bluuebunny/crossref_metadata_2025 huggingface dataset:
The effect of a slider shoe on hemiplegic gait
Authors: Cross J , Tyson S F
Published: January 2004

Objective: To assess the effect of a slider shoe on the gait speed and energy efficiency of hemiplegic gait.

Design: A–B–A single-case design to compare walking with and without the slider shoe. Results were assessed graphically using the 2SD method.

Setting: Stroke unit of an NHS general hospital in the UK.

Subjects: Four acute stroke patients undergoing gait rehabilitation.

Intervention: Walking practice with and without a slider shoe worn over the real shoe of the weak leg.

Main outcome measures: Gait speed (10-m walk test) and energy efficiency (Physiological Cost Index).

Results: All subjects showed an improvement in speed and efficiency when wearing the slider shoe compared with the baseline phase (A1). Three subjects showed a sustained improvement in efficiency and two showed a sustained improvement in speed in the second baseline phase (A2).

Conclusion: A slider shoe may improve the speed and efficiency of hemiplegic gait for people in the early stages of gait rehabilitation. Further investigation is warranted.
Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients
Authors: Daneski K , Coshall C , Tillingand K , Wolfe C D A
Published: January 2004

Objective: To adapt the Reintegration to Normal Living Index (RNLI) for postal use with stroke patients.

Design: Reliability was examined using test–retest on 26 stroke patients. Construct validity was tested on 76 patients by examining correlations between the modified RNLI and related scales.

Subjects: Patients at three months to one year post stroke.

Results: All items demonstrated better than chance agreement between test and retest and seven items substantial agreement (kappa= >0.61). The modified RNLI correlated positively with related scales. Patients with stronger reintegration to normal living had better outcomes in anxiety, depression, daily activity and quality of life.

Conclusion: This postal instrument appears reliable and valid and may be a useful outcome measure in stroke studies.
Assessing mood in patients with multiple sclerosis
Authors: Groom Madeleine J , Lincoln Nadina B , Francis Valerie M , Stephan Talal F
Published: January 2004

Objective: To assess the validity and reliability of mood measures for use with people with multiple sclerosis (MS).

Design: Four mood measures designed for use with people with communication and cognitive problems were completed; two were completed with the patient at interview and two by hospital staff or carers of the patients. This procedure was repeated two weeks later to assess test–retest reliability.

Subjects: People with MS at a rehabilitation unit ( n = 22) and living in the community ( n = 27).

Main outcome measures: The Stroke Aphasic Depression Questionnaire (SADQ) and Signs of Depression Scale (SODS) were completed by rehabilitation unit staff or by carers of the patients. An assistant psychologist completed the Visual Analogue Self-Esteem Scale (VASES) and the Visual Analogue Mood Scales (VAMS) with each patient. The Guy's Neurological Disability Scale (GNDS) was administered to assess physical disability. Nonprofessional carers were asked to complete the General Health Questionnaire 12 (GHQ-12) about themselves.

Results: In both samples there were significant correlations between scores on the two self-report measures (VASES and VAMS) ( rs = 0.51–0.79) and between scores on the two observational measures (SADQ and SODS) ( rs = 0.62–0.81) but not between the observational and self-report measures. There was a significant correlation between the SODS and the carer GHQ ( rs = 0.68, p < 0.01), indicating that carer mood infuenced reporting of patients' mood. There was no significant infuenced of profession on the observational measures, indicating good inter-rater reliability. Test–retest reliability was high for patients in the community but not for patients in hospital.

Conclusions: In both the inpatient and community samples, the self-report and observational mood measures appeared to be measuring different aspects of patients' mood. Further investigation is needed to determine which of these is providing the most accurate information.
Effects of knee joint angle and tilt table incline on force distribution at the feet and supporting straps
Authors: Morgan Claire L , Cullen Gerard P , Stokes Maria , Swan Anthony V
Published: January 2004

Objective: To investigate the effects of tilt table incline and knee flexion angle on the degree of weight bearing and forces exerted across the supporting straps.

Design: A quantitative and exploratory study to investigate the effects of a mechanical procedure.

Setting: Physiotherapy gymnasium.

Subjects: Twelve healthy subjects (9 female, 3 male) aged 22–45 years.

Interventions: Subjects stood on a tilt table, on two occasions, with simulated contractures of 10° and 40° knee flexion. Nine tilt angles, between 10° and 90°, were maintained for 1 minute each in random order.

Main outcome measures: Force was recorded from single-point load cells placed under the feet, and at knee and chest straps.

Results: The degree of simulated knee contracture (10° or 40°) influenced the distribution of forces at different recording sites. Weight bearing increased with table incline and was significantly less with the 40° than the 10° knee angle ( p < 0.001). Conversely, forces across the knee straps were systemically higher with the 40° knee angle ( p < 0.0001). The effects were accentuated by greater body weight. Forces across the chest strap also increased with tilt and were significantly larger with the 40° knee angle ( p < 0.05).

Conclusions: The relationships between table incline, angle of knee flexion and distribution of forces generated during tilt table standing have been quantified and described. Standing with flexed knees involved less weight bearing under the feet and greater force exerted across the supporting straps. These effects were more pronounced at the higher knee angle and with greater body weight, and could be modified by reducing table incline.
Prevalence of pressure sores in a community sample of spinal injury patients
Authors: Raghavan P , Raza W A , Ahmed Y S , Chamberlain M A
Published: January 2004

Objectives: To estimate the point prevalence of pressure sores in a community sample of spinal cord injured patients who were followed up by a spinal injuries unit and to evaluate whether self-management strategies were associated with decreased risk of pressure sores.

Setting: A regional spinal injuries unit, UK.

Design: Postal questionnaire survey. Main outcome measure: Presence of pressure sores.

Subjects: All patients who were being followed up on a regular basis by the unit.

Results: Out of 760, 520 replied to the questionnaire; 472 were eligible for analysis. Point prevalence of pressure sores was 23% (99). Failure to inspect the skin daily for pressure damage was associated with decreased prevalence of pressure sores (odds ratio (OR) 0.5; 95% confidence interval (CI) 0.2–0.83). Those who inspected their skin daily, however, had a higher proportion of stage I pressure sores, but this was not statistically significant. Smoking (OR 1.8; 95% CI 1–3.3) and pre-existing medical problems (OR 1.8; 95% CI 1–3) were associated with increased prevalence of pressure sores. Regular lifting of weight at least once in an hour while seated, age, gender, neurological level, employment status, living alone and faecal and urinary incontinence were not significant predictors of pressure sores.

Conclusions: Nearly one-quarter of participants had pressure sores at the time of the survey. Periodic weight lifts and daily inspection of skin for pressure damage were not associated with decreased prevalence of pressure sores in this sample. However, those who inspected skin daily tended to detect pressure damage early.
Post-discharge nursing problems of spinal cord injured patients: on which ” elds can nurses contribute to rehabilitation?
Authors: Bloemen-Vrencken J H A , de Witte L P
Published: January 2004

Objective: To identify nursing problems of spinal cord injured (SCI) patients after discharge from clinical rehabilitation and to identify gaps in the nursing care regarding the prevention of these problems.

Design: The study had an exploratory character and was divided into three phases. Phase 1 had a qualitative nature. Eight patients were interviewed to obtain insight into experienced problems after discharge. In phase 2, a panel of experts regarding nursing care for SCI patients selected nursing problems out of all problems mentioned. Phase 3 consisted of a mailed questionnaire including the nursing problem areas identified in phase 2, which was sent to all patients that were discharged during the last 18 months before the study.

Setting: Specialist rehabilitation centre, the Netherlands.

Subjects: Eight patients participated in phase 1 (100% response rate), 35 nurses participated in phase 2 (87.5% response rate) and 35 patients participated in phase 3 (62.5% response rate).

Results: The most important nursing problems in the response group appeared to be: limitations to activities of daily living, having difficulties in asking for help (assertiveness), pain, coping with the disability, dependency on personal help and problems with changed bladder regulation. The respondents made several suggestions for improving nursing care, involving both clinical care and care after discharge.

Conclusions: SCI patients experience serious problems after discharge from clinical rehabilitation. Nurses can give input on a wide variety of these problems.
APS and the brain
Authors: Sastre-Garriga J , Montalban X
Published: January 2004

Antiphospholipid antibody syndrome (APS) may present with neurological syndromes. Cerebrovascular disease, chorea/ballismus, epileptic seizures, headache, cognitive impairment, transverse myelopathy, Devic’s syndrome and multiple sclerosis-like presentations feature among others. Cerebrovasculardisease is one of the most common presentingsymptoms of APS, second only to deep vein thrombosis, and accounts for half of neurological manifestations in patients with APS; accelerated atherogenesis and cardioembolism are the most likely mechanisms implicated. Though infrequent, chorea is consistently associated with APS; the pathogenetic role of antiphospholipid antibodies (APLab) in this case might be routed through cerebrovasculardisease in some cases and through purely immunological pathways in others. Both ischemic and immunological mechanisms have been demonstrated in the pathogenesis of epileptic seizures, which may account for 7% of neurological manifestations in APS. Although frequent in APS, a causative link between APLab and most common types of headache (migraine and tension-type headache) is more than dubious. Cognitive impairment may derive from a well-defined clinical tableau of multi-infarct dementia. Nevertheless, (highly frequent) less severe cognitive impairment has also been associated with the presence of APLab in the absence of magnetic resonance findings. A relationship between APS and transverse myelopathy seems likely but small numbers in the studies published to date preclude definite statements; routinely testing for APLab patients with neurological manifestations suggestive of multiple sclerosis seems to be unrecommended at the present time.
MRI and the brain in systemic lupus erythematosus
Authors: Graham J W , Jan W
Published: January 2004

Systemic lupus erythematosus (SLE) can affect any part of the central nervous system (CNS) from the cerebrum to the cauda eqina, giving rise to diverse neurological mainfestations. Despite clinically apparent symptoms and signs, imaging will commonly be normal while at times the magnitude of changesdemonstratedon MRI may be out of proportionto the clinical presentation.We describethe MRI techniques used in CNS imaging and the pattern of presentation in SLE.
Quantitative magnetic resonance imaging in neuropsychiatric systemic lupus erythematosus
Authors: Peterson P L , Howe F A , Clark C A , Axford J S
Published: January 2004

Neuropsychiatric symptoms are common in systemic lupus erythematosus (SLE) but are poorly understood.Although there is a wide spectrum of clinical manifestations, brain histologyoften simply shows a bland vasculopathy. Magnetic resonance techniques such as magnetic resonance spectroscopy, magnetization transfer imaging and diffusion weighted imaging have been used to try to improve our understandingof the pathophysiologicalmechanisms involved in neuropsychiatric lupus (NPSLE). This article reviews the current literature on the use of these techniques and their possible future role as diagnostic tools in NPSLE.
CNS dysfunction in the antiphospholipid syndrome
Authors: Katzav A , Chapman J , Shoenfeld Y
Published: January 2004

Though many neurological deficits have been described in the antiphospholipid syndrome (APS), only stroke is well establishedand accepted as a diagnosticcriterion in this disease. We review clinical data obtainedfrom a large series of cases regardingstroke, dementia, epilepsy, chorea, migraine, white matter disease and behavioralchangesin APS or linked to laboratory criteria such as antiphospholipid antibodies (aPL). The contribution of animal models to our understanding of these manifestations of APS is stressed, especially regarding the cognitive and behavioral aspects for which we have established model systems in the mouse. These models utilize immunization of mice with b2-glycoprotein I, a central autoantigen in APS, which induces persistent high levels of aPL. These mice develop hyperactive behavior after a period of four to five months as well as deficits in learning and memory and are potentiallyvaluableas a system in which to study the pathogenesisand treatment of cognitive and behavioral aspects of APS. Another model we have developed, in which IgG from APS patients induce depolarization of brain synaptoneurosomes, may serve as a model for the pathogenesis of epilepsy in APS.
The blood-brain barrier in systemic lupus erythematosus
Authors: Abbott N J , Mendonça L LF , Dolman D EM
Published: January 2004

Central nervous system (CNS) involvement may occur in 20-70% of systemic lupus erythematosus (SLE) patients where neurological symptoms are overt; this is termed neuropsychiatric lupus or NPSLE. This review summarizes evidence that damage to the brain endothelium forming the blood-brain barrier (BBB) is a contributoryfactor in NPSLE. The normal CNS is protected by blood-tissue barriers at three sites, the brain endothelium (BBB), the choroid plexus epithelium (blood-CSF barrier) and the arachnoid epithelium. The tight junctions of the barrier layers severely restrict entry of plasma constituentsincluding proteins, so that the CSF and brain interstitial fluid contain low levels of protein. Methods for diagnosing BBB damage include imaging (CT, MRI) using contrast agents, and analysing protein content and profiles of CSF. Changes in the albumin quotient Qalbumin show evidence for barrier damage, while changes in the immunoglobulin (Ig) index can indicate intrathecal antibody production. However, BBB damage may be transient, and hence undetected or underestimated. Few mechanistic studies exist, but the two main candidate mechanisms for BBB damage are microthrombi in cerebral vessels leading to ischaemia, and immune-mediated attack and activation of the endothelium leading to local cytokine production. Both can result in barrier breakdown. Neurological syndromes could then be secondary to damage to the BBB. The implications for treatment of NPSLE are discussed.
Ribosomal P antibodies and CNS lupus
Authors: Reichlin M
Published: January 2004

Within two years of the recognitionof autoantibodiesto ribosomal P proteinsin patients with systemic lupus erythematosus(SLE) an associationwith anti-P autoantibodieswith psychosiswas noted. While there has been some controversy about this association, ample evidence suggests a meaningful relationship between anti-P antibodies and central nervous system (CNS) disease. This evidence consists of 1) seven independent studies showing a strong relationship between anti-P antibodies and CNS disease; 2) longitudinal studies showing fluctuations of anti-P antibodies with episodes of psychosis; 3) correlation of anti-P antibodies with general disease activity; and 4) acid eluates form lupus renal tissuewere foundto contain anti-Pantibodiesenriched30-fold with respectto their specific activity in serum heralding a direct role of anti-P antibodies in disease expression. Finally, there is evidencethat the P protein resides on normal cells in an immunologicallyaccessibleway and evidence exists that anti-P antibodies are able to bind and penerate cells in culture, and once inside cells can affect a profound inhibition of protein synthesis in living cells. Taken together, these observations provide evidence linking anti-P antibodies to various forms of CNS disease. While this is true, there are other autoantibodiesin SLE patients such as anti-dsDNA and antiglialfibrillary protein which may also play a role in the CNS disease of SLE patients. Continued study will inform us of the relative contribution of these autoantibodies to CNS disease in SLE patients.
Endothelium and the brain in CNS lupus
Authors: Meroni P L , Tincani A , Sepp N , Raschi E , Testoni C , Corsini E , Cavazzana I , Pellegrini S , Salmaggi A
Published: January 2004

Central nervous system (CNS) involvement in systemic lupus erythematosus (SLE) is common and results in different clinical manifestations. Several pathogenic mechanisms have been suggested to play a rolein determiningsuch a varietyof clinicalsymptoms.The thrombophilicstateassociatedto the presence of antiphospholipidantibodies has been suggested to be responsible for a noninflammatory vasculopathywhichcauses clear ischaemiceventsas well as alterationsof the cerebralmicrocirculation that are likely associated to seizures, cognitive dysfunction or psychosis. Although less frequent, a true vasculitic process affecting cerebral circulation has also been reported. In both cases, brain endothelium does represent the target of the pathogenic mechanisms. Brain endothelial cells display peculiar functional and phenotypical characteristics in comparison with endothelial cells from other anatomical districts, raising the possibility that this might be the reason for its susceptibility in lupus disease. We review and present data suggesting that a higher and firmer expression of beta 2 glycoprotein I on endothelialcell membranes can be responsiblefor a selective damage/activation by circulating anti-beta 2 glycoprotein I, and that antiendothelial cell antibodies crossreact with brain endothelium and in some cases, specifically bind brain endothelial cells only in lupus patients with central nervous involvement.
Cerebral haemostasis and antiphospholipid antibodies
Authors: Connor P , Hunt B J
Published: January 2004

One of the major clinical concerns of the antiphospholipid syndrome (APS) is the propensity of antiphospholipid(aPL) antibodiesto cause thrombosis in both the large and small vessels of the brain. In this article, we review the current understandingof haemostasis in cerebral circulation and discuss this in the context of antiphospholipidantibodies. The systemic-defect-local-phenotypeparadox is of particular importance in this discussion. In this paradigm, a systemic defect in thrombosis and haemostasis leads to a localized pattern of thrombotic disease because the regional physiological variations in the several prothromboticand anticoagulantfactors and the defect interact so as to favour thrombosis at a particular site. One possible mechanism of initiation of thrombosis in APS is the activation of endothelialcells by aPL that could occur in the cerebral vessels and provoke thrombosis. We review the evidence from gene knockout mice, other animal models and human postmortem examination studies as to which pro- and antithrombotic mechanisms are effecting haemostasis in the cerebral circulation. We conclude that there are large deficits in the understanding of the regulation of haemostasis in the human brain. As a consequencethere is a lack of knowledgeabout the effect of aPL on cerebral endothelium and thrombosis. Recent developments in gene expression profiling may have an impact on our understandingof endothelialfunctionin the brain. More research is required.
Central nervous system lupus: a clinical approach to therapy
Authors: Sanna G , Bertolaccini M L , Mathieu A
Published: January 2004

Management of central nervous system (CNS) involvement still remains one of the most challenging problems in systemic lupus erythematosus (SLE). The best available evidence for the treatment of CNS lupus is largely based on retrospectiveseries, case reports and expert opinion. Current therapy is empirical and tailored to the individual patient. Symptomatic, immunosuppressiveand anticoagulant therapies are the main strategies for the management of CNS lupus. The choice depends on the most probable underlying pathogenic mechanism and the severity of the presenting neuropsychiatric symptoms. Thrombotic and nonthrombotic CNS disease needs to be differentiated and requires different management strategies. However, this is often challenging since many, if not most CNS manifestations, may be due to a combination of different pathogenic mechanisms and multiple CNS events may occur in the individual patient. Patients with mild manifestations may need symptomatic treatment only, whereas more severe acute nonthrombotic CNS manifestations may require pulse intravenouscyclophosphamide.Plasmapheresismay also be added in patients with more severe illness refractory to conventionaltreatment. Recently, the use of intrathecalmethotrexateand dexamethasone has been reported in a small series of patients, with a good outcome in patients with severe CNS manifestations.Anticoagulationis warranted in patients with thrombotic disease, particularlyin those with the antiphospholipid syndrome (APS). This article reviews the clinical approach to therapy in patients with CNS lupus.
A psychiatric perspective on the therapy of psychosis in systemic lupus erythematosus
Authors: Bodani M , Kopelman M D
Published: January 2004

A brief descriptionof psychosis in the general psychiatricsetting and its treatment using antipsychotic agents including ‘atypical’drugs. A review of the prevalence of neuropsychiatricsyndromes in lupus (using The American College of Rheumatology standardized definitions) from recent studies showing wide variation in reported rates. Underlying pathophysiologic mechanisms postulated for neuropsychiatric manifestations of lupus are reviewed with implications for treatment. The use and success of intravenous pulsed cyclophosphamide (singly and in combination with methylprednisiolone)for severe neuropsychiatricpsychosis is reviewed.
Caring Work, Personal Obligation and Collective Responsibility
Authors: Provis Chris , Stack Sue
Published: January 2004

Studies of workers in health care and the care of older people disclose tensions that emerge partly from their conflicting obligations. They incur some obligations from the personal relationships they have with clients, but these can be at odds with organizational demands and resource constraints. One implication is the need for policies to recognize the importance of allowing workers some discretion in decison making. Another implication may be that sometimes care workers can meet their obligations to clients only by taking collective action.
Expanding Nurses’ Participation in Ethics: an empirical examination of ethical activism and ethical assertiveness
Authors: Dodd Sarah-Jane , Jansson Bruce S , Brown-Saltzman Katherine , Shirk Marilyn , Wunch Karen
Published: January 2004

This research project investigated the extent to which nurses engage in two important kinds of ethical behaviours: ethical activism (where they try to make hospitals more receptive to nurses’ participation in ethics deliberations) and ethical assertiveness (where they participate in ethics deliberations even when not formally invited). This research probed not only the extent to which nurses engage in these ethical behaviours but also whether this is influenced by professional, training and organizational factors. A random sample of 165 nurses from three major hospitals in Los Angeles provided the data. Regression analyses indicate that both ethical activism and ethical assertiveness are strongly influenced by nurses’ perceptions of the receptivity of hospitals to their inclusion in ethics deliberations. In addition, nurses’ education in ethics is a significant predictor of ethical activism. The findings have important implications for the content of nurses’ ethics training as well as for expanding the boundaries of nurses’ participation in ethics deliberations. The authors define ethics deliberations as specific meetings of a number of people to discuss an ethical issue, such as one regarding the care of a patient.
Involvement and (Potential) Influence of Care Providers in the Enlistment Phase of the Informed Consent Process: the case of aids clinical trials
Authors: Mueller Mary-Rose
Published: January 2004

This article draws on ethnographic field data collected during an investigation of the informed consent process and AIDS clinical trials. It describes the involvement of care providers (physicians, nurse practitioners, physician assistants) during the enlistment, or recruitment, phase of the informed consent process. It shows that sometimes care providers are involved in the receipt, evaluation and distribution of information on clinical trials through their interactions with research professionals and patients. It suggests that the involvement of care providers has the potential to influence the informed consent process. Some of the ethical and practice considerations of this are discussed.
Ethical Moments in Practice: the nursing ‘how are you?’ revisited
Authors: Cameron Brenda L
Published: January 2004

In seeking for an understanding of ethical practices in health care situations, our challenge is always both to recognize and respond to the call of individuals in need. In attuning ourselves to the call of the vulnerable other an ethical moment arises. Asking ‘how are you?’ in health care practice is our very first possibility to learn how a particular person finds herself or himself in this particular situation. Here, ‘how are you?’ shows itself as an ethical question that opens up a relational space that calls forth a response. It is a way to understand the situated moments in which we are already that enables us to act respectfully. Our ethical frameworks assist us in trying to decide what is the right thing to do given a set of circumstances. Yet there is a prior step that already calls us to ethical attention; this is when we ask ‘how are you?’, which transforms a seemingly small interaction into an ethical moment. ‘How are you?’ is a question that turns us back to who we are as health care professionals and calls us to be more deeply attentive to the moment. When we sincerely ask ‘how are you?’ we enact our ethical commitments to one another.
Reliability of a Structured Interview Scoring Instrument for a Canadian Postgraduate Emergency Medicine Training Program
Authors: Bandiera Glen , Regehr Glenn
Published: January 2004

Objectives: To determine the reliability of scores assigned to interviews of medical students applying to an emergency medicine program. Methods: A scoring instrument was derived based on faculty and resident input, institutional and national documents, and previous application procedures. Candidates were interviewed by four pairs of interviewers. Interviewers were asked to score the candidates on five visual analog scales (VASs) with objective anchors. Each interview assessed a unique candidate characteristic. All interviewers were given explicit instructions on scoring procedures and instrument use. The data were entered into an Excel database and transferred to SPSS, and reliabilities were measured with a two‐way mixed‐effect Cronbach's alpha. Results: Forty applications were received for the 2002 residency entry year. Thirty‐eight application packages were complete, and 16 candidates were interviewed. Data collection was complete for all 16. The average measure intraclass correlations for each individual interviewer across the five VASs ranged from 0.72 to 0.92 (mean, 0.85). The interrater reliability within the four interviews (personal characteristics, trainability, suitability for emergency medicine, and suitability for the specific training program) were low at 0.36, 0.59, 0.69, and 0.49. The overall reliability of the four interview scores was 0.83, and for the eight interviewer scores it was 0.86. Conclusions: The reliability of the overall interview scores was very high. The intraclass correlations for each interviewer's VAS scores were also high, but interrater correlations within interview teams were moderate and not higher than those across interview teams. This study suggests that an interview assessment instrument can be highly reliable overall and that interviewers base scores on an overall global impression.
Reliability and Validity of Scores on the Emergency Severity Index Version 3
Authors: Tanabe Paula , Gimbel Rick , Yarnold Paul R. , Kyriacou Demetrios N. , Adams James G.
Published: January 2004

Objectives: No widely used triage instrument accurately assesses patient acuity. The Emergency Severity Index (ESI) promises to facilitate reliable acuity assessment and possibly predict patient disposition. However, reliability and validity of ESI scores have not been established in emergency departments (EDs) outside the original research sites, and version 3 (v.3) of the ESI has not been evaluated. The study hypothesis was that scores on the ESI v.3 show good interrater reliability and predict hospital admission, admission site, and death. Methods: The authors conducted an ED‐based cross‐sectional retrospective study of 403 systematically selected ED records of patients who presented to an academic medical center. Twenty‐seven variables were abstracted, including triage level assigned, admission status, site, and death. Using a standard process, the researchers determined the true triage level. Weighted kappa and Pearson correlation were used to calculate interrater reliability between true triage level and triage score assigned by the registered nurse (RN). The relationships between the true ESI level and admission, admission site, and death were assessed. Results: Interrater reliability between RN ESI level and the true ESI level was kappa = 0.89; Pearson r= 0.83 (p < 0.001). Hospital admission by ESI level was as follows: 1 (80%), 2 (73%), 3 (51%), 4 (6%), and 5 (5%). A higher percentage of ESI level‐1 and level‐2 patients (40%, 12%) were admitted to the intensive care unit than ESI levels 3–5 (2%, 0%, 0%). Admission to telemetry for ESI levels 1‐5 was 20%, 19%, 7%, 1%, and 0%, respectively. Three of four patients who died were ESI level 1 or 2. Conclusions: Scores on the ESI assigned by nurses have excellent interrater reliability and predict hospital admission and location of admission.
Interactions between Emergency Medicine Programs and the Pharmaceutical Industry
Authors: Keim Samuel M. , Mays Mary Z. , Grant David
Published: January 2004

Objectives: To examine the beliefs and practices of emergency medicine program directors regarding interactions with the pharmaceutical industry. The authors also sought to study the prevalence of program policies and the desire for organizational policies. Methods: The Board of the Council of Emergency Medicine Residency Directors (CORD) requested and approved a member survey. An institutional review board–approved, Web‐based, 30‐item survey was sent to all CORD members subscribed to the organization's listserv in May 2002 and was completed by June 2002. Program director respondents were surveyed as to their beliefs and practices regarding industry sponsorship of speakers, social events, drug samples, travel to conferences, and the educational value of marketing representatives. Subjects were queried about their awareness of existing guidelines and whether they desired policy development by CORD. Results: Surveys were returned from 106 programs (85%). The majority of program directors (72%) “never” or “very rarely” allowed unrestricted interactions between pharmaceutical representatives and residents at work. However, only 52% of program directors said they “never” or “very rarely” allowed pharmaceutical representatives to give residents free drug samples at work. Only 46% said they “never” or “very rarely” allowed pharmaceutical representatives to teach residents. Two thirds of program directors desired CORD guidelines regarding interactions with the pharmaceutical industry. Program directors seeking guidelines were less likely to allow pharmaceutical representatives to teach residents (p = 0.001). They were also less likely to allow pharmaceutical representatives unrestricted interactions with residents (p = 0.05). Conclusions: A wide range of practices exist among emergency medicine residency program directors, and most desire organizational guidelines regarding interactions with the pharmaceutical industry.
Estimating the Degree of Emergency Department Overcrowding in Academic Medical Centers: Results of the National ED Overcrowding Study (NEDOCS)
Authors: Weiss Steven J. , Derlet Robert , Arndahl Jeanine , Ernst Amy A. , Richards John , Fernández‐Frankelton Madonna , Schwab Robert , Stair Thomas O. , Vicellio Peter , Levy David , Brautigan Mark , Johnson Ashira , Nick Todd G.
Published: January 2004

Objectives: No single universal definition of emergency department (ED) overcrowding exists. The authors hypothesize that a previously developed site‐sampling form for academic ED overcrowding is a valid model to quantify overcrowding in academic institutions and can be used to develop a validated short form that correlates with overcrowding. Methods: A 23‐question site‐sampling form was designed based on input from academic physicians at eight medical schools representative of academic EDs nationwide. A total of 336 site‐samplings at eight academic medical centers were conducted at 42 computer‐generated random times over a three‐week period by independent observers at each site. These sampling times ranged from very slow to severely overcrowded. The outcome variable was the degree of overcrowding as assessed by the charge nurse and ED physicians. The full model consisted of objective data that were obtained by counting the number of patients, determining patients' waiting times, and obtaining information from registration, triage, and ancillary services. Specific objective data were indexed to site‐specific demographics. The outcome and objective data were compared using a multiple linear regression to determine predictive validity of the full model. A five‐question reduced model was calculated using a backward stepdown procedure. Predictive validity and relationships between the outcome and objective data were assessed using a mixed‐effects linear regression model, treating center as random effect. Results: Overcrowding occurred 12% to 73% of the time (mean, 35%), with two hospitals being overcrowded more than 50% of the time. Comparison of objective and outcome data resulted in an R2 of 0.49 (p < 0.001), indicating a good degree of predictive validity. A reduced five‐question model predicted the full model with 88% accuracy. Conclusions: Overcrowding varied widely between academic centers during the study period. Results of a five‐question reduced model are valid and accurate in predicting the degree of overcrowding in academic centers.
Customer Satisfaction in a Large Urban Fire Department Emergency Medical Services System
Authors: Persse David E. , Jarvis Jeffrey L. , Corpening Jerry , Harris Bobbie
Published: January 2004

Objectives: The purpose of this study was to determine if emergency medical services (EMS) customer satisfaction could be assessed using telephone‐survey methods. The process by which customer satisfaction with the EMS service in a large, fire department–based EMS system is reported, and five month results are presented. Methods: Ten percent of all patients transported during the period of October 15, 2001, through March 15, 2002, were selected for study. In addition, during the same period, all EMS incidents in which a patient was not transported were identified for contact. Customer‐service representatives contacted patients via telephone and surveyed them from prepared scripts. Results: A total of 88,528 EMS incidents occurred during the study period. Of these, 53,649 resulted in patient transports and 34,879 did not. Ten percent of patients transported (5,098) were selected for study participation, of which 2,498 were successfully contacted; of these, 2,368 (94.8%) reported overall satisfaction with the service provided. Of the 34,879 incidents without transport, only 5,859 involved patients who were seen but not transported. All of these patients were selected for study. Of these, 2,975 were successfully contacted, with 2,865 (96.3%) reporting overall satisfaction. The most common reason given for nonsatisfaction in both groups was the perception of a long response time. Conclusions: It is possible to conduct a survey of EMS customer satisfaction using telephone‐survey methods. Although difficulties exist in contacting patients, useful information is made available with this method. Such surveys should be an integral part of any EMS system's quality‐improvement efforts. In this survey, the overwhelming majority of patients, both transported and not transported, were satisfied with their encounter with EMS.
The Demands of 24/7 Coverage: Using Faculty Perceptions to Measure Fairness of the Schedule
Authors: Zwemer Frank L. , Schneider Sandra
Published: January 2004

Objectives: Ensuring fair, equitable scheduling of faculty who work 24‐hour, 7‐day‐per‐week (24/7) clinical coverage is a challenge for academic emergency medicine (EM). Because most emergency department care is at personally valuable times (evenings, weekends, nights), optimizing clinical work is essential for the academic mission. To evaluate schedule fairness, the authors developed objective criteria for stress of the schedule, modified the schedule to improve equality, and evaluated faculty perceptions. They hypothesized that improved equality would increase faculty satisfaction. Methods: Perceived stress was measured for types of clinical shifts. The seven daily shifts were classified as weekday, weekend, or holiday (plus one unique teaching‐conference coverage shift). Faculty assigned perceived stress to shifts (ShiftStress) utilizing visual analog scales (VAS). Faculty schedules were measured (ShiftScores) for two years (1998–1999), and ShiftScore distribution of faculty was determined quarterly. Schedules were modified (1999) to reduce interindividual ShiftScore standard deviation (SD). The survey was performed pre‐ and postintervention. Results: Preintervention, 26 faculty (100% of eligible) assigned VAS to 22 shifts. Increased stress was perceived in progression (weekday data, 0–10 scale) from day to evening to night (2.07, 5.00, 6.67, respectively) and from weekday to weekend to holiday (day‐shift data, 2.07, 4.93, 5.87). The intervention reduced interindividual ShiftScore SD by 21%. Postintervention survey revealed no change in perceived equality or satisfaction. Conclusions: Faculty perceived no improvement despite scheduling modifications that improved equality of the schedule and provided objective measures. Other predictors of stress, fairness, and satisfaction with the demanding clinical schedule must be identified to ensure the success of EM faculty.
A Comparison of Trauma Intubations Managed by Anesthesiologists and Emergency Physicians
Authors: Bushra Joseph S. , McNeil Bryon , Wald David A. , Schwell Ari , Karras David J.
Published: January 2004

Although airway management by emergency physicians has become standard for general emergency department (ED) patients, many believe that anesthesiologists should manage the airways of trauma victims. Objectives: To compare the success and failure rates of trauma intubations performed under the supervision of anesthesiologists and emergency physicians. Methods: This was a prospective, observational study of consecutive endotracheal intubations (ETIs) of adult trauma patients in a single ED over a 46‐month period. All ETIs before November 26, 2000, were supervised by anesthesiologists (34 months), and all ETIs from November 26, 2000, onward were supervised by emergency physicians (12 months). Data regarding clinical presentation, personnel involved, medications used, number of attempts required, and need for cricothyrotomy were collected. Study outcomes were: 1) successful intubation within two attempts, and 2) failure of intubation. Failure was defined as inability to intubate, resulting in successful intubation by another specialist, or cricothyrotomy. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to compare results between groups. Results: There were 673 intubations during the study period. Intubation within two attempts was accomplished in 442 of 467 patients (94.6%) managed by anesthesiologists, and in 196 of 206 of patients (95.2%) managed by emergency physicians (OR = 1.109, 95% CI = 0.498 to 2.522). Failure of intubation occurred in 16 of 467 (3.4%) patients managed by anesthesiologists, and in four of 206 (1.9%) patients managed by emergency physicians (OR = 0.558, 95% CI = 0.156 to 1.806). Conclusions: Emergency physicians can safely manage the airways of trauma patients. Success and failure rates are similar to those of anesthesiologists.
Advanced Statistics: Linear Regression,Part I: Simple Linear Regression
Authors: Marill Keith A.
Published: January 2004

Simple linear regression is a mathematical technique used to model the relationship between a single independent predictor variable and a single dependent outcome variable. In this, the first of a two‐part series exploring concepts in linear regression analysis, the four fundamental assumptions and the mechanics of simple linear regression are reviewed. The most common technique used to derive the regression line, the method of least squares, is described. The reader will be acquainted with other important concepts in simple linear regression, including: variable transformations, dummy variables, relationship to inference testing, and leverage. Simplified clinical examples with small datasets and graphic models are used to illustrate the points. This will provide a foundation for the second article in this series: a discussion of multiple linear regression, in which there are multiple predictor variables.
Skeletal Abnormalities in Pth-Null Mice Are Influenced by Dietary Calcium
Authors: Miao Dengshun , He Bin , Lanske Beate , Bai Xiu-Ying , Tong Xin-Kang , Hendy Geoffrey N. , Goltzman David , Karaplis Andrew C.
Published: January 2004

We have examined the role of PTH in the postnatal state in a mouse model of PTH deficiency generated by targeting the Pth gene in embryonic stem cells. Mice homozygous for the ablated allele, when maintained on a normal calcium intake, developed hypocalcemia, hyperphosphatemia, and low circulating 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] levels consistent with primary hypoparathyroidism. Bone turnover was reduced, leading to increased trabecular and cortical bone volume in PTH-deficient mice. When mutant mice were placed on a low-calcium diet, renal 25-hydroxyvitamin D 1 α-hydroxylase expression increased despite the absence of PTH, leading to a rise in circulating 1,25(OH)2D3 levels, marked osteoclastogenesis, and profound bone resorption. These studies demonstrate the dependence of the skeletal phenotype in animals with genetically depleted PTH on the external environment as well as on internal hormonal and ionic circulatory factors. They also show that, although PTH action is the first defense against hypocalcemia, 1,25(OH)2D3 can be mobilized, even in the absence of PTH, to guard against extreme calcium deficiency.
Granulosa Cell-Specific Inactivation of Follistatin Causes Female Fertility Defects
Authors: Jorgez Carolina J. , Klysik Michal , Jamin Soazik P. , Behringer Richard R. , Matzuk Martin M.
Published: January 2004

Follistatin plays an important role in female physiology by regulating FSH levels through blocking activin actions. Failure to regulate FSH has been implicated as a potential cause of premature ovarian failure. Premature ovarian failure is characterized by amenorrhea, infertility, and elevated gonadotropin levels in women under the age of 40. Because follistatin is essential for postnatal viability, we designed a cre/loxP conditional knockout system to render the follistatin gene null specifically in the granulosa cells of the postnatal ovary using Amhr2cre transgenic mice. The follistatin conditional knockout females develop fertility defects, including reduced litter number and litter sizes and, in the most severe case, infertility. Reduced numbers of ovarian follicles, ovulation and fertilization defects, elevated levels of serum FSH and LH, and reduced levels of testosterone were observed in these mice. These findings demonstrate that compromising granulosa cell follistatin function leads to findings similar to those characterized in premature ovarian failure. Follistatin conditional knockouts may therefore be a useful model with which to further study this human syndrome. These studies are the first report of a granulosa cell-specific deletion of a gene in the postnatal ovary and have important implications for future endeavors to generate ovary-specific knockout mouse models.
Unexpected Hydrolithiation of M=M′ Double Bond (M, M′ = Si, Ge) with tBuLi
Authors: Lee Vladimir Ya , Sekiguchi Akira
Published: December 2003

The reduction of 2- and 1-disilagermirenes 1 and 2 with tBuLi proceeded regio- and stereospecifically to produce germyllithium derivative 4—the product of the formal addition of LiH across the M=M′ bond (M, M′ = Si, Ge) through single electron transfer steps. Reduction of 1,2-disila-3-germacyclopenta-2,4-diene derivative 3 with tBuLi also proceeded specifically, but with an opposite regioselectivity to form silyllithium derivative 7.
Electroreduction of Oxygen by Myoglobin on Multi-walled Carbon Nanotube-Modified Glassy Carbon Electrode
Authors: Zhang Li , Zhao Guang-Chao , Wei Xian-Wen , Yang Zhou-Sheng
Published: December 2003

Direct electrochemical response of myoglobin (Myb) on multi-walled carbon nanotube (MWNT)-modified glassy carbon (GC) electrode was observed. Interestingly, Myb on the MWNT exhibited an elegant catalytic activity for electrochemical reduction of oxygen (O2), based on which an unmediated biosensor for O2 was developed.
Synthesis of Phenylene Bridged Mesoporous Silsesquioxanes with Spherical Morphology in Ammonia Solution
Authors: Kapoor Mahendra P , Inagaki Shinji
Published: December 2003

The morphologically controlled synthesis for monodispersed spherical phenylene bridged mesoporous silsesquioxanes with relative mesoporous regularity using ammonia as catalyst and the dilute surfactants solution is reported.
Highly Anomer- and Regio-selective Transesterification Catalyzed by Alkaline Protease from Bacillus subtilis in Organic Media
Authors: Wu Qi , Lu Deshui , Xiao Yongmei , Yao Shiping , Lin Xianfu
Published: December 2003

Highly anomer-selective-6(6′)-acylation reactions from anomeric mixtures of several mono- and disaccharides with divinyl dicarboxylates ranging from 4 to 10 carbon atoms were catalyzed by an alkaline protease from Bacillus subtilis in pyridine. A series of new pure α-anomeric polymerisable vinyl sugar esters of dibasic acids were synthesized in good selectivity and yields.