bluuebunny/crossref_metadata_2025 huggingface dataset:
Knowledge, attitude and practice of Nigerian women towards breast cancer: A cross-sectional study
Authors: Okobia Michael N , Bunker Clareann H , Okonofua Friday E , Osime Usifo
Published: February 2006

Background

Late presentation of patients at advanced stages when little or no benefit can be derived from any form of therapy is the hallmark of breast cancer in Nigerian women. Recent global cancer statistics indicate rising global incidence of breast cancer and the increase is occurring at a faster rate in populations of the developing countries that hitherto enjoyed low incidence of the disease. Worried by this prevailing situation and with recent data suggesting that health behavior may be influenced by level of awareness about breast cancer, a cross-sectional study was designed to assess the knowledge, attitude and practices of community-dwelling women in Nigeria towards breast cancer.

Methods

One thousand community-dwelling women from a semi-urban neighborhood in Nigeria were recruited for the study in January and February 2000 using interviewer-administered questionnaires designed to elicit sociodemographic information and knowledge, attitude and practices of these women towards breast cancer. Data analysis was carried out using Statistical Analysis Software (SAS) version 8.2.

Results

Study participants had poor knowledge of breast cancer. Mean knowledge score was 42.3% and only 214 participants (21.4%) knew that breast cancer presents commonly as a painless breast lump. Practice of breast self examination (BSE) was low; only 432 participants (43.2%) admitted to carrying out the procedure in the past year. Only 91 study participants (9.1%) had clinical breast examination (CBE) in the past year. Women with higher level of education (X2 = 80.66, p < 0.0001) and those employed in professional jobs (X2 = 47.11, p < 0.0001) were significantly more knowledgeable about breast cancer. Participants with higher level of education were 3.6 times more likely to practice BSE (Odds ratio [OR] = 3.56, 95% Confidence interval [CI] 2.58–4.92).

Conclusion

The results of this study suggest that community-dwelling women in Nigeria have poor knowledge of breast cancer and minority practice BSE and CBE. In addition, education appears to be the major determinant of level of knowledge and health behavior among the study participants. We recommend the establishment and sustenance of institutional framework and policy guidelines that will enhance adequate and urgent dissemination of information about breast cancer to all women in Nigeria.
Accuracy of intraoperative frozen section in the diagnosis of ovarian neoplasms: Experience at a tertiary oncology center
Authors: Maheshwari Amita , Gupta Sudeep , Kane Shubhada , Kulkarni Yogesh , Goyal Lt Col Bhupesh Kumar , Tongaonkar Hemant B
Published: February 2006

Background

Epithelial ovarian neoplasms are an important cause of morbidity and mortality in women. The surgical management of ovarian neoplasms depends on their correct categorization as benign, borderline or malignant. This study was undertaken to evaluate the accuracy of intra-operative frozen section in the diagnosis of various categories of ovarian neoplasms.

Methods

Intraoperative frozen section diagnosis was retrospectively evaluated in 217 patients with suspected ovarian neoplasms who underwent surgery as primary line of therapy at our institution. This was compared with the final histopathologic diagnosis on paraffin sections.

Results

In 7 patients (3.2%) no opinion on frozen section was possible. In the remaining 210 patients frozen section report had a sensitivity of 100%, 93.5% and 45.5% for benign, malignant and borderline tumors. The corresponding specificities were 93.2%, 98.3% and 98.5% respectively. The overall accuracy of frozen section diagnosis was 91.2%. The majority of cases of disagreement were in the mucinous and borderline tumors.

Conclusion

Intraoperative frozen section has high accuracy in the diagnosis of suspected ovarian neoplasms. It is a valuable tool to guide the surgical management of these patients and should be routinely used in all major oncology centers.
The providers of health services in Lebanon: a survey of physicians
Authors: Kassak Kassem M , Ghomrawi Hassan M K , Osseiran Arabia Mohamad Ali , Kobeissi Hanaa
Published: February 2006

Background

Emerging from civil distress carries with it major challenges to reforming a health system. One such challenge is to ensure an adequate supply of competent human resources. The objective of this study was to assess the supply of physicians in Lebanon in 1998, with an assessment of their practice patterns and capacity building.

Methods

Lists of members of physician's associations were examined to determine the number of physicians in Lebanon and their geographical distribution. A self-administered survey targeted 388 physicians (5%) randomly stratified by the five regions of Lebanon. Some 377 providers reported information on their demographic profile, practice patterns and development. Further, information on continuing education activities was acquired.

Results

In Lebanon, the overall physician-to-population ratio was 248 per 100, 000, characterized by an evident maldistribution at the intracountry regional level. Physicians worked 38 hours per week examining on average 21 patients per day, with an average time of 30 minutes spent per visit. They also reported spending 11% of their time waiting for patients. Respondents reported a very wide range of income, with 90% earning less than USD 2,000 per month. Moreover, the continuing education profile revealed a total of 43.7 hours per year, similar to that required for board certification in many developed countries. Conference attendance was the dominant continuing education activity (95% of respondents) and consumed most of the time allotted for continuing education, reported at 32 hours per year.

Discussion and conclusion

Various economic indicators point to an oversupply of physicians in Lebanon and a poor allocation of their time for capacity building. Therefore, it is crucial for decision-makers to closely monitor the increasing supply of providers and institute appropriate intervention strategies, taking into consideration appropriate provision of good-quality services and ensuring that continuing education activities are well established, organized and monitored.
Computer simulation analysis of normal and abnormal development of the mammalian diaphragm
Authors: Fisher Jason C , Bodenstein Lawrence
Published: February 2006

Background

Congenital diaphragmatic hernia (CDH) is a birth defect with significant morbidity and mortality. Knowledge of diaphragm morphogenesis and the aberrations leading to CDH is limited. Although classical embryologists described the diaphragm as arising from the septum transversum, pleuroperitoneal folds (PPF), esophageal mesentery and body wall, animal studies suggest that the PPF is the major, if not sole, contributor to the muscular diaphragm. Recently, a posterior defect in the PPF has been identified when the teratogen nitrofen is used to induce CDH in fetal rodents. We describe use of a cell-based computer modeling system (Nudge++™) to study diaphragm morphogenesis.

Methods and results

Key diaphragmatic structures were digitized from transverse serial sections of paraffin-embedded mouse embryos at embryonic days 11.5 and 13. Structure boundaries and simulated cells were combined in the Nudge++™ software. Model cells were assigned putative behavioral programs, and these programs were progressively modified to produce a diaphragm consistent with the observed anatomy in rodents. Homology between our model and recent anatomical observations occurred under the following simulation conditions: (1) cell mitoses are restricted to the edge of growing tissue; (2) cells near the chest wall remain mitotically active; (3) mitotically active non-edge cells migrate toward the chest wall; and (4) movement direction depends on clonal differentiation between anterior and posterior PPF cells.

Conclusion

With the PPF as the sole source of mitotic cells, an early defect in the PPF evolves into a posteromedial diaphragm defect, similar to that of the rodent nitrofen CDH model. A posterolateral defect, as occurs in human CDH, would be more readily recreated by invoking other cellular contributions. Our results suggest that recent reports of PPF-dominated diaphragm morphogenesis in the rodent may not be strictly applicable to man. The ability to recreate a CDH defect using a combination of experimental data and testable hypotheses gives impetus to simulation modeling as an adjunct to experimental analysis of diaphragm morphogenesis.
Organizational interventions to implement improvements in patient care: a structured review of reviews
Authors: Wensing Michel , Wollersheim Hub , Grol Richard
Published: February 2006

Background

Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement.

Objective

To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care.

Design

Structured review of published reviews of rigorous evaluations.

Data sources

Published reviews of studies on organizational interventions.

Review methods

Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003.

Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings.

Results

A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain.

Conclusion

There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.
Designing theoretically-informed implementation interventions
Authors:   The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG)
Published: February 2006

Clinical and health services research is continually producing new findings that may contribute to effective and efficient patient care. However, the transfer of research findings into practice is unpredictable and can be a slow and haphazard process. Ideally, the choice of implementation strategies would be based upon evidence from randomised controlled trials or systematic reviews of a given implementation strategy. Unfortunately, reviews of implementation strategies consistently report effectiveness some, but not all of the time; possible causes of this variation are seldom reported or measured by the investigators in the original studies. Thus, any attempts to extrapolate from study settings to the real world are hampered by a lack of understanding of the effects of key elements of individuals, interventions, and the settings in which they were trialled. The explicit use of theory offers a way of addressing these issues and has a number of advantages, such as providing: a generalisable framework within which to represent the dimensions that implementation studies address, a process by which to inform the development and delivery of interventions, a guide when evaluating, and a way to allow for an exploration of potential causal mechanisms. However, the use of theory in designing implementation interventions is methodologically challenging for a number of reasons, including choosing between theories and faithfully translating theoretical constructs into interventions. The explicit use of theory offers potential advantages in terms of facilitating a better understanding of the generalisability and replicability of implementation interventions. However, this is a relatively unexplored methodological area.
Implementing and managing self-management skills training within primary care organisations: a national survey of the expert patients programme within its pilot phase
Authors: Lee Victoria , Kennedy Anne , Rogers Anne
Published: February 2006

A key element of the United Kingdom (UK) health policy reform in relation to chronic disease management is the introduction of a national programme seeking to promote self-care from within the National Health Service (NHS). The mainstay of the Expert Patients Programme (EPP) is a six-week training course that provides the opportunity for anyone with a long-term condition to develop new skills to manage their condition better on a day-to-day basis. The course forms part of the NHS self-care support programme, is administered by Primary Care Trusts (PCTs) and delivered by people who have personal experience of living with a long-term condition.

The NHS' official Expert Patients Programme website presently states that, "Pilot EPP courses began at 26 NHS PCT sites across England in May 2002, and by May 2004 approximately 300 PCTs had either actively implemented pilot courses or had committed to joining. The majority of PCTs are now coming to the end of the pilot phase, with many implementing plans to make EPP sustainable for the long-term." The NHS website heralds the pilot "a success."

A national, postal survey of PCT EPP Leads was undertaken in order to examine both the evolvement of EPP during its pilot stage and future plans for the programme. A questionnaire was sent out to the 299 PCTs known to have committed to the EPP pilot, and an excellent 100% response rate was obtained over a 3-month period (April-July 2005). One marker of success of the Expert Patients Programme implementation is the actual running of courses by the Primary Care Trusts. This paper explores the extent to which the implementation of the pilot can indeed be viewed as a "success," primarily in terms of the number of courses run, and considers the extent to which PCTs have carried out all that they were committed to do. Findings suggest that the more time an EPP Lead dedicates to the Programme, the more likely it is that EPP has run successfully in the past, and the more likely it is that it will continue to run successfully in the future. Other factors indicating future EPP success include collaborating across PCTs to share co-ordinators, tutors, and funding.
Randomized Controlled Trial of Single‐Operator vs. Two‐Operator Ultrasound Guidance for Internal Jugular Central Venous Cannulation
Authors: Milling Truman , Holden Carlos , Melniker Lawrence , Briggs William M. , Birkhahn Robert , Gaeta Theodore
Published: February 2006

Objectives:
Use of ultrasound guidance for central line placement generally requires two operators: one to hold the transducer and the other to guide the needle. The authors propose a single‐operator technique and compare it with the two‐operator technique for placement of internal jugular central lines.

Methods:
This was a randomized clinical trial conducted from June to September 2004 in a U.S. urban teaching hospital. Enrollment packets were randomized to dynamic single operator (D1) and dynamic two operator (D2). The procedure was performed under ultrasound visualization in the transverse plane. The primary outcome measure was cannulation success. A complete Bayesian analysis using noninformative priors to estimate the probability of similarity of outcomes for D1 and D2 was performed. All variables are reported with 95% confidence intervals (CIs) where appropriate.

Results:
Forty‐four patients were enrolled from the emergency department and intensive care unit. Twenty‐three patients were randomized to D1, and 21 to D2. Cannulation success was 96% (95% CI = 85% to 100%) for D1 and 95% (95% CI = 83% to 100%) for D2. There was a 90% probability that the success rates of these two groups differed by less than 10% of each other.

Conclusions:
This one‐person technique appears to be equivalent to the standard two‐person technique for successful ultrasound‐guided internal jugular central venous catheterization with respect to overall success.
Quality of Emergency Care on the Night Shift
Authors: Silbergleit Robert , Kronick Steven L. , Philpott Shelia , Lowell Mark J. , Wagner Chris
Published: February 2006

Objectives:
To determine whether performance decrements at night actually translate into worsened measures of quality of patient care in the emergency department (ED). Emergency physicians and healthcare workers are sleepier and less cognitively proficient at night than during the day. Despite a lack of data, medical errors have been attributed to these deficits, and pharmacologic solutions recently have been suggested.

Methods:
The authors studied 36 months of emergency care and measured quality indicators, including early mortality (deaths occurring after arrival in the ED or within 48 hours of hospital admission), frequency of return after ED discharge, time to thrombolysis in acute myocardial infarction (AMI), frequency of aspirin use in AMI, and performance of endotracheal intubation. Comparisons were by time of day in eight‐hour epochs.

Results:
There were 345,000 patient encounters in the study period. The distribution in time was determined for 25,079 sampled ED visits, 3,666 admissions, and 507 early deaths. Estimated early mortality was 0.5% (95% CI = 0.0 to 1.0%) greater at night compared with during the day. There was no effect of time of day on 1,828 returns with admission after ED discharge. In 257 patients who received thrombolytics for AMI, mean time‐to‐treatment and frequency of aspirin use were not worse at night. In 443 emergent endotracheal intubations, there was no difference at night in the duration or number of attempts required, or in protocol adherence.

Conclusions:
Quality indicators used in this study do not demonstrate marked deficits in patient care occurring at night. A very small, but measurable, increase in early mortality was identified. Improved measures to counter circadian disruption warrant study but may result in minimal improvements in patient care.
Defining Mild, Moderate, and Severe Pain by Using the Color Analogue Scale with Children Presenting to a Pediatric Emergency Department
Authors: McConahay Tom , Bryson Matt , Bulloch Blake
Published: February 2006

Objectives:
To define in centimeters what constitutes mild, moderate, and severe acute pain in children by using the Color Analogue Scale (CAS) for pain.

Methods:
This was a prospective study, using convenience sampling, of all children presenting to a pediatric ED between the ages of 5 and 16 years with a complaint of pain. Children were excluded if they had altered sensorium, were clinically unstable or required admission to the ICU, or were developmentally delayed. Children were asked to mark their pain severity on the standardized 10‐cm CAS. To use this measure, children were asked to slide the marker to the point on the scale that best described the pain they were currently experiencing. They then were asked to describe their pain as “none,”“mild,”“moderate,” or “severe.”

Results:
A total of 169 children were enrolled with a mean age of 10.1 years (SD ± 3.2 years). Males accounted for 94 (55%); 89 (52.7%) were Hispanic, 63 (37.3%) were white, 8 (4.7%) were African American, and 9 (5.3%) were “others.” In children who considered their pain to be mild (n= 34), the median score was 3.5 cm, and the mean score was 3.47 cm (95% CI = 2.95 to 3.99). For those with moderate pain (n= 68), the median score was 6.0 cm, the mean score was 6.04 cm (95% CI = 5.67 to 6.41), and if the pain was considered severe (n= 67) the median score was 8.5 cm, and the mean score was 8.28 cm (95% CI = 7.85 to 8.71).

Conclusions:
This study quantifies what constitutes mild, moderate, and severe pain on the CAS scale. This information should be used to properly triage children with painful conditions and to identify appropriate patients for enrollment in analgesic studies.
The Validity of Using Multiple Imputation for Missing Out‐of‐hospital Data in a State Trauma Registry
Authors: Newgard Craig D.
Published: February 2006

Objectives:
To assess 1) the agreement of multiply imputed out‐of‐hospital values previously missing in a state trauma registry compared with known ambulance values and 2) the potential impact of using multiple imputation versus a commonly used method for handling missing data (i.e., complete case analysis) in a typical multivariable injury analysis.

Methods:
This was a retrospective cohort analysis. Multiply imputed out‐of‐hospital data from 1998 to 2003 for four variables (intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate) were compared with known values from probabilistically linked ambulance records using measures of agreement (κ, weighted κ, and Bland–Altman plots). Ambulance values were assumed to represent the “true” values for all analyses. A hypothetical multivariable regression model was used to demonstrate the impact (i.e., bias and precision of model results) of handling missing out‐of‐hospital data with multiple imputation versus complete case analysis.

Results:
A total of 6,150 matched ambulance and trauma registry records were available for comparison. Multiply imputed values for the four out‐of‐hospital variables demonstrated fair to good agreement with known ambulance values. When included in typical multivariable analyses, multiple imputation increased precision and reduced bias compared with using complete case analysis for the same data set.

Conclusions:
Multiply imputed out‐of‐hospital values for intubation attempt, Glasgow Coma Scale score, systolic blood pressure, and respiratory rate have fair to good agreement with known ambulance values. Multiple imputation also increased precision and reduced bias compared with complete case analysis in a typical multivariable injury model, and it should be considered for studies using out‐of‐hospital data from a trauma registry, particularly when substantial portions of data are missing.
Anechoic Stripe Size Influences Accuracy of FAST Examination Interpretation
Authors: Ma O. John , Gaddis Gary
Published: February 2006

Objectives:
Accurate and precise interpretations of Focused Assessment with Sonography for Trauma (FAST) findings are important factors in managing trauma patients. The objectives were to analyze the influence of anechoic stripe (AS) size on interpretation accuracy by emergency physicians (EPs) and to assess the precision of FAST examination interpretation as a function of EP FAST experience.

Methods:
A prospective comparison study of FAST examination interpretation by 11 emergency medicine faculty (FAC), nine community attending EPs (ATT), and nine senior emergency medicine residents (RES) was conducted; these physicians were then divided into more experienced and less experienced cohorts to assess precision. Participants interpreted video recordings of the four standard views from five FAST examinations (20 total video clips); each examination contained views with various AS sizes. Accuracy of FAST examination interpretation was calculated for each group stratified by size of AS. Precision (reproducibility) of FAST examination interpretation was assessed by calculating κ values.

Results:
With large, moderate, or no AS, no significant differences in accuracy were found between groups. For small AS, significant differences in accuracy were found between the ATT and RES groups and between the combined FAC + ATT group and the RES group. κ was good to excellent when the nth and the (n + 1)th experienced physicians in the more experienced cohort were compared. κ values reflected that the more experienced cohort was more precise than the less experienced cohort.

Conclusions:
AS size visible on FAST examinations and EP experience level with FAST examination interpretation exerted a significant influence on the interpretation accuracy of videotaped FAST examinations. In addition, precision was enhanced by increased EP experience with FAST.
The Decision to Use Topical Anesthetic for Intravenous Insertion in the Pediatric Emergency Department
Authors: Fein Joel A. , Gorelick Marc H.
Published: February 2006

Objectives:
Topical anesthetic creams to reduce the pain of intravenous (IV) placement may be more effectively used in the emergency setting if they are applied by nurses in the triage area of the emergency department or soon after the patient is placed into a room. This strategy requires accurate prediction of which patients will require IV placement. The objective of this study was to compare triage nurse judgment regarding IV placement in pediatric patients with a triage prediction rule using chief complaint, referral status, and high‐risk medical history. A secondary objective was to evaluate whether the presence of the anesthetic cream placed in triage influenced the subsequent decision to place an IV and thus invalidate the prediction strategy.

Methods:
Triage nurses were randomly assigned to a prediction score group (PRD), classifying patients as “IV likely” if the prediction score was ≥2, or an “own judgment” (RN JDGMT) group, classifying any patient that he or she considered to have a ≥50% risk of receiving an IV. The rate of actual IV placement in the emergency department treatment rooms was compared between the triage prediction strategies. To assess the influence of the presence of lidocaine 2.5% and prilocaine 2.5% (EMLA cream) on the judgment to place an IV, only 75% of the “IV likely” patients had EMLA applied in triage; the IV placement rate was compared between “IV likely” patients who did or did not have EMLA applied.

Results:
The authors enrolled 3,790 of 5,025 (75.4%) of eligible patients. The RN JDGMT group predicted 165 of 250 (66%; 95% confidence interval = 59% to 72%) of IVs placed, compared with 127 of 305 (41%; 95% CI = 36% to 47%) in the PRD group (p < 0.0001). Positive predictive values were 59% and 53% for the RN JDGMNT and PRD groups, respectively. There was no difference in IV placement rates in the “IV likely” patients who did and did not have EMLA applied.

Conclusions:
Triage nurse judgment to predict eventual IV placement had greater sensitivity and similar predictive value compared with a prediction model based on medical history and chief complaint. The triage placement of topical anesthetic in pediatric patients did not change the eventual rate of IV placement.
The Impact of a Concurrent Trauma Alert Evaluation on Time to Head Computed Tomography in Patients with Suspected Stroke
Authors: Chen Esther H. , Mills Angela M. , Lee Bruce Y. , Robey Jennifer L. , Zogby Kara E. , Shofer Frances S. , Reilly Patrick M. , Hollander Judd E.
Published: February 2006

Background:
Emergency department (ED) overcrowding threatens quality of care by delaying the time to diagnosis and treatment of patients with time‐sensitive diseases, such as acute stroke.

Objective:
The authors hypothesized that the presence of a trauma alert evaluation would impede the time to head computed tomography (hCT) in patients with stroke‐like symptoms.

Methods:
This was a secondary analysis of prospectively collected data on patients with potential stroke who received an hCT in an urban trauma center ED from January 1, 2004, to November 30, 2004. Structured data collection included historical and examination items, National Institutes of Health (NIH) stroke scale score, laboratory and radiographic results, and final diagnosis. Admitted patients were followed in hospital. Patients who presented within one hour following a trauma evaluation were compared with patients who presented without concurrent trauma for triage time until completion of hCT. Chi‐square, t‐tests, and 95% confidence intervals (95% CIs) were used for comparisons.

Results:
The 171 patients enrolled had a mean (± standard deviation) age of 60.7 (± 7) years; 60% were female; and 58% were African American. Of these, 72 patients had a significant cerebrovascular event (38 [22%] ischemic stroke, 25 [15%] transient ischemic attack, seven [4%] intracranial hemorrhage, one [0.6%] subarachnoid hemorrhage, and one [0.6%] subdural hematoma). The remaining diagnoses included 4.6% migraine, 2.3% seizure, 2.9% syncope, 2.3% Bell's palsy, and 2.9% vertigo. There was no significant difference in time to hCT in patients who presented during a trauma activation and those who did not (99 minutes [interquartile range (IQR) = 24–156] vs. 101 minutes [IQR = 43–151.5]; p = 0.537). In subgroup analysis of patients with a significant cerebrovascular event, times to hCT were also similar (24 minutes [IQR = 12–99] vs. 61 minutes [IQR = 15–126]; p = 0.26).

Conclusions:
In the authors' institution, the presence of concurrent trauma evaluation does not delay CT imaging of patients with potential stroke.
Demographic Factors and Their Association with Outcomes in Pediatric Submersion Injury
Authors: Lee Lois K. , Mao Cheng , Thompson Kimberly M.
Published: February 2006

Objectives:
To describe the epidemiology and outcomes of serious pediatric submersion injuries and to identify factors associated with an increased risk of death or chronic disability.

Methods:
A retrospective database review of 1994–2000 Massachusetts death and hospital discharge data characterized demographic factors; International Classification of Diseases, Ninth Revision (ICD‐9), Clinical Modification (ICD‐9‐CM), or ICD‐10 injury codes; and outcomes for state residents 0–19 years of age identified with unintentional submersion injuries. The authors performed logistic regression analysis to correlate outcomes with risk and demographic factors.

Results:
The database included 267 cases of serious submersion injury, defined as those requiring hospitalization or leading to death. Of these 267 patients, 125 (47%) drowned, 118 (44%) were discharged home, 13 (5%) were discharged home with intravenous therapy or with availability of a home health aide, and 11 (4%) were discharged to an intermediate care/chronic care facility. The authors observed a trend of improved outcome in successively younger age groups (p < 0.0001). The multivariable logistic regression analysis showed an increased likelihood of poor outcome for males compared with females (odds ratio [OR]: 2.52; 95% confidence interval [95% CI] = 1.31 to 4.84) and for African Americans compared with whites (OR: 3.47; 95% CI = 1.24 to 9.75), and a decreased likelihood of poor outcome for Hispanics compared with whites (OR: 0.056; 95% CI = 0.013 to 0.24).

Conclusions:
After serious pediatric submersion injuries, the overall outcome appears largely bimodal, with children primarily discharged home or dying. The observations that better outcomes occurred among younger age groups, females, and Hispanic children, with worse outcomes in African American children, suggest that injury prevention for submersion injuries should consider differences in age, gender, and race/ethnicity.
Reliability of Computerized Emergency Triage
Authors: Dong Sandy L. , Bullard Michael J. , Meurer David P. , Blitz Sandra , Ohinmaa Arto , Holroyd Brian R. , Rowe Brian H.
Published: February 2006

Objectives:
Emergency department (ED) triage prioritizes patients based on urgency of care. This study compared agreement between two blinded, independent users of a Web‐based triage tool (eTRIAGE) and examined the effects of ED crowding on triage reliability.

Methods:
Consecutive patients presenting to a large, urban, tertiary care ED were assessed by the duty triage nurse and an independent study nurse, both using eTRIAGE. Triage score distribution and agreement are reported. The study nurse collected data on ED activity, and agreement during different levels of ED crowding is reported. Two methods of interrater agreement were used: the linear‐weighted κ and quadratic‐weighted κ.

Results:
A total of 575 patients were assessed over nine weeks, and complete data were available for 569 patients (99.0%). Agreement between the two nurses was moderate if using linear κ (weighted κ= 0.52; 95% confidence interval = 0.46 to 0.57) and good if using quadratic κ (weighted κ= 0.66; 95% confidence interval = 0.60 to 0.71). ED overcrowding data were available for 353 patients (62.0%). Agreement did not significantly differ with respect to periods of ambulance diversion, number of admitted inpatients occupying stretchers, number of patients in the waiting room, number of patients registered in two hours, or nurse perception of busyness.

Conclusions:
This study demonstrated different agreement depending on the method used to calculate interrater reliability. Using the standard methods, it found good agreement between two independent users of a computerized triage tool. The level of agreement was not affected by various measures of ED crowding.
Acetylation of Estrogen Receptor α by p300 at Lysines 266 and 268 Enhances the Deoxyribonucleic Acid Binding and Transactivation Activities of the Receptor
Authors: Kim Mi Young , Woo Eileen M. , Chong Yee Ting Esther , Homenko Daria R. , Kraus W. Lee
Published: February 2006

Using a variety of biochemical and cell-based approaches, we show that estrogen receptor α (ERα) is acetylated by the p300 acetylase in a ligand- and steroid receptor coactivator-dependent manner. Using mutagenesis and mass spectrometry, we identified two conserved lysine residues in ERα (Lys266 and Lys268) that are the primary targets of p300-mediated acetylation. These residues are acetylated in cells, as determined by immunoprecipitation-Western blotting experiments using an antibody that specifically recognizes ERα acetylated at Lys266 and Lys268. The acetylation of ERα by p300 is reversed by native cellular deacetylases, including trichostatin A-sensitive enzymes (i.e. class I and II deacetylases) and nicotinamide adenine dinucleotide-dependent/nicotinamide-sensitive enzymes (i.e. class III deacetylases, such as sirtuin 1). Acetylation at Lys266 and Lys268, or substitution of the same residues with glutamine (i.e. K266/268Q), a residue that mimics acetylated lysine, enhances the DNA binding activity of ERα in EMSAs. Likewise, substitution of Lys266 and Lys268 with glutamine enhances the ligand-dependent activity of ERα in a cell-based reporter gene assay. Collectively, our results implicate acetylation as a modulator of the ligand-dependent gene regulatory activity of ERα. Such regulation is likely to play a role in estrogen-dependent signaling outcomes in a variety of estrogen target tissues in both normal and pathological states.
In-vitro and in-vivo characterization of a buprenorphine delivery system
Authors: Kleppner Sofie R , Patel Raj , Costantini Lauren C , McDonough Joseph
Published: February 2006

Buprenorphine is a mu-opioid receptor partial agonist with enhanced safety and comparable efficacy to methadone for treatment of opioid dependence. The sublingual formulation of buprenorphine, approved for treatment of opioid dependence, produces variable buprenorphine blood levels and requires frequent dosing that limits patient compliance. To achieve stable buprenorphine levels that may improve patient outcome, an implantable sustained buprenorphine delivery system was developed. Each implant consists of ethylene vinyl acetate copolymer and 90 mg buprenorphine HCl, and measures 26 mm in length and 2.4 mm in diameter. Steady-state release in-vitro was 0.5 mg/implant/day. In-vivo pharmacokinetics and safety were examined for up to 52 weeks in beagle dogs receiving 8, 16 or 24 subcutaneous implants. Plasma buprenorphine concentrations correlated with the number of implants administered. Peak buprenorphine concentrations were generally reached within 24 h after implantation. Steady-state plasma levels were attained between 3 and 8 weeks, and were maintained for study duration, with a calculated mean release rate of 0.14 ± 0.04 mg/implant/day. There were no test-article-related adverse effects. This delivery system can provide long-term stable systemic buprenorphine levels, and may increase patient compliance, thereby improving outcome for opioid-dependent patients.
Chitosan nanoparticles encapsulated vesicular systems for oral immunization: preparation, in-vitro and in-vivo characterization
Authors: Jain Sanyog , Sharma Rakesh Kumar , Vyas S P
Published: February 2006

BSA-loaded chitosan nanoparticles were prepared and encapsulated in vesicles (liposomes and nio-somes) to make them acid resistant upon oral administration. Prepared systems were characterized in-vitro for shape, size, entrapment efficiency and stability in simulated gastric fluid (SGF, pH 1.2) and simulated intestinal fluid (SIF, pH 7.5). The immune stimulating activity was studied by measuring serum IgG titre and secretory IgA (sIgA) levels in mucosal secretions following oral administration of various formulations in albino rats. Significantly higher (P < 0.05) serum IgG titres were achieved following oral administration of novel nanoparticulate vesicular formulations as compared with unmodified chitosan nanoparticles. Further, high sIgA levels in mucosal secretions advocated a possible application of chitosan nanoparticle encapsulated in vesicles as an oral vaccine delivery carrier-adjuvant system.
Arthritis and cannabinoids: HU-210 and Win-55,212–2 prevent IL-1 α-induced matrix degradation in bovine articular chondrocytes in-vitro
Authors: Mbvundula Estery C , Bunning Rowena A D , Rainsford K D
Published: February 2006

Cannabinoids have analgesic, immunomodulatory and anti-inflammatory properties and attenuate joint damage in animal models of arthritis. In this study the mechanisms of action of the synthetic cannabinoid agonists, HU-210 and Win-55,212–2, were studied to determine if they affected interleukin-1 alpha (IL-1α)-induced proteoglycan and collagen degradation in bovine nasal cartilage explant cultures and prostaglandin E2 (PGE2) production in primary cultures of bovine articular chondrocytes. The effects of the inactive enantiomer, Win-55,212–3, were compared with those of the active enantiomer, Win-55,212–2, to determine if the effects were cannabinoid (CB)-receptor mediated. The chondrocytes and explants were stimulated by IL-1α (100 U mL−1 ≡ 0.06 nm and 500 U mL−1 ≡ 0.3 nm, respectively). Proteoglycan breakdown was determined as sulfated glycosaminoglycan (sGAG) release using the dimethylmethylene blue assay. Collagen degradation was determined as hydroxyproline in the conditioned culture media and cartilage digests. PGE2 was determined by ELISA. Expression of cannabinoid receptors, CB1 and CB2; cyclooxygenase-1 and −2 (COX-1 and COX-2); inducible nitric oxide synthase (iNOS); as well as activation of nuclear factor-kappa B (NF-κB) in chondrocytes were studied using immunoblotting techniques and immunofluorescence. The results showed that HU-210 and Win-55,212–2 (5–15 μm) significantly inhibited IL-1α-stimulated proteoglycan (P < 0.001) and collagen degradation (P < 0.001). Win-55,212–2 (5–10 μm) also significantly inhibited PGE2 production (P < 0.01). At 5 μm, Win-55,212–2 inhibited the expression of iNOS and COX-2 and activation of NF-κB. Chondrocytes appeared to constitutively express cannabinoid receptors CB1 and CB2. It is concluded that biologically stable synthetic cannabinoids protect cartilage matrix from degradation induced by cytokines and this effect is possibly CB-receptor mediated and involves effects on prostaglandin and nitric oxide metabolism. Cannabinoids could also be producing these effects via inhibition of NF-κB activation.
Suppression of matrix metalloproteinase production from synovial fibroblasts by meloxicam in-vitro
Authors: Asano Kazuhito , Sakai Misako , Matsuda Takako , Tanaka Hironori , Fujii Keigo , Hisamitsu Tadashi
Published: February 2006

The aim of this study was to evaluate the influence of meloxicam on the production of both matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) from human synovial fibroblasts by TNF-α stimulation in-vitro. Synovial fibroblasts (2 times 104 cells/mL) derived from patients with osteoarthritis were stimulated with 20.0 ng mL−1 TNF-α in the presence of various concentrations of meloxicam. After 24 h, the culture supernatants were obtained and assayed for MMP-1, MMP-2, MMP-3, MMP-13, TIMP-1 and TIMP-2 by ELISA. mRNA expression for MMPs and TIMPs in 4-h-cultured cells were examined by real-time polymerase chain reaction. Transcriptional factor (NF-κB and AP-1) activation in 2-h-cultured cells was also examined by ELISA. Meloxicam could suppress MMP production in a dose-dependent manner. The minimum concentration of the agent that showed significant suppression was 0.6 times 10−6  m for MMP-1, MMP-2 and MMP-3, and 1.3 times 10−6  m for MMP-13. The ability of synovial fibroblasts to produce TIMPs was also suppressed by meloxicam as in the case of MMP production. Addition of meloxicam into synovial fibroblast cultures inhibited dose-dependently mRNA expression for MMPs and TIMPs, which were increased by TNF-α stimulation, through the suppression of NF-κB and AP-1 activation. The suppressive effect of meloxicam on the production of MMPs and TIMPs may partly be involved in attenuation of the clinical conditions of osteoarthritis and rheumatoid arthritis.
Acute and long-term administration of citalopram desensitizes α2-adrenoceptors in the rat vas deferens
Authors: Grandoso Laura , García Laura , Pineda Joseba , Ugedo Luisa
Published: February 2006

The aim of this study was to investigate the effect of citalopram, a selective serotonin reuptake inhibitor, on the sensitivity of rat vas deferens α2-adrenoceptors and to compare it with the effects of serotonin and the dual noradrenaline-serotonin uptake inhibitor duloxetine. To this end, we studied the inhibitory effect of the α2-adrenoceptor agonist bromoxidine on the electrically induced contraction of the vas deferens. Citalopram (1, 3 times 103 and 3 times 104 nm) applied in-vitro significantly attenuated the concentration-response inhibition induced by activation of α2-adrenoceptors on the electrically evoked contraction of the vas deferens (concentration of the agonist required to promote 50% of the maximal effect, EC50, for bromoxidine increased by 232%, 421% and 818%, respectively). Similarly, serotonin also attenuated the concentration-response inhibition mediated by presynaptic α2-adrenoceptors (96% increase in EC50). Acute and long-term systemic administration of citalopram and duloxetine also produced a loss in the sensitivity of α2-adrenoceptors to bromoxidine (EC50 for bromoxidine increased by 97% and 144%, respectively, after citalopram, and by 214% and 167% after duloxetine). In addition, we observed that an increased fraction of receptors was required to be occupied to yield 50% of the inhibitory effect of bromoxidine after long-term administration of citalopram and duloxetine (KE increased by 142% and 83%). These results are indicative of early-onset and persistent down-regulation of peripheral α2-adrenoceptors by citalopram, which may account for some of its side effects.
Different anticonvulsive effects of hesperidin and its aglycone hesperetin on electrical activity in the rat hippocampus in-vitro
Authors: Dimpfel Wilfried
Published: February 2006

This study investigated the possibility that hesperidin or hesperetin might interact directly with brain matter in a physiological manner. The effects of both compounds were followed in the in-vitro hippocampus preparation by continuous superfusion in a concentration-dependent manner in the presence of single stimuli and theta-burst stimulation of the Schaffer Collaterals. Hesperidin increased the population spike response at a concentration up to 10 μm, especially after induction of long-term potentiation, but attenuated it significantly at higher concentrations of up to 60 μm. Hesperetin only attenuated the response within the same concentration range. Modulation of the pyramidal cell response in the presence of tetraethylammonium (TEA) and pentylentetrazol on one hand and 4-aminopyridine (4-AP) and bicuculline on the other was influenced in a different way. Whereas hesperidin attenuated the response to 4-AP and bicuculline but not to TEA or pentylentetrazol, hesperetin was able to attenuate the response to TEA and pentylentetrazol, but not to 4-AP or bicuculline. This feature was reproduced and confirmed ex-vivo after repetitive administration of hesperidin and hesperetin in-vivo for one week (500 mg kg−1 orally) before in-vitro testing against the challenging effects of 4-AP and TEA. Since the action of hesperidin was sensitive to the presence of iberiotoxin, the involvement of a large conductance calcium-dependent potassium channel might be assumed. In summary, the results provide the possibility for use of both compounds to control pathophysiological disturbances of brain excitability in drug abuse, migraine and epilepsy.
Inhibition of rat vas deferens contractions by flavonoids in-vitro
Authors: Capasso Raffaele , Ascione Valeria , Borrelli Francesca , Fiorino Ferdinando , Frecentese Francesco
Published: February 2006

Flavonoids are a large heterogeneous group of benzo-γ-pyrone derivatives, which are abundantly present in our diet. In this study we investigated the effect of ten flavonoids (quercetin, kaempferol, morin, galangin, rutin, apigenin, flavone, naringenin, hesperitin and silybin) on the contractile response elicited by electrical field stimulation in the rat isolated vas deferens. All flavonoids tested inhibited vas deferens contractions. The relative order of potency of the tested flavonoids was naringenin > hesperitin > morin > kaempferol > apigenin > silybin > flavone > rutin > quercetin > galangin. Analysis of the chemical structures showed that the saturation of C-2-C-3 double bond and the presence of hydroxyl groups on the flavonoidic scaffold play an important role in the activity of flavonoids.
Synthesis and evaluation of N-(3-oxo-2,3-dihydro-1H-pyrazol-4-yl)-1H-indole-carboxamides as cholecystokinin antagonists
Authors: Lattmann Eric , Singh Harjit , Lattmann Pornthip , Boonprakob Yodchai , Sattayasai Jintana
Published: February 2006

The structure-activity relationship optimization of the pyrazoline template 3a resulted in novel 3-oxo-1,2-diphenyl-2,3-dihydro-1H-pyrazol-4-yl)-indole carboxamides 4a–4e. These non-peptidal CCK ligands have been shown to act as potent CCK1 ligands in a [125]I-CCK-8 receptor binding assay. The best amides (4c and 4d) of this series displayed an IC50 of 20/25 nm for the CCK1 receptor. In a subsequent in-vivo evaluation using various behaviour pharmacological assays, an anxiolytic effect of these novel 3-oxo-1,2-diphenyl-2,3-dihydro-1H-pyrazol-4-yl)-indole carboxamides was found at high doses in the elevated plus-maze. In the despair swimming test, a model for testing antidepressants, an ED50 of 0.33/0.41 mg kg−1 was determined for amide 4c/4d and the antidepressant effect had a magnitude comparable to desimipramine.