bluuebunny/crossref_metadata_2025 huggingface dataset:
CEACAM1 is a potent regulator of B cell receptor complex-induced activation
Authors: Greicius Gediminas , Severinson Eva , Beauchemin Nicole , Öbrink Björn , Singer Bernhard B
Published: June 2003

Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1, CD66a) is a member of the immunoglobulin (Ig) superfamily, previously characterized as an adhesion and signaling molecule in epithelial, endothelial, and hematopoietic cells. Here, we show that the CEACAM1 isoform expression pattern is different in nonactivated and activated primary mouse B lymphocytes and that CEACAM1 influences B cell receptor complex-mediated activation. A CEACAM1-specific monoclonal antibody strongly triggered proliferation of mouse B cells when combined with surface IgM cross-linking. However, anti-CEACAM1 was not mitogenic when added alone. The proliferation was more pronounced and lasted longer as compared with other activators of B cells, such as anti-IgM in the presence of interleukin-4 or lipopolysaccharide. A similar, costimulatory effect was exerted by CEACAM1-expressing fibroblasts, indicating that homophilic CEACAM1–CEACAM1 cell-mediated binding is the physiological stimulus for CEACAM1-triggered B cell signaling. The anti-CEACAM1/anti-IgM-activated cells aggregated in a lymphocyte function-associated antigen-1-dependent manner. Furthermore, cells that were activated by anti-CEACAM1/anti-IgM secreted Ig but did not go through Ig class-switching. Anti-CEACAM1 induced phosphorylation of c-Jun N-terminal kinase (stress-activated protein kinase) but did not activate the extracellular signal-regulated kinase or p38 mitogen-activated protein kinases.
Regulation of platelet-activating factor synthesis in human monocytes by dipalmitoyl phosphatidylcholine
Authors: Tonks Amanda J , Tonks Alex , Morris Roger H K , Jones Kenneth P , Jackson Simon K
Published: June 2003

Platelet-activating factor (PAF) has a major role in inflammatory responses within the lung. This study investigates the effect of pulmonary surfactant on the synthesis of PAF in human monocytic cells. The pulmonary surfactant preparation Curosurf® significantly inhibited lipopolysaccharide (LPS)-stimulated PAF biosynthesis (P<0.01) in a human monocytic cell line, Mono mac-6 (MM6), as determined by 3H PAF scintillation-proximity assay. The inhibitory properties of surfactant were determined to be associated, at least in part, with the 1,2-dipalmitoyl phosphatidylcholine (DPPC) component of surfactant. DPPC alone also inhibited LPS-stimulated PAF biosynthesis in human peripheral blood monocytes. DPPC treatment did not affect LPS-stimulated phospholipase A2 activity in MM6 cell lysates. However, DPPC significantly inhibited LPS-stimulated coenzyme A (CoA)-independent transacylase and acetyl CoA:lyso-PAF acetyltransferase activity. DPPC treatment of MM6 cells decreased plasma membrane fluidity as demonstrated by electron paramagnetic resonance spectroscopy coupled with spin labeling. Taken together, these findings indicate that pulmonary surfactant, particularly the DPPC component, can inhibit LPS-stimulated PAF production via perturbation of the cell membrane, which inhibits the activity of specific membrane-associated enzymes involved in PAF biosynthesis.
Neutrophil-activating potential of antineutrophil cytoplasm autoantibodies
Authors: Rarok Agnieszka A , Limburg Pieter C , Kallenberg Cees G M
Published: June 2003

Accumulating in vivo and in vitro evidence supports the hypothesis that antineutrophil cytoplasm autoantibodies (ANCA) with specificity for proteinase 3 (PR3) and myeloperoxidase (MPO) are involved in the pathophysiology of small-vessel vasculitis. The best-described effector function of these autoantibodies is stimulation of neutrophils to produce reactive oxygen species and to release proteolytic enzymes. Neutrophil activation requires interaction of monomeric ANCA with PR3/MPO and Fcγ receptors, but also other mechanisms—for instance, stimulation by ANCA-containing immune complexes—cannot be excluded. This review focuses on the mechanisms of neutrophil activation by ANCA. We discuss the molecules involved in ANCA binding to the neutrophil surface and in triggering the functional responses. We summarize current knowledge on the signal-transduction pathways initiated by ANCA and on the factors determining susceptibility of neutrophils to activation by these autoantibodies.
Mechanism of glucocorticoid-induced depletion of human CD14+CD16+ monocytes
Authors: Dayyani Farshid , Belge Kai-Uwe , Frankenberger Marion , Mack Matthias , Berki Timea , Ziegler-Heitbrock Loems
Published: June 2003

Healthy donors infused with high doses of glucocorticoids [GCs; methyl-prednisolone (MP); 500 mg/day for 3 days] suffer a selective depletion of the CD14+CD16+ monocytes such that these cells are reduced by 95% on day 5. In vitro studies revealed that at 11 h of culture in the presence of 10−5 M MP, no depletion was observed as yet, but a reduction by 80% was seen after 24 h. In dose-response analysis, MP still led to a 50% reduction of CD14+CD16+ monocytes at 10−7 M. Depletion could not be overcome by addition of the cytokines interleukin-1β or macrophage-colony stimulating factor, and it was independent of CD95. Depletion was, however, inhibited by the caspase 3,8 blocker z-Val-Ala-Asp, suggesting that cell death occurs in a caspase-dependent manner. Furthermore, blockade of depletion by RU-486 indicates that the intracellular GC receptor (GCR) is involved. Measurement of GCR by flow cytometry revealed a 50% higher level of expression in the CD14+CD16+ monocytes. Our studies show a selective depletion of CD14+CD16+ monocytes by GC treatment in vivo and in vitro, an effect to which the modestly increased level of GCR may contribute.
CD44v7 interferes with activation-induced cell death by up-regulation of anti-apoptotic gene expression
Authors: Marhaba Rachid , Bourouba Mehdi , Zöller Margot
Published: June 2003

Blockade of CD44v7 was described to cure trinitrobenzene sulfonic acid-induced colitis, a disease not developed by mice with targeted deletion of the CD44v7 exon. There was evidence for a reduction in activation-induced cell death on lamina propria lymphocytes of control as compared with CD44v7-deficient mice. To elucidate the mechanism underlying the relative apoptosis resistance of CD44v7-competent as compared with CD44v7-deficient lymphocytes, T cell activation and induction of apoptosis were analyzed on mesenteric lymph node cells and Peyer’s patch lymphocytes of CD44v7-deficient and CD44v4-v7-transgenic mice, which overexpress rat CD44v4-v7 on T lymphocytes. CD44v7 deficiency was characterized by an increase in the percentage of apoptotic cells after stimulation, increased numbers of CD95L- and CD152-positive cells, low levels of the anti-apoptotic proteins Bcl-2 and Bcl-Xl, and decreased phosphorylation of the pro-apoptotic protein BAD. Also, lymphocytes from CD44v4-v7-transgenic mice displayed reduced levels of CD95L, low numbers of apoptotic cells, and constitutively elevated levels of Bcl-Xl. When stimulating lymphocytes by CD3 cross-linking, CD44v7 was not recruited toward the immunological synapse and preferentially associated with the cytoskeletal-linker protein ezrin. Thus, as opposed to the CD44 standard isoform, CD44v7 does not function as an accessory molecule; instead, it supports survival of activated T cells by interfering with activation-induced cell death.
Acute pancreatitis: an obscure complication of organophosphate intoxication
Authors: Harputluoglu M M Mxurat , Kantarceken Bulent , Karincaoglu Melih , Aladag Murat , Yildiz Ramazan , Ates Mehmet , Yildirim Bulent , Hilmioglu Fatih
Published: June 2003

Acute pancreatitis secondary to organophosphate intoxication is a rare and generally well-course condition, but it is important to be aware of this complication for appropriate clinical management. There are a few reports about this subject in the literature, but it is believed that there are more cases than are reported for this condition. Because symptoms of toxicity can mask this severe complication, we report two cases of acute pancreatitis due to organophosphate intoxication for alerting this condition.
Arsenic methylation by micro-organisms isolated from sheepskin bedding materials
Authors: Lehr Corinne R , Polishchuk Elena , Delisle Marie-Chantal , Franz Catherine , Cullen William R
Published: June 2003

Sudden infant death syndrome (SIDS) has been associated with the volatilization of arsenic, antimony or phosphorus compounds from infants' bedding material by micro-organisms, the so-called ‘toxic gas hypothesis’. The volatilization of arsenic by aerobic micro-organisms isolated from new sheepskin bedding material, as well as on material used by a healthy infant and by an infant who perished of SIDS, was examined. Three fungi were isolated from a piece of sheepskin bedding material on which an infant perished of SIDS, which methylated arsenic to form trimethylarsenic(V) species, precursors to volatile trimethylarsine. These three fungi were identified as Scopulariopsis koningii, Fomitopsis pinicola and Penicillium gladioli by their 26S-ribosomal RNA polymerase chain reaction products. These fungi were not previously known to methylate arsenic. The volatilization of arsenic by these three fungi was then examined. Only P. gladioli volatilized arsenic and only under conditions such that the production of sufficient trimethylarsine to be acutely toxic to an infant is unlikely. S. brevicaulis grew on the sheepskin bedding material and evolved a trace amount of trimethylarsine. Known human pathogens such as Mycobacterium neoaurum and Acinetobacter junii were isolated from used bedding.
Ochratoxin a reduces NMDA receptor subunits 2A and 2B concentrations in rat hippocampus: partial protective effect of melatonin
Authors: Delibas Namik , Altuntas Irfan , Yonden Zafer , Ozcelik Nurten
Published: June 2003

Ochratoxin A (OTA) is a mycotoxin produced by several fungi. Many foods can be contaminated by OTA, which is consequently found in the blood of humans and animals. It is known that OTA accumulates in the brain. The aim of this study was to investigate the effects of OTA on the brain. For this purpose, the effect of OTA on N-methyl-Daspartate (NMDA) receptor subunits 2A (NR2A) and 2B (NR2B) in the hippocampus and the protective effect of melatonin were investigated. Three groups of eight rats were used: controls, OTA-treated rats (OTA dose 289 mg/ kg per day) and OTA-melatonin-treated rats (melatonin dose 10 mg/kg per day). After four weeks of treatment, electrophoretic examinations were performed using SDSpolyacrylamide gel electrophoresis and Western blotting of hippocampal homogenates of the different groups. The concentrations of NR2A and NR2B in the OTA group were significantly lower than in the control group. The concentration of NR2B was significantly increased when melatonin was co-administered with OTA compared with OTA only. There was also a significant increase in NR2A levels when melatonin was co-administered with OTA. As a result, subchronic administration of OTA reduced hippocampal NMDA receptor subunits 2A and 2B concentrations in rats. It was thought that this alteration might affect cognitive functions because hippocampal NMDA receptors are involved in the memory and learning processes. Melatonin exhibited a partially protective effect on NR2A and NR2B against OTA.
Radiation-induced versus endogenous DNA damage: possible effect of inducible protective responses in mitigating endogenous damage
Authors: Pollycove Myron , Feinendegen Ludwig E
Published: June 2003

Ionizing radiation (IR) causes damage to DNA that is apparently proportional to absorbed dose. The incidence of radiation-induced cancer in humans unequivocally rises with the value of absorbed doses above about 300 mGy, in a seemingly linear fashion. Extrapolation of this linear correlation down to zero-dose constitutes the linear-no-threshold (LNT) hypothesis of radiation-induced cancer incidence. The corresponding dose-risk correlation, however, is questionable at doses lower than 300 mGy. Non-radiation induced DNA damage and, in consequence, oncogenic transformation in non-irradiated cells arises from a variety of sources, mainly from weak endogenous carcinogens such as reactive oxygen species (ROS) as well as from micronutrient deficiencies and environmental toxins. In order to relate the low probability of radiation-induced cancer to the relatively high incidence of non-radiation carcinogenesis, especially at low-dose irradiation, the quantitative and qualitative differences between the DNA damages from non-radiation and radiation sources need to be addressed and put into context of physiological mechanisms of cellular protection.

This paper summarizes a co-operative approach by the authors to answer the questions on the quantitative and qualitative DNA damages from non-radiation sources, largely endogenous ROS, and following exposure to low doses of IR. The analysis relies on published data and justified assumptions and considers the physiological capacity of mammalian cells to protect themselves constantly by preventing and repairing DNA damage. Furthermore, damaged cells are susceptible to removal by apoptosis or the immune system. The results suggest that the various forms of non-radiation DNA damage in tissues far outweigh corresponding DNA damage from low-dose radiation exposure at the level of, and well above, background radiation.

These data are examined within the context of low-dose radiation induction of cellular signaling that may stimulate cellular protection systems over hours to weeks against accumulation of DNA damage. The particular focus is the hypothesis that these enhanced and persisting protective responses reduce the steady state level of nonradiation DNA damage, thereby reducing deleterious outcomes such as cancer and aging.

The emerging model urgently needs rigorous experimental testing, since it suggests, importantly, that the LNT hypothesis is invalid for complex adaptive systems such as mammalian organisms.
Radiation-induced versus endogenous DNA damage and assays that measure parameters reflecting DNA damage on cell by cell basis: comments on the article by Pollycove and Feinendegen
Authors: Roti Roti Joseph L
Published: June 2003

The article by Pollycove and Feinendegen raises important issues regarding the relative contributions of endogenous and radiation-induced DNA damage to the overall DNA damage burden following low level radiation exposures. Clearly, resolution of the issues raised in their article will have important implications regarding regulatory philosophy. Dose-limiting studies of DNA damage measured on a cell-by-cell basis was used to analyze available data in the context of the proposed model. If one proposes that significant numbers of oxidative DNA lesions are present in cells at a steady state level at any give time, then such damage will be included in the background measure of any DNA damage dependent parameter that is sensitive to these classes of DNA damage. Then the expected number of lesions per cell was compared, prior to X- or γ-ray exposure, at the dose that gives the minimum statistically significant difference from background, at the dose where the DNA damage dependent parameter is twice background (i.e., the doubling dose). The lesion frequencies predicted from the model by Pollycove and Feinendegen are reasonable for the micronucleus assay and the inhibition of DNA supercoil rewinding, but appear to be inconsistent with results from the comet assay. Possible explanations for the inconsistency between the comet assay dose) response data and the predicted levels of DNA damage predicted by the model are discussed, suggesting that the estimates of the radiation induced damage are too low and those for endogenous damage are too high. The goal in introducing these issues is not to be negative to the article but to present a basis for future discussions and more importantly future experimental work, by which the important issues raised can be resolved.
Gamma‐hydroxybutyric Acid Tolerance and Withdrawal in a Rat Model
Authors: Bania Theodore C. , Ashar Tom , Press Gregory , Carey Patricia M.
Published: July 2003

Long‐term daily use of gamma‐hydroxybutyrate (GHB) and related compounds has recently been associated with a withdrawal syndrome. To the best of the authors' knowledge, there are currently no animal models of GHB withdrawal. Objectives: The authors studied and described the effect of chronic dosing of GHB (3–6 days) on tolerance and withdrawal in a rat model. Methods: Rats were administered GHB every three hours via intraperitoneal catheter. Groups of rats (2 per group) were dosed with GHB for either 3 (24 doses), 4 (32 doses), 5 (40 doses), or 6 (48 doses) days. The GHB dose was 0.25 g/kg for doses 1–8, 0.75 g/kg for doses 9–12, 1 g/kg for doses 13–16, 1.25 g/kg for doses 17–24, 1.5 g/kg for doses 25–32, 1.75 g/kg for doses 33–40, and 2 g/kg for doses 41–48. Following the last dose of GHB, the rats were scored using a 16‐point ethanol intoxication–withdrawal scale rating spontaneous behaviors, response to handling, grooming, and neurological signs. Lower scores indicate intoxication, while higher scores indicate withdrawal. Scores were recorded at hours 0, 1, 2, 3, 4, 5, 6, 9, 12, and 24. Results:Tolerance: Rats dosed with GHB for more days were less intoxicated one hour after their last GHB dose despite receiving higher doses. Withdrawal: The scores for all rats dosed with GHB increased at hours 4 (p = 0.028), 5 (p = 0.037), 6 (p = 0.007), and 9 (p = 0.024) after the last dose, indicating withdrawal. The scores demonstrated a linear increase dependent upon the number of days of GHB dosing at hours 3 (p < 0.000), 4 (p = 0.004), 5 (p = 0.002), and 12 (p = 0.039) as well as prior to the last dose at hour 0 (p = 0.000). No rats developed seizures. Conclusions: Tolerance and mild withdrawal in rats can be induced by administering intraperitoneal GHB every three hours for 3–6 days. More prolonged dosing and higher doses of GHB may be necessary to induce severe withdrawal.
Effect of Cocaine Use on Bone Marrow‐mediated Erythropoiesis
Authors: Weber Jim Edward , Larkin Gregory Luke , Boe Christopher T. , Fras Andrew , Kalaria Amit S. , Maio Ronald F. , Luchessi Benjamin , Ensign Lars , Sweeney Brian , Hollander Judd E.
Published: July 2003

Objectives: Cocaine‐mediated erythrocytosis is one of several effects that cocaine may have on hematologic indices; however, the precise mechanism by which cocaine induces peripheral erythrocytosis is not fully understood. The objective of this study was to examine the contribution of the bone marrow to cocaine‐mediated erythrocytosis. Methods: Differences in mean hemoglobin concentration, hematocrit, and reticulocyte counts were measured in consecutive cocaine‐exposed and cocaine‐unexposed patients who presented to the emergency department (ED) with chest pain. Acute cocaine exposure (<3 hours) was confirmed by history and toxicologic analysis of the urine on all patients. Means were compared using independent‐samples t‐test and covariates were examined using multiple regression. Results: Seventy‐nine patients met enrollment criteria. Hemoglobin and hematocrit levels were significantly elevated in the cocaine‐using subjects (13.5/39.8) compared with controls (12.6/37.7; p < 0.02). However, no corresponding elevation in reticulocyte count (p = 0.2) was observed. Multivariate logistic regression revealed that male chest pain patients were significantly more likely to be exposed to cocaine (OR 5.15 [95% CI = 1.77 to 15.3]) than females (p = 0.001), and all relative increases in hemoglobin concentration in the cocaine‐exposed group were attributable to gender. Cocaine exposure was not significantly associated with reticulocyte count. Multivariate linear regression revealed that of demographic, medical, and substance use covariates, only a history of diabetes mellitus was significantly associated with an elevated reticulocyte count (p = 0.009). Conclusions: Acute cocaine exposure is not associated with erythrocytosis in younger ED patients with chest pain. The lack of an elevated reticulocyte count suggests that bone marrow does not contribute to any transient erythrocytosis that may occur.
Emergency Department Gridlock and Out‐of‐hospital Delays for Cardiac Patients
Authors: Schull Michael J. , Morrison Laurie J. , Vermeulen Marian , Redelmeier Donald A.
Published: July 2003

Objectives: To determine the effect of simultaneous ambulance diversion at multiple emergency departments (EDs) (gridlock) on transport delays for patients with chest pain. Methods: Retrospective data on consecutive ambulance patients with chest pain and the diversion status of EDs in Toronto were obtained from January 1998 to December 1999. Gridlock was calculated separately for the four city quadrants as the daily duration of episodes where all EDs in the quadrant were simultaneously diverting ambulances. The primary outcome was 90th percentile ambulance transport interval (scene departure to hospital arrival). Results: Eleven thousand four hundred patients were included (mean age 67 years; female 51%; severity of illness: moderate to life‐threatening 89%). Gridlock occurred an average of 1.1 hour/day, and 3,060 patients were transported on days when it occurred. Ninetieth percentile transport interval was 15.5 minutes (95% CI = 15.3 to 15.9) for patients not exposed to gridlock vs. 17.4 minutes (95% CI = 16.8 to 17.8) for patients who were exposed to gridlock. In multivariate analyses, gridlock was associated with both transport and total out‐of‐hospital interval delays (0.2 min/hour, 95% CI = 0.1 to 0.4 and 0.2 min/hour, 95% CI = 0.04 to 0.4, respectively). Delays were similar regardless of patient severity of illness (p = 0.5). Age (0.8 min/10 years, 95% CI = 0.5 to 1), female gender (1.9 min, 95% CI = 1.3 to 2.6), advanced care paramedics (5.3 min, 95% CI = 4.4 to 6.3), and snowfall (0.8 min/cm, 95% CI = 0.2 to1.5) were also independently associated with delays. Conclusions: Ambulance diversion was associated with delays in out‐of‐hospital ambulance transport for chest pain patients, but only when it resulted in gridlock. The magnitude of the out‐of‐hospital delay was the same regardless of the patient's severity of illness.
Multivariate Predictors of Failed Prehospital Endotracheal Intubation
Authors: Wang Henry E. , Kupas Douglas F. , Paris Paul M. , Bates Robyn R. , Costantino Joseph P. , Yealy Donald M.
Published: July 2003

Objectives: Conventionally trained out‐of‐hospital rescuers (such as paramedics) often fail to accomplish endotracheal intubation (ETI) in patients requiring invasive airway management. Previous studies have identified univariate variables associated with failed out‐of‐hospital ETI but have not examined the interaction between the numerous factors impacting ETI success. This study sought to use multivariate logistic regression to identify a set of factors associated with failed adult out‐of‐hospital ETI. Methods: The authors obtained clinical and demographic data from the Prehospital Airway Collaborative Evaluation, a prospective, multicentered observational study involving advanced life support (ALS) emergency medical services (EMS) systems in the Commonwealth of Pennsylvania. Providers used standard forms to report details of attempted ETI, including system and patient demographics, methods used, difficulties encountered, and initial outcomes. The authors excluded data from sedation‐facilitated and neuromuscular blockade‐assisted intubations. The main outcome measure was ETI failure, defined as failure to successfully place an endotracheal tube on the last out‐of‐hospital laryngoscopy attempt. Logistic regression was performed to develop a multivariate model identifying factors associated with failed ETI. Results: Data were used from 45 ALS systems on 663 adult ETIs attempted during the period June 1, 2001, to November 30, 2001. There were 89 cases of failed ETI (failure rate 13.4%). Of 61 factors potentially related to ETI failure, multivariate logistic regression revealed the following significant covariates associated with ETI failure (odds ratio; 95% confidence interval; likelihood ratio p‐value): presence of clenched jaw/trismus (9.718; 95% CI = 4.594 to 20.558; p < 0.0001); inability to pass the endotracheal tube through the vocal cords (7.653; 95% CI = 3.561 to 16.447; p < 0.0001); inability to visualize the vocal cords (7.638; 95% CI = 3.966 to 14.707; p < 0.0001); intact gag reflex (7.060; 95% CI = 3.552 to 14.033; p < 0.0001); intravenous access established prior to ETI attempt (3.180; 95% CI = 1.640 to 6.164; p = 0.0005); increased weight (ordinal scale) (1.555; 95% CI = 1.242 to 1.947; p = 0.0001); and electrocardiographic monitoring established prior to ETI attempt (0.199; 95% CI = 0.084 to 0.469; p = 0.0003). This model was the most parsimonious of the models evaluated and demonstrated good fit (Hosmer‐Lemeshow test p = 0.471) and discrimination (area under ROC curve = 0.906). There were no significant interaction terms. Conclusions: The authors used multivariate logistic regression to identify a set of factors associated with failure to accomplish ETI in adult out‐of‐hospital patients. Findings from this analysis could provide the basis for clinical protocols or decision rules aimed at minimizing the incidence of out‐of‐hospital ETI failure.
The Effect of a New Emergency Medicine Residency Program on Patient Length of Stay in a Community Hospital Emergency Department
Authors: Lammers Richard L. , Roiger Michelle , Rice Laura , Overton David T. , Cucos Diana
Published: July 2003

Objectives: It is not clear how emergency medicine residents affect emergency department (ED) efficiency. The objective of this study was to determine whether a new emergency medicine residency program affected the length of stay (LOS) of patients in a community hospital ED. Methods: A before‐and‐after observational study was conducted during a one‐year period prior to, and for three years after, the start of a new residency. An additional year's worth of data were collected during the fifth year after the residency started. Patients were excluded if their LOS was less than 30 minutes and they were admitted directly to the hospital. Explanatory variables included scheduled resident and student hours/day; scheduled faculty hours/day; nursing plus clerk hours/day; patients/day; ambulances/day; and admissions/day. The data were analyzed using descriptive and correlation statistics and regression analysis. Results: Average patient LOS prior to the residency was 122.9 minutes. During the first year of residency, it was 126.6 minutes; second year, 129.9 minutes; third year, 158.9 minutes; and fifth year, 162.4 minutes. There was a positive correlation between LOS and third‐postgraduate‐year resident (PGY‐3) hours (rho = 0.43), and between LOS and PGY‐3 hours/patients/day (rho = 0.42). All other correlations were poor (rho < 0.4). Conclusions: In this ED, there was a weak, positive correlation between ED patient length of stay and the presence of PGY‐3 emergency medicine residents.
Resident Evaluation of Clinical Teachers Based on Teachers' Certification
Authors: Steiner Ivan P. , Yoon Philip W. , Kelly Karen D. , Diner Barry M. , Donoff Michel G. , Mackey Duncan S. , Rowe Brian H.
Published: July 2003

Objective: To examine the influence of emergency medicine (EM) certification of clinical teaching faculty on evaluations provided by residents. Methods: A prospective cohort analysis was conducted of assessments between July 1994 and July 2000 on residents' evaluations of EM faculty at the University of Alberta, Edmonton, Canada. Resident‐ and faculty‐related variables were entered anonymously using the validated evaluation tool (ER Scale). Credentialing and demographic information on EM faculty was supplemented by data obtained through a nine‐question survey. Groups were compared using ANOVA. Results: The 562 residents returned 705 (91%) valid evaluation sheets on 115 EM faculty members. The four domains of didactic teaching, clinical teaching, approachability, and helpfulness were assessed. The majority of ratings were in the very good or superb categories for each domain. Instructors with certification in EM had higher scores in didactic, clinical teaching compared with others, and teachers without national certification scored lower in the helpful and approachable categories (p < 0.05). The route of obtaining EM certifications either through training or practice eligibility did not affect scores. Instructors under the age of 40 years had higher scores than the older age groups in three of four categories (p < 0.05). Instructors working at the teaching sites on a half‐time basis received higher scores than those working full‐time, and scores varied based on site. Overall, teaching ratings improved over the study period (p < 0.05). Conclusions: Significant differences exist among instructors in the EM setting that affect their teaching rating scores. National certification in EM, academic track, rotation year, and site are all correlated with better teaching performance.
Emergency Medicine Residency Training in Electrocardiogram Interpretation
Authors: Ginde Adit A. , Char Douglas M.
Published: July 2003

Objectives: A national survey of emergency medicine (EM) residency program directors (PDs) was conducted to review training and evaluation of residents in electrocardiogram (ECG) interpretation and to assess the attitudes of PDs toward establishing national criteria for ECG competency. Methods: An eight‐question multiple‐part survey was mailed to all 122 EM PDs. The presence of a formal ECG curriculum, teaching formats, and methods to assess competency were queried. The PDs' opinions on developing a national ECG curriculum, standardized assessment tool, and competency requirement for graduation were solicited on a five‐point Likert scale. Results: Surveys were received from 87 (71.3%) of the 122 EM residency programs. Of the responding programs, 56 (64.4%) had a formal ECG curriculum. Only 18 (20.7%) programs stated that they test for ECG competency, and even fewer, ten (11.5%) programs, require that residents prove competency to graduate. Although 32 (48.3%) PDs endorsed the idea of a national ECG curriculum, 51 (58.6%) opposed the implementation of a national ECG examination for EM. Similarly, 50 (57.5%) PDs opposed a national ECG competency requirement for graduation. Conclusions: While a majority of EM residency programs surveyed have a formal curriculum for ECG interpretation, less than a fourth formally test their residents or require proof of competency. The majority of residency PDs oppose the development of a national ECG examination or competency requirement for graduation. Implementation of the Accreditation Council for Graduate Medical Education directive for the demonstration of clinical competencies will be challenging given the current position of PDs.
Geographic Variation of Pediatric Burn Injuries in a Metropolitan Area
Authors: Williams Kristine G. , Schootman Mario , Quayle Kimberly S. , Struthers Jim , Jaffe David M.
Published: July 2003

Objectives: To use a geographic information system (GIS) and spatial statistics to describe the geographic variation of burn injuries in children 0–14 years of age in a major metropolitan area. Methods: The authors reviewed patient records for burn injuries treated during 1995 at the two children's hospitals in St. Louis. Patient addresses were matched to block groups using a GIS, and block group burn injury rates were calculated. Mapping software and Bayesian analysis were used to create maps of burn injury rates and risks in the city of St. Louis. Results: Three hundred eleven children from the city of St. Louis were treated for burn injuries in 1995. The authors identified an area of high incidence for burn injuries in North St. Louis. The filtered rate contour was 6 per 1,000 children at risk, with block group rates within the area of 0 to 58.8 per 1,000 children at risk. Hierarchical Bayesian analysis of North St. Louis burn data revealed a relative risk range of 0.8771 to 1.182 for census tracts within North St. Louis, suggesting that there may be pockets of high risk within an already identified high‐risk area. Conclusions: This study shows the utility of geographic mapping in providing information about injury patterns within a defined area. The combination of mapping injury rates and spatial statistical analysis provides a detailed level of injury surveillance, allowing for identification of small geographic areas with elevated rates of specific injuries.
Surveillance of Infectious Disease Occurrences in the Community: An Analysis of Symptom Presentation in the Emergency Department
Authors: Suyama Joe , Sztajnkrycer Matthew , Lindsell Christopher , Otten Edward J. , Daniels Judith M. , Kressel Amy B.
Published: July 2003

Objectives: To determine the effectiveness of a simulated emergency department (ED)‐based surveillance system to detect infectious disease (ID) occurrences in the community. Methods: Medical records of patients presenting to an urban ED between January 1, 1999, and December 31, 2000, were retrospectively reviewed for ICD‐9 codes related to ID symptomatology. ICD‐9 codes, categorized into viral, gastrointestinal, skin, fever, central nervous system (CNS), or pulmonary symptom clusters, were correlated with reportable infectious diseases identified by the local health department (HD). These reportable infectious diseases are designated class A diseases (CADs) by the Ohio Department of Health. Cross‐correlation functions (CCFs) tested the temporal relationship between ED symptom presentation and HD identification of CADs. The 95% confidence interval for lack of trend correlation was 0.0 ± 0.074; thus CCFs > 0.074 were considered significant for trend correlation. Further cross‐correlation analysis was performed after chronic and non‐community‐acquirable infectious diseases were removed from the HD database as a model for bioterrorism surveillance. Results: Fifteen thousand five hundred sixty‐nine ED patients and 6,489 HD patients were identified. Six thousand two hundred eight occurrences of true CADs were identified. Only 87 (1.33%) HD cases were processed on weekends. During the study period, increased ED symptom presentation preceded increased HD identification of respective CADs by 24 hours for all symptom clusters combined (CCF = 0.112), gastrointestinal symptoms (CCF = 0.084), pulmonary symptoms (CCF = 0.110), and CNS symptoms (CCF = 0.125). The bioterrorism surveillance model revealed increased ED symptom presentation continued to precede increased HD identification of the respective CADs by 24 hours for all symptom clusters combined (CCF = 0.080), pulmonary symptoms (CCF = 0.100), and CNS symptoms (CCF = 0.120). Conclusions: Surveillance of ED symptom presentation has the potential to identify clinically important ID occurrences in the community 24 hours prior to HD identification. Lack of weekend HD data collection suggests that the ED is a more appropriate setting for real‐time ID surveillance.
Violence and Substance Use among an Injured Emergency Department Population
Authors: Cunningham Rebecca , Walton Maureen A. , Maio Ronald F. , Blow Fredric C. , Weber James E. , Mirel Lisa
Published: July 2003

Objectives: This study evaluated a sample of emergency department (ED) patients for history of violence and substance abuse. Methods: Injured patients (n= 320) completed questionnaires (14% refusal rate) during a visit to a Level 1 urban ED after an acute injury. Specific questions were asked regarding whether the injury was related to acute violence (AV), whether there was past‐year violence history (VH), including violence victimization and perpetration in both partner and nonpartner relationships, as well as any substance use in the past month and any substance‐related consequences in the past year. Results: Fourteen percent of the participants presented with an AV‐related injury, and 53% reported VH. Most AV patients (89%) reported VH. No significant differences were found between the participants with AV and VH in demographic, substance use, or substance‐related consequences. The AV and VH groups were combined (V), with analyses comparing these participants with those without AV and VH. Men were significantly more likely than women to report V (odds ratio = 2.0). V was significantly related to substance use and substance‐related consequences. For example, in comparison with the participants reporting no alcohol or drug use, those reporting illicit drug use were 6.2 times as likely to report V, and those drinking any alcohol only were 2.0 times as likely to report V. Conclusions: A large percentage of injured patients in this urban ED experienced violence in the past year. Alcohol and illicit drugs appear to be concomitant with violence.
Report of the CIMERC Drexel University Emergency Department Terrorism Preparedness Consensus Panel*
Authors: Greenberg Michael I. , Hendrickson Robert G.
Published: July 2003

This report describes the consensus recommendations of an expert panel convened to develop recommendations for a hospital‐based emergency department (ED) to attain a minimal level of preparedness necessary to respond to mass casualty events derived from the use of weapons of mass destruction. The recommendations were created for use by hospital‐based EDs of a variety of sizes and locations (urban, suburban, or rural). The disasters that were considered included those that are biological, chemical, or radiological. The panel focused on preparation for a single disaster that could generate 250–500 total patients in 24–48 hours. This number included asymptomatic, exposed, and symptomatic patients. The panel chose not to address circumstances where a small number of patients with an infectious disease are seen in one or a few hospitals. In addition, the panel believed that preparation of a single hospital for an overwhelming mass casualty situation (e.g., 10,000 patients) would not be broadly applicable and would not be required for an individual ED to “minimally prepared.” Prior to the convening of this consensus panel, in June 2002, a search of all relevant agencies found no comprehensive, published, validated recommendations for preparedness for individual EDs. Although several agencies had released information on disaster management, clinical diagnosis and treatment tools, and training, no agency had produced a comprehensive list of items and issues that individual EDs must consider when preparing for a terrorist attack. The current report attempts to fill this void in information regarding ED preparedness.
Quantile Regression: A Statistical Tool for Out‐of‐hospital Research
Authors: Austin Peter C. , Schull Michael J.
Published: July 2003

The performance of out‐of‐hospital systems is frequently evaluated based on the times taken to respond to emergency requests and to transport patients to hospital. The 90th percentile is a common statistic used to measure these indicators, since they reflect performance for most patients. Traditional regression models, which assess how the mean of a distribution varies with changes in patient or system characteristics, are thus of limited use to researchers in out‐of‐hospital care. In contrast, quantile regression models estimate how specified quantiles (or percentiles) of the distribution of the outcome variable vary with patient or system characteristics. The authors examined the performance of traditional linear regression vs. that of quantile regression to assess the association between hospital transport interval and patient and system characteristics. They demonstrate that richer inferences can be drawn from the data using quantile regression, utilizing data drawn from a study of ambulance diversion and out‐of‐hospital delay. The results demonstrate that the effect of ambulance diversion upon out‐of‐hospital transport intervals is not uniform, but is worse on the right tail of the distribution of transport intervals. In other words, ambulance diversion disproportionately affects those patients who already have longer transport intervals. Second, the distribution of transport intervals, conditional on a given set of variables, is positively skewed, and not uniformly or symmetrically distributed. The flexibility of quantile regression models makes them particularly well suited to out‐of‐hospital research, and they may allow for more relevant evaluation of out‐of‐hospital system performance.
Emergency Nursing: Historical, Current, and Future Roles
Authors: Schriver John A. , Talmadge Robin , Chuong Roberta , Hedges Jerris R.
Published: July 2003

Building upon a historical context, the current and future roles of the clinical emergency nurse are reviewed. For several reasons, emergency nurse availability is expected to be insufficient to meet staffing demands in the near future. Emergency physicians can partner with emergency nurses and hospital administrators to pursue the following strategies for addressing the nursing shortage: 1) improve the workplace environment by improving nurse‐to‐patient ratios and avoiding the boarding of admitted patients in the emergency department (ED); 2) refocus the emergency nurse job description to patients and their families; 3) promote mutually supportive relationships and comradeship between emergency nurses and physicians; 4) create an environment that allows unique solutions to staff scheduling and accommodates shiftwork; 5) increase nursing wages, and recognize special contributions of emergency nurses with financial reward; 6) identify and promote the personnel of the hospital ED as members of an elite unit; 7) develop preceptorships and internships for nurses new to emergency nursing and invest in clinical specialists or nurse‐mentors to assist in “on‐the‐job” instruction of nurses with previous experience; and 8) invest in nursing education. Taking these steps today will strengthen the ED health care safety net for decades to come.
Clinical Operations in Academic Emergency Medicine
Authors: Beach Christopher , Haley Leon , Adams James , Zwemer Frank L.
Published: July 2003

The operations of an emergency department are increasingly being recognized as vital to the provision of safe, efficient, quality care. The numerous and highly variable processes that characterize our system must be closely examined and investigated to identify those which are effective and those which are not. Original research in this field should be promoted and embraced by our society for both our patients and our profession. Effective operational processes should ultimately be seen as those which preserve and enhance the patient–physician relationship.
Digital Imaging: A Promising Tool for Mushroom Identification
Authors: Fischbein Connie B. , Mueller Gregory M. , Leacock Patrick R. , Wahl Michael S. , Aks Steven E.
Published: July 2003

Mushroom poisoning is a diagnostic and treatment dilemma for health care professionals. Decisions regarding treatment following ingestions are usually made without a firm identification of the fungus and tend to be more aggressive than necessary. The identification of mushrooms is beyond the scope of health care professionals, and a mycologist is essential to make an accurate identification. Telemedicine and digital imaging is an emerging technology that can assist in mushroom identification and facilitate patient care. The efficacy of using digital images sent over the Internet was tested in a pilot project. This article describes three cases in which digital images and verbal descriptions assisted in mushroom identification. When the actual specimen was sent to a mycologist, a definitive identification was obtained and compared with the presumptive identification. Digital images alone do not permit definitive identification; however, they often contain sufficient information to help the clinician rule out the possibility of a severely toxic species. Data accumulated to date indicate that digital imaging can be an important tool in the diagnosis and treatment of mushroom ingestion, and possibly other biologicals such as plants, insects, and reptiles.
Customer Satisfaction Measurement in Emergency Medical Services
Authors: Kuisma Markku , Määttä Teuvo , Hakala Taisto , Sivula Tommi , Nousila‐Wiik Maria
Published: July 2003

Objectives: The annual patient volume in emergency medical services (EMS) systems is high worldwide. However, there are no comprehensive studies on customer satisfaction for EMS. The authors report how a customer satisfaction survey on EMS patients was conducted, the results, and the possible causes for dissatisfaction. Methods: Two prospective customer satisfactions surveys were conducted in an urban EMS system. Consecutive patients treated by EMS received a postal questionnaire approximately two weeks after service. Satisfaction was measured in a scale from 1 (very poor) to 5 (excellent). Neither EMS personnel nor patients were made aware prospectively that patient satisfaction would be measured. Results: Response rates to the surveys were 36.8% (432/1,175) in 2000 and 40.0% (464/1,150) in 2002. The mean general grades for the service were 4.6 and 4.5, respectively. Patients reported the highest degree of dissatisfaction when they were not taken to their hospital of choice, when they perceived that the paramedics were not able to meet their needs, and when paramedics did not introduce themselves or communicate directly with the patient's relatives. In high‐volume calls (i.e., frequent chief complaints), the general satisfaction was highest in patients with arrhythmias, breathing difficulties, and hypoglycemia. Patients with drug overdose included the highest proportion of unsatisfied patients. None of the background variables (e.g., gender, transport decision, working shift) was statistically related to general patient satisfaction. Conclusions: This study shows that customer satisfaction surveys can be successfully conducted for EMS. EMS systems should consider routinely using customer satisfaction surveys as a tool for quality measurement and improvement.
Emergency Medicine Resident Scheduling and Patient Exposure
Authors: Cushman Jeremy T. , Witting Michael D.
Published: July 2003

Objectives: As a result of increasing emergency department census and patient waiting times at the authors' institution, attending physician staffing was increased, followed by a change in resident shift schedule. A study was undertaken to ascertain any change in residents' exposure to patients during the times before and immediately following the staffing and scheduling changes. Methods: The number and triage acuity of patients seen by residents were recorded and compared during four distinct time periods: two historical control periods with double attending coverage and two simultaneously scheduled residents; a period of triple attending coverage with two simultaneously scheduled residents; and a final period of triple attending coverage and staggered resident scheduling. Results: Residents tend to see more patients per shift as the academic year progresses (mean increase of two per shift between fall and spring [95% CI = 1.5 to 2.4]). The increase to triple attending coverage during peak times did not alter the number or acuity of patients being seen by emergency medicine residents. However, a change in the resident's schedule from simultaneous day shifts to staggered day and night shifts was associated with a crude decrease in the number of patients seen by 0.7 per shift (95% CI = 0 to 1.3), and a decrease of 1.0 (95% CI = 0.4 to 1.2) when adjusted for patient census. Conclusions: After an increase in attending coverage, there was no change in the number or triage acuity of patients seen by residents. Staggered scheduling may decrease residents' exposure to patients compared with simultaneous scheduling.