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Objectives: The authors sought to compare the safety and efficacy of subdissociative-dose ketamine versus fentanyl as adjunct analgesics for emergency department (ED) procedural sedation and analgesia (PSA) with propofol.Methods: This double-blind, randomized trial enrolled American Society of Anesthesiology (ASA) Class I or II ED patients, aged 14-65 years, requiring PSA for orthopedic reduction or abscess drainage. Subjects received 0.3 mg ⁄ kg ketamine or 1.5 lg ⁄ kg fentanyl intravenously (IV), followed by IV propofol titrated to deep sedation. Supplemental oxygen was not routinely administered. The primary outcomes were the frequency and severity of cardiorespiratory events and interventions, rated using a composite intrasedation event rating scale. Secondary outcomes included the frequency of specific scale component events, propofol doses required to achieve and maintain sedation, times to sedation and recovery, and physician and patient satisfaction.Results: Sixty-three patients were enrolled. Of patients who received fentanyl, 26 ⁄ 31 (83.9%) had an intrasedation event versus 15 ⁄ 32 (46.9%) of those who received ketamine. Events prospectively rated as moderate or severe were seen in 16 ⁄ 31 (51.6%) of fentanyl subjects versus 7 ⁄ 32 (21.9%) of ketamine subjects. Patients receiving fentanyl had 5.1 (95% confidence interval [CI] = 1.9 to 13.6; p < 0.001) times the odds of having a more serious intrasedation event rating than patients receiving ketamine. There were no significant differences in secondary outcomes, apart from higher propofol doses in the ketamine arm.Conclusions: Subdissociative-dose ketamine is safer than fentanyl for ED PSA with propofol and appears to have similar efficacy.ACADEMIC EMERGENCY MEDICINE 2008; 15:877-886 ª

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Objective:To determine if peripheral venous blood gas values for pH, partial pressure of carbon dioxide (PCO2) and the resultant calculated bicarbonate (HCO3) predict arterial values accurately enough to replace them in a clinical setting.Methods:This prospective observational study was performed in a university tertiary care emergency department from June to December 1998. Patients requiring arterial blood gas analysis were enrolled and underwent simultaneous venous blood gas sampling. The following data were prospectively recorded: age, sex, presenting complaint, vital signs, oxygen saturation, sample times, number of attempts and indication for testing. Correlation coefficients and mean differences with 95% confidence intervals (CIs) were calculated for pH,PCO2and HCO3. A survey of 45 academic emergency physicians was performed to determine the minimal clinically important difference for each variable.Results:The 218 subjects ranged in age from 15 to 90 (mean 60.4) years. The 2 blood samples were drawn within 10 minutes of each other for 205 (96%) of the 214 patients for whom data on timing were available. Pearson’s product–moment correlation coefficients between arterial and venous values were as follows: pH, 0.913;PCO2, 0.921; and HCO3, 0.953. The mean differences (and 95% CIs) between arterial and venous samples were as follows: pH, 0.036 (0.030–0.042);PCO2, 6.0 (5.0–7.0) mm Hg; and HCO3, 1.5 (1.3–1.7) mEq/L. The mean differences (± 2 standard deviations) were greater than the minimum clinically important differences identified in the survey.Conclusions:Arterial and venous blood gas samples were strongly correlated, and there were only small differences between them. A survey of emergency physicians suggested that the differences are too large to allow for interchangeability of results; however, venous values may be valid if used in conjunction with a correction factor or for trending purposes.

While substantial proportions of the population of Ontario, Canada continue to have teeth extracted, little is known about the reasons for this loss. In this survey of Ontario general dental practitioners, 128 dentists provided information on 6143 patients they saw during a reference week. Approximately one-in-seven of these patients had or were going to have one or more extractions as part of their current course of treatment. The mean number of extractions for patients having at least one tooth taken out was 2.3 (SD = 2.5). Emergency patients were more likely than regular patients to have at least one extraction but, on average, had fewer teeth taken out. Orthodontic considerations were the main reason for tooth loss in childhood, caries continued to be an important cause of tooth loss at all ages and periodontal disease accounted for more teeth lost after 40 years of age than caries. This study differs from almost all others in finding that, overall, more permanent teeth were extracted because of periodontal disease than because of caries. The former accounted for 35.9% of teeth lost and the latter for 28.9%. While this may be due to methodological differences between this and other studies, it is consistent with epidemiological data on periodontal disease in the Ontario population and data showing that Ontarians receive little in the way of periodontal care.

Although many epidemiological studies have been conducted concerning periodontal disease, the majority were not included in this review because of deficiencies in the measures used. Although it is increasingly common for studies in this field to measure periodontal disease using clinical attachment level, attachment loss or bone loss, the evidence pertaining to prevalence, incidence and risk in older adult populations is limited. Although it is the best indicator to date, characterizing periodontal disease by means of attachment loss has some limitations. Prevalence and incidence rates may vary according to the number of teeth and sites probed and bias and case misclassification may occur because of the healthy survivor effect. Moreover, prevalence data that document lifetime disease experience are of little use in planning for periodontal treatment needs. Problems with sampling or subject selection and idiosyncratic ways of reporting data also limit the quality of the evidence currently available. In order to standardize the collection of data on loss of attachment and to measure it as accurately as possible, Papapanou (63) recommends that studies use full-mouth periodontal examinations and the assessment of clinical attachment level at four sites on each remaining tooth. Given the inconsistencies in and problems with the methods used in the studies reviewed above, only broad conclusions can be drawn concerning periodontal disease in older adults. These confirm the conclusions reached in other reviews of the literature. While moderate levels of attachment loss are to be found in a high percentage of middle-aged and elderly subjects, severe loss is confined to a minority, albeit a substantial one. Severe loss is evident in only a few sites and, in general, affects only a small proportion of sites examined. Nevertheless, approximately one-fifth of older individuals have experienced more generalized severe loss; the rate is much higher in the oldest subjects and subjects from minority groups. Although not universal, severe disease is common in some older populations and some population subgroups. Studies using common approaches are needed to fully elucidate the extent to which disease experience varies across different populations. Similar conclusions can be drawn from prevalence studies measuring bone loss. These show that a minority of subjects accounted for most sites with advanced loss. Studies of incidence suggest that 50-75% of older adults experience additional loss of attachment of 2 or 3 mm or more at a minimum of one site over relatively short periods of time. Rates fall dramatically when more stringent case definitions are used. Moreover, relatively few sites examined show evidence of additional loss so that, although rates are high, extent and severity are low. More detailed analyses of incidence data, although few, indicate that new lesions are more common than progressing lesions, and the pattern of loss tends to support an episodic model of periodontal disease progression.

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Background:The ABCD2 score (Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes) is used to identify patients having a transient ischemic attack who are at high risk for imminent stroke. However, despite its widespread implementation, the ABCD2 score has not yet been prospectively validated. We assessed the accuracy of the ABCD2 score for predicting stroke at 7 (primary outcome) and 90 days. Methods:This prospective cohort study enrolled adults from eight Canadian emergency departments who had received a diagnosis of transient ischemic attack. Physicians completed data forms with the ABCD2 score before disposition. The outcome criterion, stroke, was established by a treating neurologist or by an Adjudication Committee. We calculated the sensitivity and specificity for predicting stroke 7 and 90 days after visiting the emergency department using the original "high-risk" cutpoint of an ABCD2 score of more than 5, and the American Heart Association recommendation of a score of more than 2. Results:We enrolled 2056 patients (mean age 68.0 yr, 1046 (50.9%) women) who had a rate of stroke of 1.8% at 7 days and 3.2% at 90 days. An ABCD2 score of more than 5 had a sensitivity of 31.6% (95% confidence interval [CI] 19.1-47.5) for stroke at 7 days and 29.2% (95% CI 19.6-41.2) for stroke at 90 days. An ABCD2 score of more than 2 resulted in sensitivity of 94.7% (95% CI 82.7-98.5) for stroke at 7 days with a specificity of 12.5% (95% CI 11.2-14.1). The accuracy of the ABCD2 score as calculated by either the enrolling physician (area under the curve 0.56; 95% CI 0.47-0.65) or the coordinating centre (area under the curve 0.65; 95% CI 0.57-0.73) was poor.Interpretation: This multicentre prospective study involving patients in emergency departments with transient ischemic attack found the ABCD2 score to be inaccurate, at any cutpoint, as a predictor of imminent stroke. Furthermore, the ABCD2 score of more than 2 that is recommended by the American Heart Association is nonspecific. AbstractSee related commentary by Hill and Coutts on page 1127 and at