00

The use of anthrax as a biologic weapon in 2001 and concern about the health effects of exposure to particles and gases at the World Trade Center site (discussed by...

IMAGES IN CLINICAL MEDICINE: Septic Peripheral Embolization from Endocarditis

J.H. Marc Groeneveld, M.D. and Julien B.C.M. Puylaert, M.D., Ph.D. — Thu, 12Â SepÂ 2002 00:00:00 -05:00

Figure 1. A 21-year-old, previously healthy man with excellent dentition presented with a two-week history of high-grade fever, chills, and malaise. On the fourth hospital day, an early decrescendo diastolic...

ORIGINAL ARTICLE: Cough and Bronchial Responsiveness in Firefighters at the World Trade Center Site

Thu, 12Â SepÂ 2002 00:00:00 -05:00

Background: Workers from the Fire Department of New York City were exposed to a variety of inhaled materials during and after the collapse of the World Trade Center. We evaluated...

IMAGES IN CLINICAL MEDICINE: Severe Abdominal Pain in a Girl

Carrie A. Czarnecki, M.D. and D. Fergus O'Coclain, M.D. — Thu, 05Â SepÂ 2002 00:00:00 -05:00

Figure 1. A 17-year-old girl with a history of bulimia and binge eating presented to the emergency room with severe, diffuse abdominal pain six hours after ingesting massive amounts of...

CLINICAL PROBLEM-SOLVING: Out of Africa

Thu, 05Â SepÂ 2002 00:00:00 -05:00

A 42-year-old man with a recent history of insomnia and problems concentrating during the day presented to the hospital with emotional distress and an inability to cope. He denied any...

CLINICAL PRACTICE: Adolescent Depression

David A. Brent, M.D., and Boris Birmaher, M.D. — Thu, 29Â AugÂ 2002 00:00:00 -05:00

A 16-year-old boy is brought by his parents to his primary care physician because of a decline in school performance, which began at least three years earlier and has become...

IMAGES IN CLINICAL MEDICINE: Coronary-Stent Fracture

Pertha S. Chowdhury, M.D. and Renato G. Ramos, M.D. — Thu, 22Â AugÂ 2002 00:00:00 -05:00

Figure 1. A 57-year-old man presented with several hours of chest discomfort accompanied by ischemic changes on his electrocardiogram. He had undergone coronary-artery bypass grafting and subsequent percutaneous coronary intervention...

REVIEW ARTICLE: Illness after International Travel

Edward T. Ryan, M.D., Mary E. Wilson, M.D., and Kevin C. Kain, M.D. — Thu, 15Â AugÂ 2002 00:00:00 -05:00

Between 20 and 70 percent of the 50 million people who travel from the industrialized world to the developing world each year report some illness associated with their travel.12 Although...

REVIEW ARTICLE: Bites of Venomous Snakes

Barry S. Gold, M.D., Richard C. Dart, M.D., Ph.D., and Robert A. Barish, M.D. — Thu, 01Â AugÂ 2002 00:00:00 -05:00

Approximately 15 percent of the 3000 species of snakes found worldwide are considered to be dangerous to humans (Table 1).1 The last comprehensive survey of snake-venom poisoning, completed in the...

CLINICAL PRACTICE: Herpes Zoster

John W. Gnann, Jr., M.D., and Richard J. Whitley, M.D. — Thu, 01Â AugÂ 2002 00:00:00 -05:00

A 77-year-old man reports a five-day history of burning and aching pain in his right side and a two-day history of erythema and clusters of clear vesicles, accompanied by headache...

IMAGES IN CLINICAL MEDICINE: Work-Related Vascular Injuries of the Hand â Hypothenar Hammer Syndrome

Manuela Birrer, M.D. and Iris Baumgartner, M.D. — Thu, 01Â AugÂ 2002 00:00:00 -05:00

Figure 1. A 47-year-old construction worker reported a two-month history of blanching of the second to fifth fingers and a recent ulcer on the tip of the third finger of...

ORIGINAL ARTICLE: Rapid Measurement of B-Type Natriuretic Peptide in the Emergency Diagnosis of Heart Failure

Thu, 18Â JulÂ 2002 00:00:00 -05:00

Background: 02071822.xml B-type natriuretic peptide is released from the cardiac ventricles in response to increased wall tension.

Methods: We conducted a prospective study of 1586 patients who came to the emergency...

REVIEW ARTICLE: Heat Stroke

Abderrezak Bouchama, M.D., and James P. Knochel, M.D. — Thu, 20Â JunÂ 2002 00:00:00 -05:00

Heat stroke is a life-threatening illness characterized by an elevated core body temperature that rises above 40Â°C and central nervous system dysfunction that results in delirium, convulsions, or coma.1 02062024.xml...

ORIGINAL ARTICLE: Salmeterol for the Prevention of High-Altitude Pulmonary Edema

Thu, 23Â MayÂ 2002 00:00:00 -05:00

Background: 02052326.xml Pulmonary edema results from a persistent imbalance between forces that drive water into the air space and the physiologic mechanisms that remove it. Among the latter, the absorption...

REVIEW ARTICLE: Major Radiation Exposure â What to Expect and How to Respond

Fred A. Mettler, Jr., M.D., M.P.H., and George L. Voelz, M.D. — Thu, 16Â MayÂ 2002 00:00:00 -05:00

Uncontrolled, large-scale exposure to radiation has been caused by the detonation of atomic bombs over Japan, fallout from atomic-bomb tests, nuclear-reactor accidents, and the release of material from radiotherapy devices....

ORIGINAL ARTICLE: Tissue Plasminogen Activator in Cardiac Arrest with Pulseless Electrical Activity

Thu, 16Â MayÂ 2002 00:00:00 -05:00

Background: Coronary thrombosis and pulmonary thromboembolism are common causes of cardiac arrest. We assessed whether the administration of tissue plasminogen activator (t-PA) during cardiopulmonary resuscitation would benefit patients with cardiac...

CLINICAL PRACTICE: Peanut Allergy

Hugh A. Sampson, M.D. — Thu, 25Â AprÂ 2002 00:00:00 -05:00

A 19-year-old woman is brought to the emergency room because of the acute onset of dyspnea, wheezing, vomiting, and generalized flushing. She has well-controlled asthma as well as a history...

REVIEW ARTICLE: Responding to Medical Events during Commercial Airline Flights

Mark A. Gendreau, M.D., and Charles DeJohn, D.O., M.P.H. — Thu, 04Â AprÂ 2002 00:00:00 -05:00

The provision of medical assistance to passengers during flights aboard commercial aircraft is a matter of concern to most physicians.1234 Although close to 2 billion people travel on commercial airlines...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 6-2002 â A 54-Year-Old Woman with Left, Then Right, Central-Retinal-Vein Occlusion

Robert Weinstein, M.D., and Mohammad Mahmood, M.D. — Thu, 21Â FebÂ 2002 00:00:00 -05:00

A 54-year-old woman was admitted to the hospital because of occlusion of the central retinal vein in her left eye, followed by occlusion of the central retinal vein in her...

ORIGINAL ARTICLE: Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia

Thu, 21Â FebÂ 2002 00:00:00 -05:00

Background: Cardiac arrest outside the hospital is common and has a poor outcome. Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve...

ORIGINAL ARTICLE: Mild Therapeutic Hypothermia to Improve the Neurologic Outcome after Cardiac Arrest

The Hypothermia after Cardiac Arrest Study Group — Thu, 21Â FebÂ 2002 00:00:00 -05:00

Background: Cardiac arrest with widespread cerebral ischemia frequently leads to severe neurologic impairment. We studied whether mild systemic hypothermia increases the rate of neurologic recovery after resuscitation from cardiac arrest...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 4-2002 â A 75-Year-Old Man with Acute Renal Failure Five Months after Cystoprostatectomy and Urethrectomy for Carcinoma

Hasan Bazari, M.D.,and Shamila Mauiyyedi, M.D. — Thu, 31Â JanÂ 2002 00:00:00 -05:00

A 75-year-old man was admitted to the hospital because of acute renal failure.

He had undergone cystoprostatectomy and urethrectomy with construction of an ileal conduit five months earlier because of prostatic...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 3-2002 â A 17-Year-Old Boy with Biliary Obstruction

M. Susan Moyer and Fiona M. Graeme-Cook — Thu, 24Â JanÂ 2002 00:00:00 -05:00

A 17-year-old boy was admitted to the hospital because of evidence of biliary obstruction.

Seventeen months before admission, the patient was admitted to another hospital because of bloody diarrhea. The serum...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 40-2001 â An Eight-Year-Old Boy with Fever, Headache, and Vertigo Two Days after Aural Trauma

Cliff A. Megerian and Tessa A. Hadlock — Thu, 27Â DecÂ 2001 00:00:00 -05:00

An eight-year-old boy was admitted to the Massachusetts Eye and Ear Infirmary because of fever, headache, vertigo, and vomiting.

The child had been well until two days before admission, when he...

EDITORIAL: Computed Tomography of the Head before a Lumbar Puncture in Suspected Meningitis â Is It Helpful?

Thu, 13Â DecÂ 2001 00:00:00 -05:00

Meningitis remains a formidable foe because it often progresses rapidly and causes substantial morbidity and mortality.123 The rational management of meningitis has generally included a lumbar puncture to substantiate the...

ORIGINAL ARTICLE: Computed Tomography of the Head before Lumbar Puncture in Adults with Suspected Meningitis

Thu, 13Â DecÂ 2001 00:00:00 -05:00

Background: In adults with suspected meningitis clinicians routinely order computed tomography (CT) of the head before performing a lumbar puncture.

Methods: We prospectively studied 301 adults with suspected meningitis to determine...

IMAGES IN CLINICAL MEDICINE: Atloido-Occipital Dislocation in a Small Child after Air-Bag Deployment

Carlos A. Angel, M.D. and Richard A. Ehlers, M.D. — Thu, 25Â OctÂ 2001 00:00:00 -05:00

Figure 1. A two-year-old girl riding in an automobile was involved in a low-speed collision in which the air bags deployed. At the time of the crash she was sitting...

ORIGINAL ARTICLE: Wild-Mushroom Intoxication as a Cause of Rhabdomyolysis

Thu, 13Â SepÂ 2001 00:00:00 -05:00

The growing popularity of eating wild mushrooms has led to an increase in the incidence of mushroom poisoning. Most fatalities are due to amatoxin-containing species, which cause fulminant hepatocytolysis, and...

EDITORIAL: Clinical Research on Out-of-Hospital Emergency Care

Thu, 30Â AugÂ 2001 00:00:00 -05:00

Status epilepticus is a series of successive grand mal seizures lasting minutes or even hours, without the recovery of normal consciousness. The resulting metabolic derangement of cells, depletion of the...

ORIGINAL ARTICLE: A Comparison of Lorazepam, Diazepam, and Placebo for the Treatment of Out-of-Hospital Status Epilepticus

Thu, 30Â AugÂ 2001 00:00:00 -05:00

Background: It is uncertain whether the administration of benzodiazepines by paramedics is an effective and safe treatment for out-of-hospital status epilepticus.

Methods: We conducted a randomized, double-blind trial to evaluate intravenous...

IMAGES IN CLINICAL MEDICINE: Nail Injury to the Skull

Wayne X. Shandera, M.D. and Anne Hayman, M.D. — Thu, 02Â AugÂ 2001 00:00:00 -05:00

Figure 1. A 58-year-old carpenter was working at a home-construction site while a colleague working above him fired nails into a board with a nail gun. The board broke during...

REVIEW ARTICLE: High-Altitude Illness

Peter H. Hackett, M.D., and Robert C. Roach, Ph.D. — Thu, 12Â JulÂ 2001 00:00:00 -05:00

The term âhigh-altitude illnessâ is used to describe the cerebral and pulmonary syndromes that can develop in unacclimatized persons shortly after ascent to high altitude. Acute mountain sickness and high-altitude...

SPECIAL ARTICLE: Deaths and Injuries from House Fires

Thu, 21Â JunÂ 2001 00:00:00 -05:00

Background: We sought to define the factors associated with house fires and related injuries by analyzing the data from population-based surveillance.

Methods: For 1991 through 1997, we linked the following data...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 16-2001 â A 17-Year-Old Girl with Worsening Abdominal Pain, Fever, and Diarrhea after a Recent Cesarean Section

J. Thomas LaMont, Fiona M. Graeme-Cook — Thu, 24Â MayÂ 2001 00:00:00 -05:00

A 17-year-old girl (gravida 1, para 1) was admitted to the hospital because of abdominal pain, fever, and diarrhea.

The patient had been in good health before admission. Three weeks earlier,...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2001 â A 47-Year-Old Woman with Diabetes, Crohn's Colitis, and a Painful Swelling of the Foot

Harley A. Haynes, Fiona M. Graeme-Cook, Lisa H. Lerner — Thu, 10Â MayÂ 2001 00:00:00 -05:00

A 47-year-old woman was admitted to the hospital for the third time because of a painful, red swelling of the right foot.

Nine months before the third admission, the patient had...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 12-2001 â A 16-Year-Old Boy with an Altered Mental Status and Muscle Rigidity

Mark H. Libenson, Jane M. Yang — Thu, 19Â AprÂ 2001 00:00:00 -05:00

A 16-year-old boy was admitted to the hospital because of an altered mental and emotional status.

At an uncertain interval before admission, the patient began to have diarrhea. One week before...

EDITORIAL: Hypothermia for Traumatic Brain Injury â A Good Idea Proved Ineffective

Thu, 22Â FebÂ 2001 00:00:00 -05:00

Traumatic brain injury is an important cause of death and disability in both civilians and military personnel.1 In areas with organized trauma care systems and adequate critical care, the mortality...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 6-2001 â A 17-Year-Old Girl with Marked Jaundice and Weight Loss

Maureen M. Jonas, Fiona M. Graeme-Cook — Thu, 22Â FebÂ 2001 00:00:00 -05:00

A 17-year-old girl was admitted to the hospital because of progressive jaundice and weight loss.

The patient had been well until four months earlier, when she experienced the onset of malaise,...

IMAGES IN CLINICAL MEDICINE: Four Types of Acute Post-Traumatic Intracranial Hemorrhage

Julian A. Mattiello, M.D. and Michael Munz, M.D. — Thu, 22Â FebÂ 2001 00:00:00 -05:00

Figure 1. A 71-year-old man was pushed onto his back by a slow-moving vehicle. Initially, he was alert and fully oriented. In the emergency department, the patient was disoriented to...

ORIGINAL ARTICLE: Lack of Effect of Induction of Hypothermia after Acute Brain Injury

Thu, 22Â FebÂ 2001 00:00:00 -05:00

Background: Induction of hypothermia in patients with brain injury was shown to improve outcomes in small clinical studies, but the results were not definitive. To study this issue, we conducted...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 5-2001 â A 52-Year-Old Man with Chronic Anemia and Sudden Severe Abdominal Pain

Farhad Navab, Rhonda K. Yantiss — Thu, 15Â FebÂ 2001 00:00:00 -05:00

A 52-year-old man was admitted to the hospital because of an attack of severe abdominal pain.

During the preceding four years, the patient had been evaluated repeatedly for chronic iron-deficiency anemia,...

ORIGINAL ARTICLE: Fomepizole for the Treatment of Methanol Poisoning

Thu, 08Â FebÂ 2001 00:00:00 -05:00

Background: Methanol poisoning may result in metabolic acidosis, blindness, and death. The inhibition of alcohol dehydrogenase is fundamental to the treatment of methanol poisoning. We performed a multicenter study to...

ORIGINAL ARTICLE: Adverse Events, Including Death, Associated with the Use of 1,4-Butanediol

Thu, 11Â JanÂ 2001 00:00:00 -05:00

Background: 1,4-Butanediol is an industrial solvent that, when ingested, is converted to Î³-hydroxybutyrate, a drug of abuse with depressant effects, primarily on the central nervous system. After reports of toxic...

IMAGES IN CLINICAL MEDICINE: Lichtenberg Figures Due to a Lightning Strike

Yves Domart, M.D. and Emmanuel Garet, M.D. — Thu, 23Â NovÂ 2000 00:00:00 -05:00

Figure 1. A 54-year-old man was struck by lightning and was initially stuporous. The emergency medical team found him conscious and in sinus rhythm, with normal vital signs and numbness...

ORIGINAL ARTICLE: Use of Automated External Defibrillators by a U.S. Airline

Thu, 26Â OctÂ 2000 00:00:00 -05:00

Background: Passengers who have ventricular fibrillation aboard commercial aircraft rarely survive, owing to the delay in obtaining emergency care and defibrillation.

Methods: In 1997, a major U.S. airline began equipping its...

ORIGINAL ARTICLE: Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in Casinos

Thu, 26Â OctÂ 2000 00:00:00 -05:00

Background: The use of automated external defibrillators by persons other than paramedics and emergency medical technicians is advocated by the American Heart Association and other organizations. However, there are few...

REVIEW ARTICLE: Treatment of Acute Ischemic Stroke

Thomas Brott, M.D., and Julien Bogousslavsky, M.D. — Thu, 07Â SepÂ 2000 00:00:00 -05:00

Ischemic stroke exacts a heavy toll in death and disability worldwide. In the United States, where it is the third leading cause of death and the leading cause of serious...

ORIGINAL ARTICLE: A Comparison of Inhaled Fluticasone and Oral Prednisone for Children with Severe Acute Asthma

Thu, 07Â SepÂ 2000 00:00:00 -05:00

Background: Inhaled corticosteroids are effective in the treatment of children with asthma. It is uncertain how inhaled corticosteroids compare with oral corticosteroids in the management of severe acute disease.

Methods: We...

REVIEW ARTICLE: Blurred Vision

Bradford J. Shingleton, M.D., and Mark W. O'Donoghue, O.D. — Thu, 24Â AugÂ 2000 00:00:00 -05:00

Blurred vision is the most common symptom related to the eye. It is manifested in many ways and has a wide variety of causes. Here we review for nonophthalmologists the...

REVIEW ARTICLE: The Red Eye

Howard M. Leibowitz, M.D. — Thu, 03Â AugÂ 2000 00:00:00 -05:00

A red eye is the most common ocular disorder that primary care physicians encounter. Most cases are relatively benign. Some, however, herald a vision-threatening or even life-threatening disorder. A detailed...

IMAGES IN CLINICAL MEDICINE: Methemoglobinemia

Gerard B. Donnelly, M.D. and Diana Randlett, M.S. — Thu, 03Â AugÂ 2000 00:00:00 -05:00

Figure 1. A 39-year-old woman who had a small-bowel obstruction after resection of an appendiceal carcinoid tumor was given benzocaine topical spray for retropharyngeal discomfort from a nasogastric tube. Within...

IMAGES IN CLINICAL MEDICINE: Boerhaave's Syndrome

Ramana Gopalan, M.D., M.P.H. and Colleen G. Cooke, M.D. — Thu, 20Â JulÂ 2000 00:00:00 -05:00

Figure 1. A 71-year-old man began to have burning substernal pain while he was eating a sandwich. The pain became excruciating, worsened with breathing, and was accompanied by dyspnea. On...

ORIGINAL ARTICLE: Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma

Thu, 13Â JulÂ 2000 00:00:00 -05:00

Background: Because clinicians fear missing occult cervical-spine injuries, they obtain cervical radiographs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clinical criteria...

EDITORIAL: Who is at Low Risk after Head or Neck Trauma?

Thu, 13Â JulÂ 2000 00:00:00 -05:00

Emergency physicians have traditionally relied heavily on diagnostic imaging in the evaluation of patients with head or neck trauma. This conservative approach is intended to reduce the risk of missing...

ORIGINAL ARTICLE: Indications for Computed Tomography in Patients with Minor Head Injury

Thu, 13Â JulÂ 2000 00:00:00 -05:00

Background: Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and...

IMAGES IN CLINICAL MEDICINE: Elemental Mercury Embolism to the Lung

Figure 1. A 21-year-old dental assistant attempted suicide by injecting 10 ml (135 g) of elemental mercury (quicksilver) intravenously. She presented to the emergency room with tachypnea, a dry cough,...

EDITORIAL: Cardiopulmonary Resuscitation â Strengthening the Links in the Chain of Survival

Thu, 25Â MayÂ 2000 00:00:00 -05:00

The major determinants of survival after witnessed out-of-hospital cardiac arrest due to ventricular fibrillation include whether a bystander initiates cardiopulmonary resuscitation (CPR) and how quickly defibrillation is accomplished.

The now-classic observations...

ORIGINAL ARTICLE: Cardiopulmonary Resuscitation by Chest Compression Alone or with Mouth-to-Mouth Ventilation

Thu, 25Â MayÂ 2000 00:00:00 -05:00

Background: Despite extensive training of citizens of Seattle in cardiopulmonary resuscitation (CPR), bystanders do not perform CPR in almost half of witnessed cardiac arrests. Instructions in chest compression plus mouth-to-mouth...

IMAGES IN CLINICAL MEDICINE: Pneumomediastinum and Severe Subcutaneous Emphysema

Frank G.H. van der Kleij, M.D. and Jan G. Zijlstra, M.D., Ph.D. — Thu, 04Â MayÂ 2000 00:00:00 -05:00

Figure 1. A 76-year-old man with chronic obstructive pulmonary disease was admitted after a car accident. The initial clinical and radiographic evaluation showed no evidence of rib fractures or other...

EDITORIAL: Missed Diagnoses of Acute Coronary Syndromes in the Emergency Room â Continuing Challenges

Thu, 20Â AprÂ 2000 00:00:00 -05:00

Patients with suspected acute coronary syndromes, or acute cardiac ischemia, account for nearly 1.7 million hospital admissions per year in the United States. Between 2 and 8 percent of patients...

REVIEW ARTICLE: Evaluation of the Patient with Acute Chest Pain

Thomas H. Lee, M.D., and Lee Goldman, M.D., M.P.H. — Thu, 20Â AprÂ 2000 00:00:00 -05:00

The evaluation of acute chest pain remains challenging, despite many insights and innovations over the past two decades. The percentage of patients who present at the emergency department with acute...

ORIGINAL ARTICLE: Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department

Thu, 20Â AprÂ 2000 00:00:00 -05:00

Background: Discharging patients with acute myocardial infarction or unstable angina from the emergency department because of missed diagnoses can have dire consequences. We studied the incidence of, factors related to,...

IMAGES IN CLINICAL MEDICINE: Retroperitoneal Hemorrhage

David J. Kastan, M.D. and Thomas H. Burke, R.T. — Thu, 09Â MarÂ 2000 00:00:00 -05:00

Figure 1. Left flank pain and hypotension developed in a 62-year-old woman during treatment with intravenous heparin (900 U per hour) and warfarin (7.5 mg per day) for deep venous...

REVIEW ARTICLE: Ingestion of Toxic Substances by Children

Michael Shannon, M.D., M.P.H. — Thu, 20Â JanÂ 2000 00:00:00 -05:00

Ingestion of a harmful substance is among the most common causes of injury to children less than six years of age. Fortunately, in most cases, the ingested agent has minimal...

IMAGES IN CLINICAL MEDICINE: A Medical Mystery

Michiel G.H. Betjes, M.D., Ph.D. — Thu, 20Â JanÂ 2000 00:00:00 -05:00

Figure 1. A 79-year-old woman presented to the emergency department with a several-hour history of facial swelling (Panel A). The photograph shown in Panel B was taken seven days later....

SPECIAL ARTICLE: Mass Psychogenic Illness Attributed to Toxic Exposure at a High School