Patients complaining of HT-related olfactory dysfunction typically have anosmia and rarely regain normal olfactory ability, parosmia prevalence decreases over time in such patients, and damage to olfaction-related brain structures can be observed in most such patients using an appropriate MRI protocol.

A discordancy exists between the apparently minor circumstances and serious injuries sustained by child bicyclists who impact bicycle handlebars. Recognition of the mechanism of handlebar-related injuries might aid the practitioner in early diagnosis of serious abdominal injuries in child bicyclists. This injury mechanism may be avoided through bicycle redesign that would involve both limiting rotation of the front wheel and modifying the ends of handlebars. An integrated approach involving a surveillance system to identify an injury hazard supplemented by in-depth, on-site crash investigations effectively provided the detailed mechanism of injury needed to develop interventions.

Summary. Paediatric studies have demonstrated that L-arginine (L-arg), the precursor to nitric oxide, is diminished in vaso-occlusive crisis (VOC). This study aimed to determine whether L-arginine levels are altered in adult VOC in the emergency department. Plasma L-arg and nitric oxide metabolite (NOx) levels were obtained in adult VOC patients presenting to the emergency department. Fifty patients had significantly low plasma L-arg (29AE78 lmol/l ± 11AE21, P < 0AE05 vs steady-state control ¼ 41AE16 lmol/l ± 5AE04) and significantly low plasma NOx (12AE33 lmol/l ± 10AE28, P < 0AE05 vs steady-state control ¼ 25AE2 ± 2AE6 lmol/l). Neither L-arg nor NOx levels could predict VOC clinical course.

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Abstract. Objective: To determine the short-term medical outcome of hypoglycemic insulin-dependent diabetic patients who refuse transport after out-ofhospital therapy and return to baseline mental status. Methods: Prospective, descriptive, short-term medical outcome data for adult patients were collected between May 1996 and December 1996. Paramedics responding to the aid of hypoglycemic insulin-dependent diabetic patients who refused transport after administration of dextrose solution (D,W) contacted a medical command physician a t the University of Pennsylvania. The patients' medical histories, names, addresses, and telephone numbers were recorded. Three days after their hypoglycemic episodes, these patients were contacted by telephone by a registered nurse to determine their medical conditions. Results: Of 132 patients enrolled in the study, 103 (78%) could be contacted by telephone follow-up. Ninety-four (91%) of these patients had no recurrence of symptoms. Nine patients (9%) had recurrence of hypoglycemia and recontacted 911. Eight of these (8%) were transported to a hospital via ambulance and 3 (3%) were admitted, 1 (1%) for a cancer-related illness and 2 (2%) for hypoglycemia, 1 of whom died (1%). The remaining patient refused transport a second time after being treated, despite having the risks of refusal explained to him by a medical command physician. Conclusions: The practice of treating and releasing most hypoglycemic insulindependent diabetic patients who return to normal mental status after D,,W administration appears in general to be safe. Patients should be advised of the risks of recurrent hypoglycemia. Key words: hypoglycemia; diabetes; emergency medical services; glucose; paramedics; advanced life support; refusal of care. ACADEMIC EMERGENCY MEDICINE 1998; 5: 768 -772 EPENDING on the emergency medical ser-D vices (EMS) system cited, patients not transported to the hospital account for 25-75% of EMS responses.' In these situations, out-of-hospital care providers often have the patient sign a refusal of medical treatment and/or transport form, in some cases after consultation with a medical command physician. This theoretically frees the EMS system of liability. A patient who refuses care or transport and signs such a form must first demonstrate to out-of-hospital personnel a normal mental status and the faculty to make decisions.2 This is essen-