Initial Complaint Research Articles

Effect of aging on quality of nocturnal erections: evaluation with NPTR testing.

Nocturnal penile tumescence and rigidity testing (NPTR) has traditionally been performed to distinguish psychogenic from organic impotence. However, considerable lack of uniformly accepted normative data for NPTR readings makes the reproducibility of the method questionable. In this study, we try to evaluate the impact of aging as independent criteria for quality of erectile episodes. A total of 455 patients (ages 20-71 y) whose initial complaints were erectile dysfunction underwent two nights NPTR measurement with Rigiscan device. After analyzing the data, 353 men out of 455 were regarded as having normal NPTR recordings. The number of normal erectile episodes (erectile episode of penile tip rigidity greater than 60% more than 10 min duration), RAU Tip, RAU Base, TAU Tip, TAU Base, Average event rigidity of Tip (%), Average event rigidity of Base (%) and Duration of erectile episodes > or =60% minute were re-evaluated with regard to five age groups (group I: <30 y; group II: 30-39 y; group III: 40-49 y; group IV: 50-59 y; group V: > or =60 y). The mean values of erectile episodes in the age groups were as follows: group I, 2.46; group II, 2.28; group III, 2.40; group IV, 1.58; group V, 1.27. When we analyzed the groups between themselves, we observed statistically significant difference after the age of 50 y. The mean erectile episodes in patients younger than 50 y were 2.37 (s.d.: 1.50), whereas 1.49 (s.d.: 1.15) in patients older than 50 y (P<0.001). We also observed statistically significant difference at all of the above-mentioned NPTR parameters with regard to age. The results of our study showed that aging negatively influence quality of nocturnal erections especially after 50 y and we suggest that age needs to be taken into account in the diagnostic interpretation of NPTR testing.

Neoplasm at the head of the pancreas: a case study.

1. Kristina Marie Griffin, CLS(NCA)[⇑][1] 1. is a recent graduate from Florida Gulf Coast University, Ft Myers FL. This case study was originally developed when she was a clinical laboratory science student 1. Address for correspondence: Kristina Marie Griffin, 5115 Cobble Creek Court #103, Naples FL 34110, (239) 598-5022, KMGHerbalScience{at}aol.com. CASE PRESENTATION A 68-year-old male was seen by his anticoagulation clinic doctor for a scheduled warfarin check up. He had been diagnosed with deep vein thrombosis (DVT) about two years ago. The patient's international normalized ratio (INR) was 6.31; his target range is 2.0 to 3.0. The patient was referred to the evaluation clinic, where he was administered 2.5 mg of vitamin K. Consideration was given to his initial complaints of stomach ailments at the start of fluctuating INRs in the following weeks (Table 1). In addition to unintentional weight loss, physician examination revealed that the patient claimed episodes of hematuria. He also complained of recent lower back and stomach pain, and for the past four weeks, blood-tinged sputum in the mornings. The patient has a history of smoking. A urinalysis was performed and was negative for blood. Upon palpitation, his abdomen was non-tender and without masses. A 48-hour follow-up appointment was made with the anticoagulation clinic. On the second day, the patient's prothrombin time (PT) was redrawn, and demonstrated an INR of 4.29. He maintained his directed warfarin dosage and was scheduled to return in 12 days. At 14 days he displayed a critical INR of 6.58 and was administered another 2.5 mg of vitamin K. However, at this appointment, the patient confessed missing a warfarin dose within the last ten days. Plans were documented to decrease his warfarin dosage when the patient's INR fell to within his target range. His next appointment was scheduled for two days later. ABBREVIATIONS: DVT = deep vein thrombosis; ERCP = endoscopic retrograde cholangiopancreatography; INR = international normalized ratio; PTCA = percutaneous transhepatic cholangiogram. [1]: #corresp-1

Takayasu's arteritis: results of a university hospital of 45 patients in Turkey

Background: Takayasu's arteritis (TA) is a rare disease which appears to be most common in East Asia. However, the disease has been reported to be worldwide. The clinical features of the disease can show variations in different geographical areas. The aim of this study is to evaluate clinical, laboratory and radiological features and the outcome of patients with TA in our hospital. Methods: The hospital files of patients who were followed with the diagnosis of TA between the years 1973 and 2003 in Hacettepe University Hospital were retrospectively evaluated. Results: Male/female ratio was 5/40, and the mean age was 34 years (18–59). Constitutional symptoms were present in 71% of the patients. Claudication and pallor of the extremity, decreased extremity pulsations, arterial hypertension, and arterial bruits were present in 44%, 56%, 58%, and 27% of the patients, respectively. Aortic valvular insufficiency, abdominal aortic aneurism, and cardiomegaly were present in four, one, and four patients, respectively. The initial complaint of six patients was cerebrovascular events. The distribution of the patients according to the angiographic findings was as follows, 56% Type I, 18% Type II, 22% Type III, and 4% Type IV arteritis. The need for vascular surgical interventions were significantly less common in patients who were treated with immunosuppressives plus alternate dose steroids (6%) compared to patients who were treated only with antiaggregant agents (33%). Conclusions: The demographic and angiographic findings of our patients were similar to previous observations from Japan and Italy, and disclose distinct clinical features in comparison to other Asian countries. Alternate-day glucocorticoids plus cytotoxic drugs may be beneficial and safe in patients with TA.

Abnormal vaginal bleeding in the nonpregnant patient

Vaginal bleeding is a common complaint in most emergency departments. Abnormal vaginal bleeding causes many patients a great deal of stress and inconvenience. Although treatment of most cases is straightforward, vaginal bleeding can herald serious occult disease including cancer, coagulopathy, and systemic illness. Vaginal bleeding can also be the initial complaint in patients suffering sexual abuse or trauma. From an emergency medicine perspective, vaginal bleeding should be approached in terms of whether the patient is stable or not. Subsequent evaluation should exclude or treat problems that might cause the patient's condition to deteriorate. The emergency physician is able to provide initial therapy for most causes of vaginal bleeding, and in most cases the patient must be referred to a gynecologist for further evaluation and treatment.

Foveal spot: a report of thirteen patients.

To describe the natural history of a series of patients with a small foveal or juxtafoveal red lesion. Retrospective chart review of 13 patients with a small foveal or juxtafoveal red spot. Long-term follow-up examination was obtained in seven patients. Thirteen patients with a mean age of 34.6 years are reported. Initial visual complaints ranged from no complaints to mild blurring and central distortion of vision. None of the patients had a history of sun gazing or known macular disease. Eleven of the 13 patients had best-corrected visual acuities in the involved eye that were better than 20/30. The lesions were bilateral in five patients and unilateral in eight. When performed, optical coherence tomography and fluorescein angiography were unremarkable. Follow-up was obtained in seven patients (mean, 58 months), and visual acuity remained stable in all affected eyes. In all patients, the lesions remained stable without expansion or alteration of the foveal appearance over the course of follow-up. This report identifies a foveal or juxtafoveal, irregular, apparently intraretinal, red lesion of unclear cause. Long-term follow-up of these patients has demonstrated stable visual acuity and lesion appearance.

Forefoot Pain in a Female College Soccer Player

Idiopathic forefoot pain, often termed metatarsalgia, is a common complaint among running athletes. Whereas several causes are often included in the differential diagnosis, Freiberg’s infraction is rarely considered. The signs and symptoms present with Freiberg’s infraction however, can mimic those present with more common forefoot injuries. The article presents the case of a female Division-I college soccer player who developed and was successfully treated for bilateral Freiberg’s infraction. Her initial complaint of unilateral forefoot pain, induced only by vigorous running, progressed to intolerable bilateral forefoot pain with light exercise. Conservative treatment was unsuccessful, and therefore surgery was required to enable her continued athletic participation. As with all weight-bearing joints, clinicians need to be aware of the potential for progressive degenerative changes at the metatarsal heads and the steps used in the evaluation and subsequent treatment of Freiberg’s infraction

Hepatocellular carcinoma with obstructive jaundice: diagnosis, treatment and prognosis.

Obstructive jaundice as the main clinical feature is uncommon in patients with hepatocellular carcinoma (HCC). Only 1-12 % of HCC patients manifest obstructive jaundice as the initial complaint. Such cases are clinically classified as "icteric type hepatoma", or "cholestatic type of HCC". Identification of this group of patients is important, because surgical treatment may be beneficial. HCC may involve the biliary tract in several different ways: tumor thrombosis, hemobilia, tumor compression, and diffuse tumor infiltration. Bile duct thrombosis (BDT) is one of the main causes for obstructive jaundice, and the previously reported incidence is 1.2-9 %. BDT might be benign, malignant, or a combination of both. Benign thrombi could be blood clots, pus, or sludge. Malignant thrombi could be primary intrabiliary malignant tumors, HCC with invasion to bile ducts, or metastatic cancer with bile duct invasion. The common clinical features of this type of HCC include: high level of serum AFP; history of cholangitis with dilation of intrahepatic bile duct; aggravating jaundice and rapidly developing into liver dysfunction. It is usually difficult to make diagnosis before operation, because of the low incidence rate, ignorant of this disease, and the difficulty for the imaging diagnosis to find the BDT preoperatively. Despite recent remarkable improvements in the imaging tools for diagnosis of HCC, such cases are still incorrectly diagnosed as cholangiocarcinoma or choledocholithiases. Ultrasonography (US) and CT are helpful in showing hepatic tumors and dilated intrahepatic and /or extrahepatic ducts containing dense material corresponding to tumor debris. Direct cholangiography including percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP) remains the standard procedure to delineate the presence and level of biliary obstruction. Magnetic resonance cholangiopancreatography (MRCP) is superior to ERCP in interpreting the cause and depicting the anatomical extent of the perihilar obstructive jaundice, and is particularly distinctive in cases associated with tight biliary stenosis and along segmental biliary stricture. Choledochoscopy and bile duct brushing cytology could be alternative useful techniques in the differentiating obstructions due to intraluminal mass, infiltrating ductal lesions or extrinsic mass compression applicable before and after duct exploration. Jaundice is not necessarily a contraindication for surgery. Most patients will have satisfactory palliation and occasional cure if appropriate procedures are selected and carried out safely, which can result in long-term resolution of symptoms and occasional long-term survival. However, the prognosis of icteric type HCC is generally dismal, but is better than those HCC patients who have jaundice caused by hepatic insufficiency.

術後早期に再発した腰部脊柱管内嚢腫の一例

We report a case of recurrent intraspinal cyst. The patient was a 29-year-old male. His initial complaint was lumbago. Four weeks after onset, lumbago and left sciatica appeared. An epidural mass was detected at L4/5 by MR imaging, myelogram and CTM. In MR imaging, the mass showed low intensity in T1, high intensity in T2 and ringed enhancement effect with gadolinium. The mass was thought to be a synovial cyst or ganglion, but surgical and histological diagnosis was a discal cyst. His pain subsided after surgery, but left sciatica appeared again seventh seven days after the operation. A cyst larger than the first one was found with MR imaging.

Uroneurological assessment of spina bifida cystica and occulta.

Spina bifida is a rare but well-documented congenital spinal anomaly comprising a cystic form, which appears in infancy, and an occult form, which appears in late childhood and in adulthood. Herein, we report the results of uroneurological assessment in patients with spina bifida cystica and occulta, with respect to diagnosis and management of the disorders. We performed a neurological examination, urinary questionnaire, and urodynamic studies in 28 consecutive patients with urinary symptoms, including 16 with the cystic form (nine male and seven female patients, ages 2 to 25 years), all of whom underwent neonatal surgical management, and 12 with occult form (six men and six women, ages 7 to 32 years) diagnosed by myelography and spinal magnetic resonance imaging who did not undergo surgery. Neurological examination revealed a combination of flaccid and spastic paresis, with dominant lower motoneuron signs in the cystic form, whereas there were dominant upper motoneuron signs in the occult form. Four patients with occult spina bifida presented with urinary symptoms as the sole initial complaint. There was no correlation between neurological findings and urodynamic abnormalities. Urinary incontinence and enuresis were common at all ages, and large post-micturition residuals and vesicoureteral reflux were not uncommon, particularly in the cystic form. Bladder abnormalities in the cystic and occult forms included detrusor hyperreflexia during filling in 38% and 42%, low compliance detrusor in 81% and 67%, supersensitivity to bethanechol in two (100%) patients with the cystic form and in three of four (75%) with the occult form, and impaired bladder sensation in 25% and 8% in each form, respectively. Urethral abnormalities in cystic and occult forms included detrusor/sphincter dyssynergia in 50% and 27%, low Pure max in 56% and 17%, silent sphincter electromyographic activity in 25% and 0%, absent bulbocavernosus reflex in 87% and 56%, absent anal reflex in 100% and 57%, neurogenic motor unit potentials in one patient with cystic form studied and in two of three patients with occult form, respectively. Spina bifida cystica and occulta present with a wide spectrum of urodynamic abnormalities including upper and lower motoneuron types of bladder and urethral dysfunction. Careful uroneurological assessment and spinal magnetic resonance imaging are important for diagnosing young adult patients with spina bifida occulta because they may present with urinary symptoms as the sole initial complaint and have no other obvious neurological abnormalities.

An outbreak of food-borne illness due to methomyl contamination.

On December 26, 2002, 124 dinners took ill while eating lunch at a seafood restaurant in the town of Chiching in Kaohsiung municipality of Taiwan. Sixty-nine people were sent to the emergency departments of the Municipal Chiching Hospital and Yuan's General Hospital. We analyzed the clinical symptoms, detailed food history, and ingested amount of each food from 59 hospitalized adult patients and identified the source of the outbreak. The median latency period from beginning eating to first symptoms was 5 min. Twenty-six symptoms and signs were recorded. The most commonly reported clinical effects were general weakness (84%), ataxia (82%), dizziness (82%), vomiting (80%), sweating (75%), floating sensation (71%), headache (69%), dyspnea (69%), and blurred vision (67%). Thirty-one patients had residual symptoms 7 days after ingestion. Of the six residual symptoms reported, the most frequent ones were dizziness (40%), poor appetite and dry mouth (11%), and gastrointestinal disturbance (11%). The presence of residual symptoms correlated with the severity of the initial complaints (p < 0.01). Almost all patients ate cooked rice (93%) and leaf vegetable stir-fried with crab claw (93%). The amount of each food eaten by the patients was not associated with the severity of symptoms (p > 0.05). High levels of methomyl in leaf vegetables of "leaf vegetables stir-fried with crab claws" (380 ppm) and fried mussels (1113 ppm) were found by the Food Inspection Center at the Department of Health. The food history and chemical analysis of the poison indicated methomyl was the cause of this outbreak. Twenty-four patients recovered completely within 7 days. Food-related methomyl intoxication produced a rapid onset of significant clinical toxicity in 124 individuals. Based on the analysis of 55 adult patients, the most common effects were gait ataxia, dizziness, generalized weakness, and vomiting.

Book of the Month: The Autonomous Patient: Ending Paternalism in Medical Care

Book of the Month: The Autonomous Patient: Ending Paternalism in Medical Care

Treatment of Plantar Verrucae Using 2% Sodium Salicylate Iontophoresis

Iontophoretic sodium salicylate treatment of plantar warts was studied. Twenty patients with 104 plantar verrucae were studied. Two percent sodium salicylate solution was administered iontophoretically (22.5 mA-minute/electrode, 3 treatments at 6- to 9-day intervals). Results. Nineteen subjects were followed. Verrucae area declined in 15 subjects (78.9%) and increased in 2 subjects (10.5%). One subject (5.3%) no longer had verrucae, and 1 subject (5.3%) exhibited no change. Overall, the number of verrucae and total area decreased. Four of 6 subjects (66.6%) with initial complaints of load-bearing pain reported diminished pain following treatment. Two subjects whose verrucae's size increased reported an increase in pain at the end of the study. Sodium salicylate iontophoresis appeared to compare favorably with other office-based interventions in diminishing the size of plantar warts and their associated pain. Application of iontophoresis to weight-bearing surfaces in some subjects appeared to decrease the pain and scarring associated with freezing and electrocautery and the fixation problems associated with medicated patches.

The natural history of the syndrome of primary progressive freezing gait.

Primary progressive freezing gait disorder is considered to be a distinct clinical entity that manifests predominantly as a progressive freezing gait disorder without accompanying abnormalities. However, confusion remains about its clinical presentation, natural history, and classification. To examine the natural history, clinical and brain imaging characteristics, and response to dopaminergic medications of primary progressive freezing gait (PPFG) disorder. Review of medical records, videotape examinations, and computed tomographic and magnetic resonance imaging of the brain and results of neurological evaluations, including the Unified Parkinson's Disease Rating Scale, in patients with PPFG. Thirty patients (16 male) were diagnosed as having PPFG (mean age at onset, 72.2 years; mean duration of disease, 5 years). Gait disorder was the initial complaint in 27 patients. Freezing gait was the initial manifestation in 18 and was present within the first year in 27. Natural history included 25 patients falling within 3 years of onset, 20 experiencing retropulsion within 4 years, and 16 requiring wheelchairs by 5 years. On neurological examination, bradykinesia was present in 29 patients, muscle rigidity in 15, and postural tremor in 11. Other features included speech abnormalities in 10, hyperreflexia without clonus in 17, and dementia in 8. Extraocular movement abnormalities and dysphagia were rare. All 30 patients were treated with levodopa with minimal effect. Eighteen were treated with a dopamine agonist with no notable effect. Of the 23 patients with magnetic resonance imaging scans, results were normal in 9 and included minor nonspecific changes in 14. The computed tomographic scans obtained in 12 patients showed similar results. One patient underwent fluorine F ((18)F) labeled deoxyglucose positron emission tomography, which showed mild reduction in medial frontal glucose metabolism. Primary progressive freezing gait appears to be a clinically distinct progressive neurological disorder that primarily affects gait, initially resulting in freezing and later in postural instability. A wheelchair-bound state often develops within 5 years. It is accompanied by other parkinsonian features, particularly bradykinesia, but is unresponsive to dopaminergic medications. It progresses in a fairly stereotyped manner. Primary progressive freezing gait disorder should be a unifying term for this disorder that has gone by many names in the literature and should be classified as a Parkinson-plus disorder.

Stalking Laws and Implementation Practices: A National Review for Policymakers and Practitioners

In 1990, California enacted the first criminal law specifically directed at stalking. Since that time there has been considerable research on the dynamics of stalking, including, for example, who stalks and why stalkers stalk. However, little research has been conducted on the stalking laws themselves and how they have been implemented. The present research was conducted to fill that knowledge gap. The research examined state and federal anti-stalking laws, court decisions, social science and medical research on stalking and stalkers, and anti-stalking actions by law enforcement, prosecutor, and victim service agencies around the country. Although the researchers initially contemplated evaluating the effectiveness of the new stalking laws, that was deemed not feasible. Instead, developing a best practices catalogue became the study's second focus. This report presents the findings of the multi-layered research. Key findings include these: -Stalking is pervasive and injurious. It affects between 2 million and 6 million victims annually, depending on the definition of stalking used. Official recognition of stalking actions falls far below this number. This failure is significant because stalking often has serious injurious effects on its victims. -Implementation of the new stalking laws is still limited. Most law enforcement and prosecution agencies lack policies for responding to stalking complaints and do not have personnel with expertise in stalking cases. Such expertise is important because stalking is a different type of crime. It combines elements of assault, threat, harassment, intimidation, and invasion of privacy. It occurs repeatedly and often must be investigated prospectively (by gathering evidence as stalking behaviors continue to occur after the initial complaint). -A number of agencies have established special stalking units or assigned specialized staff to handle stalking cases. These efforts both demonstrate the importance of stalking case expertise and provide a model for other jurisdictions to emulate. This report first presents findings from a review of the prior research on stalking and some original information gathering; this combination resulted in a reassessment of the significance of stalking as a policy issue for criminal justice. The review also examines stalking's definitions, prevalence, and impact on victims. Next comes an examination of criminal law, namely, the enactment of stalking laws and their reception in the courts. The report then discusses how stalking laws have been implemented, based on (1) surveys of law enforcement, prosecutor, and victim service agencies, and (2) field work with agencies having specialized anti-stalking units. The empirical findings from the field work together with a review of training and other materials used by these agencies combine to produce a best practices synthesis. The report concludes with recommendations for legislators, agency administrators, funders, and researchers.

The role of the family physician in eating disorders.

The steady increase in Eating Disorders (ED) during the last three decades has raised increasing concern over the early diagnosis and treatment of this disease. Due to the multi-factorial etiology of ED, treatment is complex, prolonged, and demands a team approach. Family physicians are often approached first for consultation following the patient's initial physical complaints. For this reason, the general practitioner can play a critical role in the early diagnosis and treatment of these disorders. By asking the appropriate questions and providing relevant information, the family physician (FP) may be able to refer the patient to treatment necessary for recovery, as well as assist in this process. Because the family physician typically has previous acquaintance with the patient and her family, he or she may be of considerable import to creating a therapeutic liaison and support framework with the professional team. This article will discuss the potential involvement and significance of the family physician in the successful diagnosis, prevention, and treatment of ED. The importance of the FP in the decision for hospitalization, referral, and follow-up is emphasized, as well as the pivotal role of the FP as a multi-disciplinary team coordinator.

Women in the barracks: the VMI case and equal rights

In June 2001, there was a decidedly new look to the graduating class at Military Institute. For the first time ever, the line of graduates who received their degrees at the West Point of the South included women who had spent four years at VMI. For 150 years, VMI had operated as a revered, state-funded institution an amalgam of Southern history, military tradition, and male bonding rituals and throughout that long history, no one had ever questioned the fact that only males were admitted. Then in 1989 a female applicant complained of discrimination to the Justice Department, which brought suit the following year to integrate women into VMI. In a book that poses serious questions about equal rights in America, Philippa Strum traces the origins of this landmark case back to VMI's founding, its evolution over fifteen decades, and through competing notions about women's proper place. Unlike most works on women in military institutions, this one also provides a complete legal history from the initial complaint to final resolution in States v. Virginia and shows how the Supreme Court's ruling against VMI reflected changing societal ideas about gender roles. At the heart of the VMI case was the rat line: a ritualized form of hazing geared toward instilling male solidarity. VMI claimed that its system of toughening individuals for leadership was even more stringent than military service and that the system would be destroyed if the Institute were forced to accommodate women. Strum interviewed lawyers from Justice and VMI, heads of concerned women's groups, and VMI administrators, faculty, and cadets to reconstruct the arguments in this important case. She was granted interviews with both Justice Ginsburg, author of the majority opinion, and Justice Scalia, the lone dissenter on the bench, and meticulously analyzes both viewpoints. She shows how Ginsburg's opinion not only articulated a new constitutional standard for institutions accused of gender discrimination but also represented the culmination of gender equality litigation in the twentieth century. Women in the Barracks is a case study that combines both legal and cultural history, reviewing the long history of male elitism in the military as it explores how new ideas about gender equality have developed in the United States. It is an engrossing story of change versus tradition, clear and accessible for general readers yet highly instructive and valuable for students and scholars. Now as questions continue to loom concerning the role of state funding for single-sex education, Strum's book squarely addresses competing notions of women's place and capabilities in American society.

Vascular dementia in patients with immune thrombocytopenic purpura

Introduction: Platelets have been implicated in memory disorders but this has not been investigated in patients with immune or idiopathic thrombocytopenia (ITP). ITP is an autoimmune disorder in which autoantibodies bring about platelet destruction. We previously reported a group of ITP patients who manifested TIA-like syndrome and gradual memory loss leading to dementia: platelet microparticles (PMP), a marker of platelet activation, were often elevated, suggesting that procoagulant PMP released from stimulated platelets contributed to thrombosis in small vessels. We have expanded on those studies to better define the clinical, laboratory, and radiologic characteristics of this syndrome. Materials and methods: Twenty ITP patients with this syndrome were studied in comparison to twenty-three ITP patients without it (patient controls). Clinical and laboratory features were compared and radiologic images were analyzed. Factors influencing the rate of progression to advanced dementia were also investigated. Results and conclusion: Recurring dizzy or weak spells, TIA-like syndrome, recent memory loss, and cognitive impairment were common initial complaints. In some, these symptoms progressed rapidly to dementia but was indolent in others. Progression was faster in those with splenectomy and higher platelet counts. MRI showed enhanced signal in subcortical, periventricular areas, consistent with ischemic small vessel disease. Compared to patient controls, bleeding was less frequent and platelet activation (increased PMP, CD62p) was more frequent in the study group. Thrombotic complications may occur in ITP, manifested as TIA-like syndrome or memory loss due to ischemic small vessel disease, progressing to vascular dementia. Memory disturbances associated with platelet disorders warrants further investigation.

Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department

Study objective: We determine the frequency of patients presenting without a primary complaint of chest pain who are admitted with acute myocardial infarction (AMI) and identify factors associated with an increased risk of a presentation without chest pain. Methods: This was a retrospective, cross-sectional study over a 5-year period (July 1, 1993, to June 30, 1998) of patients presenting to a large urban, public hospital emergency department who were admitted and determined to have an AMI based on International Classification of Diseases, 9th Revision, coding and chart review. Main outcome measures were prevalence of presentation without chest pain and prevalence of other predefined presentations (ie, shortness of breath, cardiac arrest, abdominal pain, dizziness/weakness/syncope) as determined by the primary chief complaint entered on arrival at the ED. We calculated univariate relative risks and multivariate odds ratios (ORs) for presentation without chest pain in women, nonwhite ethnic groups, and older age groups. Results: Of the 721 cases of diagnosed AMI, 53% (380; 95% confidence interval [CI] 49% to 56%) of patients presented with chest pain. The frequency of other complaints were shortness of breath, 17% (121); cardiac arrest, 7% (50); dizziness/weakness/syncope, 4% (32); abdominal pain, 2% (14); and other, 17% (124). The risk of a presentation without chest pain in a patient with AMI increased with age. The characteristic with the highest risk for a presentation without chest pain in patients with AMI was age older than 84 years old (multivariate OR 5.76; 95% CI 3.06 to 10.83). Women were more likely than men to present without chest pain (multivariate OR 1.59; 95% CI 1.11 to 2.28). Conclusion: Our results demonstrate that patients with AMI commonly present to the ED without a primary initial complaint of chest pain and that the frequency of initial presentations without chest pain in our urban, public hospital is as high or higher than that reported in the general ED population. Heightened awareness of atypical presentations may affect assessment of patients with AMI and provide further focus for research into presentations of acute coronary syndrome other than chest pain. [Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med. August 2002;40:180-186.]

Potential Choking Hazard when Using a Scented Pen

Trident Medical International, Inc., Indianapolis, IN. brichmond@parholdings.comIn Reply:—The T5000 Mask-Ease scented pens were purchased from an outside vendor of Trident Medicals and sold to a few specific customers in the European Market only. After receiving the initial complaint from the University Children's Hospital in Zurich, Switzerland, a thorough investigation into the root cause of the problem was performed by the Trident Medical quality assurance department.The conclusions drawn from this investigation and analysis led to the immediate recall of all Mask-Ease scented pens from the market and a discontinuation of any and all future sales of the Mask-Ease scented pens by Trident Medical International.

Spontaneous rupture of uterus

Spontaneous rupture of the uterus is a life-threatening obstetrical emergency. Diagnosis may be delayed because of the bizarre presentation or absence of significant pain and tenderness, which could have been masked by the analgesic medications used during labor. We present a case of spontaneous rupture in a multigravid female who was undergoing oxytocin-augmented labor while receiving epidural analgesia. She had had no previous cesarean deliveries or uterine surgery. Half an hour after an initial complaint of left inguinal pain, which was thought to be related to a patchy epidural block, she presented with changes in vital signs and significant fetal decelerations. At emergent cesarean section, a uterine rupture was noted. The uterine rupture extended down to the left vaginal angle, was not reparable and a hysterectomy was performed. The fetus survived.