bluuebunny/crossref_metadata_2025 huggingface dataset:
Histopathologic Effects of Cutaneous Tape Stripping in Pigs
Authors: Berrutti Luis E. , Singer Adam J. , McClain Steve A.
Published: January 2008

Abstract. Objective: The stratum corneum (SC) is the major barrier to topical absorption of medications. Skin tape stripping (TS) removes the stratum corneum, allowing more rapid absorption of drugs such as local anesthetics. Prior to evaluating TS in human clinical trials, this study was performed to evaluate its immediate and delayed histopathologic effects in swine. Methods: This was a prospective, interventional, longitudinal, experimental animal study using two isoflurane‐anesthetized young swine. Cellophane tape was applied to the skin of clipped swine flanks and peeled away 10, 15, 20, 25, or 30 times. Each level of tape stripping was performed three times in each pig. Full‐thickness biopsies were taken at 30 minutes and two weeks later for blinded histopathologic evaluation by a dermatopathologist using randomly ordered hematoxylin‐and‐eosin‐stained tissue sections and conventional light microscopy. The absolute thickness of the cornified layer was measured and compared with normal (unstripped) cornified layer. Results: Tape stripping up to 30 times produces thinning of the SC without detectable changes in the underlying epidermis and dermis at 30 minutes and 14 days post‐stripping. The degree of thinning was proportional to the number of tape applications. Complete recovery of the cornified layer was noted at two weeks. There were no adverse effects, such as infection, scarring, or inflammatory cell infiltrates. Conclusions: Under the conditions studied, TS not only appears safe, but appears to produce no long‐term sequelae.
Comparison of Intravenous Midazolam with Pentobarbital for Sedation for Head Computed Tomography Imaging
Authors: Moro‐Sutherland Donna M. , Algren John T. , Louis Penelope T. , Kozinetz Claudia A. , Shook Joan E.
Published: January 2008

Abstract. Objective: To compare the efficacy of intravenous (IV) midazolam with that of IV pentobarbital when used for sedation for head computed tomography (CT) imaging in emergency department (ED) pediatric patients. Methods: Prospective, randomized clinical trial in an urban children's hospital. During a two‐and‐a‐half‐year period, 55 patients were enrolled: 34 males and 21 females. Measurements included induction time, recovery time, efficacy, side effects, complications, and failure with each drug. Success of sedation was graded as good (GS), adequate (AS), poor (PS), or unsuccessful (US). Results: Sedation for CT was used for patients with the following problems: head trauma (21/55), central nervous system pathology (17/55), ventriculoperitoneal shunt evaluation (6/55), periorbital cellulitis (6/55), and retropharyngeal abscess (5/55). Twenty‐nine (53%) patients received pentobarbital (mean ± SD dose 3.75 ± 1.10 mg/kg) and 26 (47%)patients received midazolam (mean ± SD dose 0.2 ± 0.03 mg/kg). In the pentobarbital group, 28 (97%) patients were scanned and successfully sedated. Pentobarbital's mean induction time was 6 minutes and duration of sedation averaged 86 minutes. In the midazolam group, only five (19%) patients were successfully scanned with midazolam alone. Of the 21 (81%) patients given midazolam who were unsuccessfully sedated, 12 (61%) were subsequently sedated with the addition of pentobarbital for completion of CT imaging. Mild oxygen desaturation, O2 sat >90% yet <94%, was seen in only four patients. All four patients responded to blow‐by oxygen and required no other intervention. Conclusion: Intravenous pentobarbital is more effective than IV midazolam for sedation of children requiring CT imaging.
The Rationale for Developing Public Health Surveillance Systems Based on Emergency Department Data
Authors: Hirshon Jon Mark
Published: January 2008

Abstract. Emergency departments (EDs) are well positioned to provide national data on several aspects of public health. The large volume of patients seen annually, improving medical record technology, and emergency uniform data sets make the development of public health surveillance systems a realistic opportunity for emergency medicine. Such data could identify public health concerns and suggest interventions to improve the health of the nation. This article describes current concepts and status of ED surveillance systems, their advantages and disadvantages, the rationale for their existence, and recommendations to allow their continued consideration and development.
Bier Block Exsanguination: A Volumetric Comparison and Venous Pressure Study
Authors: Mabee John , Orlinsky Michael
Published: January 2008

Abstract. Objectives: Intravenous regional anesthesia (IVRA) is a useful ED anesthetic technique. However, venous pressure elevation during injection can cause anesthetic leakage and toxicity. This is minimized by preinjection limb exsanguination. Although standard, Esmarch exsanguination is intolerable with limb trauma. Thus, the authors' objective was to study alternative methods. Methods: Volunteers had upper limb exsanguination performed by Esmarch bandage, arm elevation/arterial compression (AE/AC), and a pneumatic vinyl splint. Resultant volume changes, measured by volume displacement, were normalized, and expressed as percent decreases from baseline. Volume changes of all three methods were compared. The physiologic effectiveness of the AE/AC method was tested by measuring IV pressures during simulated IVRA. Attainment of maximum venous pressure (MVP) indicated leakage under the tourniquet. Results: All methods reduced limb volume compared with baseline (p < 0.05). No difference occurred between AE/AC and vinyl splint exsanguination (p > 0.99), but neither method was as effective as Esmarch (p < 0.05). Gender differences were noted in absolute volumes exsanguinated, but there was no difference in percent exsanguination. The AE/AC method was the simplest procedure to perform. Peak IV pressure during simulated IVRA after AE/AC was 85 mm Hg (males), and 199 mm Hg (females) (p < 0.05). The MVP was not reached. Conclusions: While Esmarch was the most effective exsanguinating method, the two alternatives provided significant and equivalent decreases in limb volume. The AE/AC technique was physiologically effective in preventing attainment of MVP. Further studies are indicated to determine the clinical effectiveness of this technique in providing anesthesia for patients with limb trauma.
Lower‐extremity Doppler for Deep Venous Thrombosis—Can Emergency Physicians Be Accurate and Fast?
Authors: Blaivas Michael , Lambert Michael J. , Harwood Robert A. , Wood Joseph P. , Konicki John
Published: January 2008

Abstract. Clinical diagnosis of lower‐extremity (LE) deep venous thrombosis (DVT) requires confirmation by an imaging study before committing the patient to anticoagulation therapy. Studies have shown that demonstrating compressibility of leg veins under ultrasound is accurate for ruling out DVTs when performed by vascular specialists. Although LE Doppler has become the preferred test for diagnosing DVTs, it is not always available 24 hours per day. Objectives: To evaluate the accuracy and speed with which emergency physicians (EPs) could perform LE color duplex ultrasonography for the detection of DVT. Methods: Patients presenting to an urban community emergency department (ED) between August 1, 1998, and March 3, 1999, were enrolled into this prospective study. The EPs, who underwent brief and standardized training, scanned patients at high risk for DVT with leg pain, swelling, or both. Physicians performed color duplex ultrasound examinations with compression at the common femoral and popliteal veins. The time until completion of the ED scan was recorded with a standardized method. The vascular laboratory performed a complete duplex ultrasound examination within eight hours. Results: One hundred twelve patients were enrolled in the study, with 34 positive for DVT. The median examination time was 3 minutes 28 seconds (95% CI = 2 min 45 sec to 4 min 2 sec; IQR 3 min 9 sec). Times ranged from 1: 02 to 18:20 minutes. The ED results had a high correlation with vascular laboratory studies, giving a kappa of 0.9 and a 98% agreement (95% CI = 95.4% to 100%). Conclusion: Emergency physicians can perform LE duplex ultrasound examinations accurately and quickly.
Out‐of‐hospital Intravenous Cannulation: The Perspective of Patients Treated by London Ambulance Service Paramedics
Authors: Halter Mary , Lees‐Mlanga Shelley , Snooks Helen , Koenig Kristi L. , Miller Keith
Published: January 2008

Abstract. Objectives: Previous research has highlighted concern about infection rates in field‐placed intravenous (IV) cannulae. In a study of IV placement by London Ambulance Service (LAS) paramedics, 17% of placements were judged to be inappropriate. Large variations in rates of IV placement between LAS paramedics were found. The authors' hypothesis was that placement of an IV carries disadvantages—pain, discomfort, distress, and infection—which may be unacceptable to patients. Methods: This was a survey of all patients having an IV placed by LAS paramedics and transported to one of three London emergency departments (EDs) over a three‐week period in December 1996. Patients were excluded if they had a self‐inflicted injury/illness, were less than 14 years old, had no known address, or were visitors to the UK, or if their family doctor suggested it was not appropriate to contact the patient. Pain, discomfort, and distress; infection; satisfaction; understanding of the reason for cannulation; and out‐of‐hospital cannula use were all ascertained and analyzed with chi‐square analysis. Results: Thirty‐nine percent of the respondents experienced some discomfort, 39% some pain, and 17% some distress. No patient reported an infection. Distress was more likely to be reported if there was no understanding of why the IV cannula was placed (χ2 [1] 6.1; p < 0.05). Further unstructured information revealed satisfaction with the IV cannulation and with general care. Conclusions: Despite the disadvantages of IV placement being reported by some respondents, overall levels of satisfaction were high, suggesting that these disadvantages were not unacceptable to patients. However, in the context of the 24,000 patients cannulated each year by LAS paramedics, “costs” to the patient are considerable.
Traumatic Brain Injuries Evaluated in U.S. Emergency Departments, 1992‐1994
Authors: Jager Thomas E. , Weiss Harold B. , Coben Jeffrey H. , Pepe Paul E.
Published: January 2008

Abstract. Objective: To describe the incidence and patient characteristics of traumatic brain injuries (TBIs) treated in U.S. emergency departments (EDs). Methods: A secondary analysis was performed on data from the National Hospital Ambulatory Medical Care Survey administered from 1992 to 1994. An ED visit was determined to represent a case of TBI if the case record contained ICD‐9‐CM codes of 800.0‐801.9, 803.0‐804.9, or 850.0‐854.1. Results: The average annual estimate of new TBI treated in U.S. EDs was 1,144,807, equaling 444 per 100,000 persons (95% CI = 390 to 498), which represents approximately 3,136 new cases of TBI per day and accounts for 1.3% of all ED visits. Males were 1.6 times as likely as females to suffer TBI until the age of 65 years, when the female rate exceeded the male. The rate for blacks was 35% higher than that for whites. The highest overall incidence rate of TBI occurred in the less‐than‐5‐year age group (1,091 per 100,000), closely followed by the more‐than‐85‐year age group (1,026 per 100,000). Falls represented the most common mechanism of TBI injury, followed by motor vehicle‐related trauma. Conclusions: This study underscores the ongoing need for effective surveillance of all types of TBI and evaluation of prevention strategies targeting high‐risk individuals. It serves as a clinically grounded and ED‐based corroboration of prior survey research, providing a basis for comparison of incidence rates over time and a tool with which to measure the efficacy of future interventions.
Evaluation of the Physician's Ability to Recognize the Presence or Absence of Anemia, Fever, and Jaundice
Authors: Hung Oliver L. , Kwon Nancy S. , Cole Alexandra E. , Dacpano Geraldine R. , Wu Tina , Chiang William K. , Goldfrank Lewis R.
Published: January 2008

Abstract. Objective: The evaluation of the patient through a comprehensive history and physical examination is considered the cornerstone of medical diagnosis, but many studies suggest that physicians have inadequate physical examination skills. It is unknown whether these skills are reliable and whether they can be adequately acquired through training. The objective of this study was to evaluate the ability of the clinician to detect the presence and discriminate the extent of clinical anemia, fever, and jaundice in an ED or hospitalized patient. Methods: This was a prospective observational study of a convenience sample of patients presenting to the ED or admitted to the hospital who had a rectal temperature measurement within 30 minutes prior to the observation, serum hematocrit measurement on the day of observation, or serum bilirubin measurement one day prior to the day of observation. Observers' (emergency medicine attending physicians', resident physicians', and rotating medical students') estimated serum hematocrit, rectal temperature, and serum bilirubin values were obtained after each observation. Sensitivity, specificity, positive predictive value, negative predictive value, and mean absolute difference between actual and estimated values were calculated for each observer. Results: The physicians detected the presence or absence of anemia, fever, and jaundice in patients with sensitivities and specificities of approximately 70%. Their predictions varied from the measured value on average by 6.0 ± 4.6% for serum hematocrit, 1.3 + 1.1°F for rectal temperature, and 3.4 ± 5.3 mg/dL for serum bilirubin. Observer accuracy decreased when evaluating patients with high and low measured values. Conclusions: The ability to correctly perform and interpret the physical examination appears to be independent of the observer level of training, patient ethnicity, or patient gender. The examination for pallor, warmth, and jaundice is unreliable in predicting the corresponding laboratory or electronic measurement. Certain anemic, febrile, or jaundiced patients may not be reliably detected solely by a focused physical examination.
The Focused Abdominal Sonography for Trauma (FAST) Examination: Considerations and Recommendations for Training Physicians in the Use of a New Clinical Tool
Authors: Salen Philip N. , Melanson Scott W. , Heller Michael B.
Published: January 2008

Abstract. Focused abdominal sonography for trauma (FAST) is being used by growing numbers of emergency physicians and surgeons because it has proven to be an accurate, rapid, and repeatable bedside test for evaluating abdominal trauma victims. Controversy exists about the optimal means of FAST education and the number of examinations necessary to demonstrate competency. Most FAST educators agree that FAST education should consist of three phases: didactic, practical, and experiential. This article summarizes options and preliminary recommendations suitable for developing a FAST curriculum.
Do Emergency Medical Services Dispatch Nature and Severity Codes Agree with Paramedic Field Findings?
Authors: Neely Keith W. , Eldurkar Jayant A. , Drake Markely E. R.
Published: January 2008

Abstract. Emergency medical services (EMS) systems increasingly seek to triage patients to alternative EMS resources. Emergency medical services dispatchers may be asked to perform this triage. New protocols may be necessary. Alternatively, existing protocols may be sufficient for this task. For an existing dispatch protocol to be sufficient, it at least must accurately categorize patient condition and severity based on an external standard. Objective: To examine the extent to which nature codes (NCs), or patient condition codes, and severity codes (SCs) currently assigned in one urban 911 center agree with paramedic field findings. The null hypothesis was that there is no routine agreement (75%) between dispatcher‐assigned NC or SC and paramedic‐assigned NC or SC for the same patient using the same protocol. Methods: Emergency medical services dispatch nature and severity code data and matching out‐of‐hospital data were prospectively gathered over six months. Dispatch data included the NC: caller‐identified problem, and the SC: dispatcher‐assessed severity. Each NC is modified by one of three SCs (1, 3, or 9): 1 is emergent, 3 is urgent, and 9 is neither. Paramedics verified and/or corrected dispatcher‐assigned NCs and SCs using the same dispatch protocol. Results: One thousand forty usable cases fell into 33 unique NC/SC combinations. The designation of SC 1 was assigned 275 times, SC 3 was assigned 736 times, and SC 9 was assigned 24 times. The SC was missing five times. The overall NC agreement was 0.70 (95% CI = 0.697 to 0.703). The overall SC agreement was 0.65 (95% CI = 0.645 to 0.655). The NC agreement exceeded 75% for ten (59%) NC/SC combinations. The SC agreement exceeded 75% for five (29%) NC/SC combinations. There was both NC and SC agreement for four (24%) combinations: urgent breathing problems, urgent diabetic problems, urgent falls, and urgent overdoses. The greatest NC/SC disagreement occurred within emergent and urgent traffic crashes. Paramedics adjusted SC toward lower severity 29% of the time and toward higher severity 5.4% of the time. There was no upward SC adjustment for eight (47%) combinations. Conclusions: Certain dispatcher‐assigned NC and SC codes and NC/SC combinations achieved the study threshold. Overall agreement failed to achieve the threshold. The lowest SC level was rarely assigned, preventing a meaningful analysis of all severity levels.
Domestic Violence and Out‐of‐hospital ProvidersA Potential Resource to Protect Battered Women
Authors: Husni M. Elaine , Linden Judith A. , Tibbles Carrie
Published: January 2008

Objective: The primary objective was to determine the prevalence of domestic violence (DV) in a subset of women presenting to the Boston emergency medical services (EMS) system and to evaluate documentation. A secondary objective was to determine the rate of refusal of transport to the hospital for DV‐positive patients, compared with the general population. Methods: A retrospective chart review of ambulance run sheets from a nonconsecutive, convenience sample between July and December 1995 was performed. Women presenting with injury, obstetric/gynecologic complaints, or psychiatric complaints were included. Records were reviewed, and labeled as positive, probable, suggestive, or negative for DV, based on a previously used classification system. A weighted kappa test was performed, and data were analyzed using chi‐square and t‐test. Results: Among 1,251 charts reviewed, 876 met criteria for inclusion. The percentage of positive cases was 5.4% (95% CI = 3.9% to 6.9%), probable 10.8% (8.8% to 12.9%), suggestive 2.6% (1.6% to 3.7%), and negative 81.2% (78.6% to 83.6%). Among DV‐positive patients, the refusal to transport rate was 23.4% (11.3% to 35.5%), compared with a 7.1% (5.8% to 9.3%) rate for the entire study population (n= 876), and 4.7% for the general Boston EMS population during the same year. More DV patients presented during the night shift compared with other shifts. Conclusions: Domestic violence is common in this high‐risk population. A substantial proportion of women in this population refuse transport to the hospital. Out‐of‐hospital personnel should be trained with the tools to identify and document DV, assess patient safety, offer timely resources, and empower victims to make choices.
Return to the Emergency Department among Elders: Patterns And Predictors
Authors: McCusker Jane , Cardin Sylvie , Bellavance Franc¸ois , Belzile Éric
Published: January 2008

Objectives: 1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits. Methods: Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three‐month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self‐report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database. Results: Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use. Conclusions: In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self‐report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.
Development of a Histomorphologic Scale to Quantify Cutaneous Scars after Burns
Authors: Singer Adam J. , Thode Henry C. , McClain Steve A.
Published: January 2008

Abstract. Objective: Cutaneous wound healing in adults invariably results in scarring; however, there are few scales to quantify the degree of such scarring. The authors developed a histomorphologic scale for quantifying scarring after cutaneous burn injury. Methods: As part of a randomized trial comparing a variety of burn therapies, 40 partial‐thickness burns were created on the backs and flanks of anesthetized pigs and treated with a tissue adhesive, antibiotic ointment, occlusive dressing, or dry gauze. Gross scar appearance was independently assessed by two investigators at 90 days on a 100‐mm visual analog scale (VAS) marked “best appearance” at the high end. One of the investigators repeated the observation 30 days later. Full‐thickness biopsies were taken 90 days after injury and evaluated histologically by a dermatopathologist for the presence of hyperkeratosis, epidermal hyperplasia, presence and depth of scar (defined as abnormally oriented collagen under polarized light), fibroplasia, vascular proliferation, and absence of adnexa, including hair follicles, apocrine glands, and smooth muscles. One point was assigned for each category in the presence of a normal finding, whereas an abnormal finding was assigned a score of zero. The normal dermis (absence of abnormal collagen) was given a score of 3, while decreasing scores of 2 to 0 were given for progressively deeper scars (i.e., 2 for papillary dermis, 1 for upper half of reticular dermis, and 0 for deep dermal lower half). The total histomorphologic score was derived by adding the scores on the individual items. The score ranges from 0 to 10 from worst scarring to absence of scarring, respectively. A subset of observations was evaluated a second time by one of the observers one month later. Intraobserver reliability of the histomorphologic scale was assessed with Spearman's correlation. Inter‐ and intraobserver Pearson's correlations for the gross scar VAS were calculated, and the correlation between gross and histomorphologic scores was assessed. Results: Intraobserver correlation for individual histomorphologic categories ranged from 0.19 to 1.00. Intraobserver correlation for the total histologic score was 0.95. Inter‐ and intraobserver correlations for the gross scar VAS were 0.8 each. Correlation between the histomorphologic scale and the gross scar VAS was 0.38. Conclusions: A new reliable histomorphologic method for quantifying and scoring cutaneous scars is described together with a reliable scar VAS. However, these two scales are not highly correlated.
The Efficacy of Nebulized Racemic Epinephrine in Children with Acute Asthma: A Randomized, Double‐blind Trial
Authors: Plint Amy C. , Osmond Martin H. , Klassen Terry P.
Published: January 2008

Abstract. Objectives: Recent work in bronchiolitis has demonstrated a significant clinical improvement in children treated with epinephrine over nebulized salbutamol. The objective of this study was to determine whether nebulized epinephrine, as compared with nebulized salbutamol, causes a greater clinical improvement in children with acute asthma. Methods: Children, aged 1 to 17 years, with acute asthma presenting to the emergency department (ED) were eligible. In this double‐blind study, patients were randomly allocated to receive either salbutamol or racemic epinephrine by nebulization at 0, 20, and 40 minutes. All patients received oral steroids. The primary outcome measure was a change in pulmonary index score (PIS). Results: One hundred twenty patients were randomized. The groups were comparable in terms of age, gender, asthma severity, previous treatments, and use of inhaled steroids. There was no significant difference between treatments in the change in PIS, length of stay, admission to hospital, or relapse rate. The epinephrine‐treated group had significantly more minor side effects (such as excess or brownish nasal discharge). Conclusions: There is no significant clinical benefit of nebulized epinephrine over salbutamol in children 1‐17 years old with mild to moderate acute asthma. Salbutamol remains the treatment of choice in children with known asthma.
Standardized Burn Model Using a Multiparametric Histologic Analysis of Burn Depth
Authors: Singer Adam J. , Berruti Luis , Thode Henry C. , McClain Steve A.
Published: January 2008

Abstract: Objective: Burn depth and extent determine prognosis and therapy. The current classification into first‐, second‐, and third‐degree burns is crude, making comparisons between studies difficult. The authors standardized a reproducible burn model and a precise histopathologic method for describing burn depth in swine. Methods: This was a prospective, cross‐sectional interventional animal study. Eighteen paired sets of burns were inflicted on the clipped flank skin of two anesthetized domestic pigs with a 2.5 cm by 2.5 cm by 7.5 cm aluminum bar preheated in water to 50°C, 60°C, 70°C, 80°C, 90°C, or 100°C. The bar was applied for 10, 20, or 30 seconds. Full‐thickness skin biopsies were obtained 30 minutes after injury for blinded histopathologic evaluation using hematoxylin and eosin staining. Two dermatopathologists made two sets of measurements and were masked to each other's evaluations. The depth of injury was measured with an ocular microtome for each of five dermal parameters: collagen discoloration, intercollagen basophilic material, endothelial cell necrosis, epithelial cell necrosis, and mesenchymal cell necrosis. The correlation between burn depths of the paired sets of experiments was calculated to assess the reliability of the model. Inter‐ and intraobserver correlations were calculated to assess the reliability of the scale. Analysis of variance (ANOVA) was used to assess the relation between temperature and exposure times on burn depth. Results: Depth of injury for all five dermal elements was related to temperature and exposure times (ANOVA, p < 0.001 for each). The depth of injury in the paired sets of burns was highly consistent (Pearson correlation, range = 0.88‐0.95). Inter‐ and intraobserver correlations were excellent for all measured elements (range = 0.91‐0.97 and 0.95‐0.99, respectively). Conclusions: The authors describe a simple and reproducible animal burn model and histopathologic scale for measuring burn depth that they believe will facilitate standardization and comparison within future burn studies.
Alcoholism in the Emergency Department: An Epidemiologic Study
Authors: Whiteman Paula J. , Hoffman Robert S. , Goldfrank Lewis R.
Published: January 2008

Abstract: Objective: To describe the epidemiology of alcoholism in ED patients. Methods: Over a two‐month period, every adult patient brought by ambulance to the ED of a large municipal hospital was prospectively enrolled by questionnaire. Data collected included demographics, previous ED use, triage complaint‐related diagnoses, hospital admission rates, and ethanol levels (if determined). The CAGE alcoholism questions were administered to all patients by trained assistants. The only exclusion criterion was the inability to communicate while in the ED. A chisquare analysis was used to compare categorical variables. Results: A total of 2,658 patients were enrolled in the study; 226 were unable to respond to the CAGE questions. Five hundred eighty‐eight of the remaining 2,432 patients (24%) were defined as being alcoholic by an affirmative response to at least two of the CAGE questions. All four questions were answered affirmatively by 17% of the total patients. Alcoholic patients were more likely to be male (88% vs 60%), unemployed (87% vs 71%), undomiciled (46% vs 20%), polysubstance users (52% vs 25%), and tobacco users (77% vs 41%), and to have had an ED visit in the previous six months (51% vs 35%) (p < 0.001 for all tests). Ethanol levels ranged from zero to 573 mg/dL. Whereas no positive response to a single CAGE question was predictive of a final diagnosis of alcoholism, a blood ethanol level more than 300 mg/dL predicted an affirmative response to at least two CAGE questions in 97% of cases. Conclusions: Alcoholism should be presumed to be present in a substantial number of patients who present to urban EDs by ambulance.
Setting‐based Practice Variation in the Management of Simple Febrile Seizure
Authors: Hampers Louis C. , Trainor Jennifer L. , Listernick Robert , Eddy Jennifer J. , Thompson David A. , Sloan Edward P. , Chrisler Oliver P. , Gatewood Leonora M. , McNulty Bruce , Krug Steven E.
Published: January 2008

Abstract: Objective: To identify provider‐based differences in the ED assessment and management of children presenting with uncomplicated, first‐time febrile seizures. Methods: Multicenter, retrospective cohort study of seven EDs in the Chicago area: two tertiary academic pediatric EDs (PEDs) and five community‐based general EDs (GEDs). The visits of all patients with a discharge diagnosis including the term “seizure” were identified from a 30‐month period. Records of patients who met criteria for simple, first‐time febrile seizure were reviewed (age 6‐60 months; temperature ≥38.0°C; single, generalized, tonic‐clonic seizure <20 minutes; “alert” or “arousable” on presentation; absence of known neurologic disease). Results: Four hundred fifty‐five records were included: 330 and 125 patients presenting to GEDs and PEDs, respectively. The two groups did not differ in mean age, vital signs, reported duration of seizure, or prior antibiotic use. Lumbar puncture (LP) was performed more often in the GED group (33% vs 22%). No patients were found to have bacterial meningitis. The patients in the GED group were more likely to receive parenteral antibiotics in the ED (56% vs 22%) and to be admitted or transferred (18% vs 4%). In a logistic regression model incorporating age, temperature, seizure duration, seizure in the ED, prior antibiotic use, primary care, and insurance status, the GED patients remained more likely to have an LP (OR 1.5), receive parenteral antibiotics (OR 2.5), and be admitted or transferred (OR 2.5). Conclusions: There were significant setting‐based differences in the evaluation and management of children with simple febrile seizures presenting to GEDs and PEDs.
Clinical Characteristics as Predictors of Recurrent Alcohol‐related Seizures
Authors: Rathlev Niels K. , Ulrich Andrew , Fish Susan S. , D'Onofrio Gail
Published: January 2008

Abstract. Objective: To determine whether clinical data available in the emergency department can accurately predict a subset of patients at low risk of developing recurrent seizures following one or more initial alcohol‐related seizures in the out‐of‐hospital arena. Methods: This was a retrospective secondary analysis of data obtained from the placebo arms of two prospective, randomized trials of drug treatments for the prevention of recurrent alcohol‐related seizures. Subjects with and without one or more recurrent alcohol‐related seizures during the study period were compared according to the following characteristics: 1) age, 2) gender, 3) daily ethanol consumption, 4) years of ethanol abuse, 5) previous alcohol‐related seizure, 6) previous seizure of other etiology, 7) temperature, 8) heart rate, 9) systolic blood pressure, 10) diastolic blood pressure, 11) respiratory rate, and 12) ethanol level. Data were analyzed with t‐tests and chi‐square where appropriate. Results: One hundred five placebo‐treated patients were analyzed and 31 (30%) developed recurrent alcohol‐related seizures. None of the listed characteristics were statistically different between the two groups except for the initial ethanol level. Subjects with an ethanol level higher than 100 mg/dL were less likely (0%) to develop recurrent seizures than patients with a level equal to or below 100 mg/dL (36%) (p < 0.01). Conclusions: An initial ethanol level higher than 100 mg/dL was significantly associated with a low risk for recurrent alcohol‐related seizures during the observation period. No other low‐risk clinical characteristics could be identified.
A Descriptive Analysis of 290 Liver Transplant Patient Visits to an Emergency Department
Authors: Savitsky Eric A. , Votey Scott R. , Mebust Donald P. , Schwartz Evan , Uner Atilla B. , McCain Skeet
Published: January 2008

Abstract. Objective: To provide a descriptive analysis of emergency department (ED) presentations and management of orthotopic liver transplant (OLT) patients. Methods: A retrospective chart review was performed of OLT patients presenting to the University of California at Los Angeles (UCLA) ED during 1995. The sole inclusion criterion was receiving an OLT within three years prior to the ED visit. Data describing chief complaint(s), history of present illness, physical findings, laboratory results, imaging studies, and final diagnoses were collected. Results: One hundred forty‐three patients accounted for a total of 290 ED visits. The patients had a mean age of 37 years (range 3 months to 74 years) and presented at mean post‐OLT duration of 9 months (range 2 weeks to 34 months). There were 660 presenting complaints, of which abdominal (39%), fever (17%), respiratory (13%), and neurologic (11%) symptoms were the most common. There were 478 final diagnoses, of which abdominal (27%), infectious (24%), and metabolic (11%) disorders were the most common. Eightyfour percent of ED visits resulted in extensive diagnostic testing and 69% resulted in hospitalization. Conclusions: Serious illnesses with nonspecific presentations were frequently encountered in this study population. These factors resulted in a majority of the patients' undergoing extensive diagnostic evaluations and being hospitalized.
Bedside Emergency Department Ultrasonography in the Evaluation of Ocular Pathology
Authors: Blaivas Michael
Published: January 2008

Abstract. The number of potential uses of emergency department (ED) ultrasound is growing. This brief report describes its use in two ED patients who presented with acute ocular pathology. The diagnoses were quickly made with ED ultrasound, and subsequently confirmed with more traditional methods of ocular evaluation.
Ultrasound Training for Emergency Physicians— A Prospective Study
Authors: Mandavia Diku P. , Aragona Jodi , Chan Linda , Chan Dennis , Henderson Sean O.
Published: January 2008

Abstract. Objectives: Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16‐hour introductory ultrasound course. Methods: In phase I of the study, a condensed 16‐hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo‐cardiography. In addition, each student received eight hours of hands‐on ultrasound instruction over the two‐day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate‐year‐2 (PGY2) houseofficers over a ten‐month period were examined and the standardized test was readministered. Results: In phase I, a total of 80 health professionals underwent standardized training and testing. The mean ± SD pretest score was 15.6 ± 4.2, 95% CI = 14.7 to 16.5 (65% of a maximum score of 24), and the mean ± SD posttest score was 20.2 ± 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0.05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow‐up ultrasound written test showed continued good performance (20.7 ± 1.2, 95% CI = 20.0 to 21.4). Conclusions: Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16‐hour course serves as a good introductory foundation.
Faculty Evaluation by Residents in an Emergency Medicine Program: A New Evaluation Instrument
Authors: Steiner Ivan P. , Franc‐Law Jeffrey , Kelly Karen D. , Rowe Brian H.
Published: January 2008

Abstract. Objective: Evaluation of preceptors in training programs is essential; however, little research has been performed in the setting of the emergency department (ED). The goal of this pilot study was to determine the validity and reliability of a faculty evaluation instrument—the Emergency Rotation (ER) scale—developed specifically for use in emergency medicine (EM). Methods: A prospective study comparing the ER scale with two alternative faculty evaluation instruments was completed in three of the five EDs affiliated with an EM teaching program, where emergency physicians are members of the clinical teaching faculty. The participants were 18 residents (postgraduate years 1, 2, and 3) who were completing four‐week clinical rotations in EM. Residents at the end of the rotation recorded their evaluations of each emergency physician with whom they had clinical encounters on the following evaluation tools: the ER scale, a longer validated scale (Irby), and a global assessment scale (GAS). Domain scores were correlated with the previously validated scale and the GAS to determine validity using a multitrait‐multimethod matrix. The reliability of the ER scale was measured using a Chronbach's alpha coefficient. Results: Forty‐eight preceptor evaluations were completed on 29 individual preceptors. The rating of preceptors was high using the ER scale (median: 16 of 20; IQR: 13, 18), Irby (median: 300 of 378; IQR: 267, 321), or GAS (mean: 7.8 of 10; SD: 1.3). Domain scores for each tool were used in the multitrait‐multimethod matrix and the correlations between a previously validated tool and the ER scale were found to be high (>0.70) in the various domains. The internal consistency of the ER scale was also high (r = 0.85). Conclusions: The ER scale appears to be valid and reliable. It performs well when compared with previously psychometrically tested tools. It is a sensible, well‐adapted tool for the teaching environment offered by EM.
Proposed Curriculum for an “Observational” International Emergency Medicine Fellowship Program
Authors: Holliman C. James , Green Gary B. , VanRooyen Michael J. , Clem Kathleen , Smith Jeffrey P. , Ankel Felix K. , Hirshon Jon Mark , Thomas Tamara , Perez Norvin , Davis Mark , Wolf Leslie R.
Published: January 2008

Abstract. This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs’ content would be “observational” rather than involving direct “hands‐on” clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.
Diagnostic Evaluation of Patients with Blunt Abdominal Trauma: A Decision Analysis
Authors: Brown Charles K. , Dunn Kathleen A. , Wilson Kenneth
Published: January 2008

Abstract. Objectives: Using decision analysis, to compare the expected utility (EU) of diagnostic peritoneal lavage (DPL), computed tomography (CT), and ultrasonography (US) to determine the optimal modality for the evaluation of blunt abdominal trauma (BAT) in hemodynamically stable adults. Methods: Data points for the decision analysis were obtained from three sources: 1) prevalence of BAT and the sensitivity and specificity of each diagnostic modality were determined through a criteria‐based review of the literature; 2) rate of BAT necessitating immediate intervention, perioperative complication rate, and operative mortality rate were calculated using data from the authors’ institution's trauma registry; and 3) outcome utilities were determined by telephone survey of adults in a random sample of households in the region. The decision tree was constructed and evaluated in standard fashion. For each diagnostic modality, the authors calculated the EU using the minimum, mean, and maximum sensitivity and specificity across a range of prevalence. Mean outcome utilities were used for each branch of the tree when calculating the EU. Results: The EU of CT was consistently lower than the EUs of DPL and US at all levels of prevalence. However, the rank order of the EUs of US and DPL varied with the prevalence of BAT. When the prevalence was <30%, the EU of US was higher than that for DPL. When the prevalence was 30‐40%, the EUs were similar. When the prevalence was >40%, the EU of US was less than that of DPL. Conclusions: Among institutions operating under constraints similar to those used in this model, the optimal diagnostic modality for the evaluation of BAT can be determined based on the sensitivity and specificity of the modality at their institution and the prevalence of BAT in their patient population.
Regulation of Liver and Kidney Glucose‐6‐phosphatase Gene Expression in Hemorrhage and Resuscitation
Authors: Maitra Subir R , Wang Shiying , El‐Maghrabi M Raafat , Henry Mark C
Published: January 2008

Abstract. The authors have recently demonstrated that increased gene expression of glucose‐6‐phosphatase (Glu‐6‐Pase) in hemorrhagic hypotension (HH) and following lactated Ringer's resuscitation (LR) is associated with a decrease in insulin and an increase in corticosterone concentrations. Objective: To evaluate the in‐vivo role of hormones the authors used insulin (IN), phentolamine and propranolol (PP) as an adrenergic blocker, and cyclic somatostatin (CS) as a glucagon blocker to prevent the induction of Glu‐6‐Pase gene expression in liver and kidney following HH and LR. Methods: Hemorrhage was induced in fasted anesthetized rats, and the reduction of blood pressure to 40 mm Hg for a duration of 30 minutes was accomplished by withdrawal or infusion of shed blood. The resuscitated group underwent hemorrhage followed by fluid resuscitation with lactated Ringer's solution. Results: Neither PP nor CS treatment could block the induction of Glu‐6‐Pase messenger ribonucleic acid (mRNA) following either HH or LR. However, the administration of IN significantly prevented the increase of Glu‐6‐Pase mRNA level and activity in both liver and kidney following HH and LR. This was associated with a normalization of plasma glucose, corticosterone, and glucagon levels and glucose‐6‐phosphate concentrations in liver and kidney toward prehemorrhage levels. Conclusions: These results indicate that in‐vivo treatment with insulin during hemorrhagic hypotension and resuscitation is capable of preventing the increase in Glu‐6‐Pase gene expression in liver and kidney responsible for the observed hyperglycemia.
Wide‐complex Tachycardia: Continued Evaluation of Diagnostic Criteria
Authors: Isenhour Jennifer L , Craig Sandra , Gibbs Michael , Littmann Laszlo , Rose Geoffrey , Risch Robert
Published: January 2008

Abstract. Objective: To evaluate the accuracy of the Brugada algorithm for analysis of wide‐complex tachycardia (WCT) when applied by board‐certified emergency physicians and board‐certified cardiologists. Methods: A database consisting of 157 electrocardiograms of WCTs were evaluated in a blinded fashion using the Brugada criteria to determine the presence of ventricular tachycardia (VT) or supraventricular tachycardia with aberrancy. These results were then compared with the electrophysiologically proven diagnosis for each tracing. Sensitivity and specificity of the Brugada criteria for diagnosis of VT were calculated. Two board‐certified emergency physicians and two board‐certified cardiologists analyzed each tracing, and interobserver agreement was determined using the kappa statistic. Results: Sensitivity and specificity for the determination of VT using the Brugada algorithm were 85% [95% confidence interval (95% CI) = 79% to 91%] and 60% (95% CI = 43% to 78%) for cardiologist 1 (C 1) and 91% (95% CI = 86% to 96%) and 55% (95% CI = 37% to 72%) for C 2. Emergency physician (EP 1) achieved a sensitivity of 83% (95% CI = 78% to 91%) and a specificity of 43% (95% CI = 25% to 59%), while EP 2 attained 79% (95% CI = 73% to 87%) and 70% (95% CI = 51% to 84%), respectively. The original authors achieved a sensitivity of 98.7% and specificity of 96.5% when determining VT in their study population. Interobserver agreement for the emergency physicians and the cardiologists in determining VT was 82% and 81%, respectively. Conclusions: Neither the emergency physicians nor the cardiologists were able to achieve a sensitivity or specificity as high as that reported by the original investigators when using the Brugada algorithm to determine the presence of VT.