bluuebunny/crossref_metadata_2025 huggingface dataset:
First Report of Anther Smut Caused by Microbotryum violaceum on Forked Catchfly (Silene dichotoma) in Turkey
Authors: Berner D. , Tunali B.
Published: January 2008

Forked catchfly (Silene dichotoma Ehrh.), family Caryophyllaceae, is a common and native plant in rangelands and pastures in Turkey. It is also an introduced plant that is widely distributed in North America. In May of 2007, approximately 20 forked catchfly plants on the campus of Ondokuz Mayis University in Samsun, Turkey were found diseased with the anther smut fungus Microbotryum violaceum (Pers.:pers.) G. Deml & Oberw. (Basidiomycota, Microbotryomycetes, Microbotryales [3], Microbotryaceae). All anthers in all flowers of diseased plants were smutted. Diseased flowers were collected, air dried, and sent to the quarantine facility of the Foreign Disease-Weed Science Research Unit (FDWSRU), USDA/ARS, Fort Detrick, MD. Teliospores within the flowers were extracted and observed microscopically. Teliospores were globose, 6 to 9 μm (mean 6.5 μm) in diameter, pale violet, with reticulate walls, and matching the description of M. violaceum (4). Nucleotide sequences for the internal transcribed spacers (ITS 1 and 2) and 5.8S ribosomal region (GenBank Accession No. EU122308) were aligned with other sequences in GenBank with the BLAST algorithm. Sequences of this isolate aligned 99% with sequences of other isolates of M. violaceum, M. lychnidis-dioicae (A.P. de Candolle ex J.I. Liro) G. Deml & F. Oberwinkler, and M. silenes-inflatae (A.P. de Candolle ex J.I. Liro) G. Deml & F. Oberwinkler and clustered with other M. violaceum isolates. M. violaceum is an obligate parasite of many plant species in the Caryophyllaceae family, and the fungus has been widely studied as a model for population genetics and evolutionary biology (2). To our knowledge, this is the first report of M. violaceum parasitizing forked catchfly in Turkey, and is the only report of this fungus-plant interaction in Asia Minor (1). The fungus has not been reported from this plant in North America (1). A voucher specimen has been deposited with the U.S. National Fungus Collections (BPI 878235) and living spores are being maintained at FDWSRU.

References: (1) D. F. Farr et al. Fungal Databases. Systematic Botany and Mycology Laboratory. Online publication. ARS, USDA, 2007. (2) T. Giraud. Heredity 93:559, 2004. (3) D. S. Hibbett et al. Mycol. Res. 111:509, 2007. (4) K. Vánky. European Smut Fungi. Gustav Fischer Verlag, Stuttgart, Germany, 1994.
Maternal cardiac function and uterine artery Doppler at 11–14 weeks in the prediction of pre‐eclampsia in nulliparous women
Authors: Khaw A , Kametas NA , Turan OM , Bamfo JEAK , Nicolaides KH
Published: January 2008

Objective  To assess maternal cardiac function in nulliparous women in the first trimester of pregnancy and evaluate its potential role for predicting pre‐eclampsia and small for gestational age (SGA).

Design  Prospective, observational, cross‐sectional study.

Setting  Maternity unit of a teaching hospital.

Population  Nulliparous women with singleton pregnancies presenting consecutively for routine antenatal care (n= 534).

Methods  Two‐dimensional and M‐mode echocardiography and uterine artery Dopplers were carried out at 11‐14 weeks.

Main outcome measures  Cardiac output (CO), stroke volume (SV), mean arterial pressure (MAP), total vascular resistance and uterine artery pulsatility index (UAPI) were compared in four outcome groups according to the development of pre‐eclampsia and/or SGA.

Results  Compared with the normal outcome group (n= 457), in those with pre‐eclampsia but not SGA (n = 8), CO and MAP were increased; in the group with pre‐eclampsia and SGA (n= 19) MAP, TRP and UAPI were increased and in the group with SGA but no pre‐eclampsia (n= 50) total peripheral resistance and UAPI were increased. Independent predictors of pre‐eclampsia were MAP, SV and UAPI and of SGA SV and UAPI.

Conclusions  Alterations in maternal cardiac function and UAPI are observed in the first trimester of pregnancy in nulliparous women that subsequently develop pre‐eclampsia and/or SGA.
Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort
Authors: Laursen M , Hedegaard M , Johansen C
Published: January 2008

Objectives  To describe the association between fear of childbirth and social, demographic and psychological factors in a cohort of 30 480 healthy nulliparous women with uncomplicated singleton pregnancies.

Design  Nationwide population‐based study.

Setting  The Danish National Birth Cohort.

Population  Healthy nulliparous women (n= 30 480) with singleton pregnancies.

Methods  Data from computer‐assisted telephone interviews twice in pregnancy linked with national health registers.

Main outcome measures  Characteristics of women with fear of childbirth in early (mean, 16 weeks) and late pregnancy (mean, 32 weeks) and changes in fear of childbirth between 1997 and 2003.

Results  Low educational level, lack of a social network, young age and unemployment were associated with fear of childbirth, as were being a smoker and having low self‐rated health. The odds ratio for fear of childbirth among women with anxiety symptoms was 4.8 (4.1–5.7) after adjustment for socio‐demographic, lifestyle, fertility and depression variables. During the study period, the prevalence of fear of childbirth was stable. Fear of childbirth was reported by 7.6% in early pregnancy and 7.4% in late pregnancy. Only 3.2% of the women expressed fear of childbirth in both interviews.

Conclusions  The prevalence of fear of childbirth among healthy nulliparous women with singleton pregnancies did not increase during the study period. Fear of childbirth among nulliparous women was most often seen in individuals with few social and psychological resources. Testing the women twice, we found the same prevalence of fear in early and late pregnancy, but found that half the women who expressed fear during early pregnancy had no fear later in pregnancy, an effect that was counterbalanced by a similar number of women who became fearful between the two interviews.
Statistical Methodology
Authors: Bryant Fred B. , Yarnold Paul R. , Michelson Edward A.
Published: January 2008

How many underlying characteristics (or factors) does a set of survey questions measure? When subjects answer a set of self‐report questions, is it more appropriate to analyze the questions individually, to pool responses to all of the questions to form one global score, or to combine subsets of related questions to define multiple underlying factors? Factor analysis is the statistical method of choice for answering such questions. When researchers have no idea beforehand about what factors may underlie a set of questions, they use exploratory factor analysis to infer the best explanatory model from observed data “after the fact.” If, on the other hand, researchers have a hypothesis beforehand about the underlying factors, then they can use confirmatory factor analysis (CFA) to evaluate how well this model explains the observed data and to compare the model's goodness‐of‐fit with that of other competing models. This article describes the basic rules and building blocks of CFA: what it is, how it works, and how researchers can use it. The authors begin by placing CFA in the context of a common research application—namely, assessing quality of medical outcome using a patient satisfaction survey. They then explain, within this research context, how CFA is used to evaluate the explanatory power of a factor model and to decide which model or models best represent the data. The information that must be specified in the analysis to estimate a CFA model is highlighted, and the statistical assumptions and limitations of this analysis are noted. Analyzing the responses of 1,614 emergency medical patients to a commonly‐used “patient satisfaction” questionnaire, the authors demonstrate how to: 1) compare competing factor‐models to find the best‐fitting model; 2) modify models to improve their goodness‐of‐fit; 3) test hypotheses about relationships among the underlying factors; 4) examine mean differences in “factor scores”; and 5) refine an existing instrument into a more streamlined form that has fewer questions and better conceptual and statistical precision than the original instrument. Finally, the role of CFA in developing new instruments is discussed.
Comparison of the Toxicities of Two Iron Formulations in a Swine Model
Authors: Nordt Sean Patrick , Williams Saralyn R. , Behling Cynthia , Richter Phillip , Manoguerra Anthony S. , Clark Richard F.
Published: January 2008

Objective: To describe the histopathologic and pharmacokinetic differences of acute iron poisoning between chewable multivitamins with iron and solid iron tablets in a swine model. Methods: This was a prospective, randomized, unblinded toxicity study of iron poisoning of two iron formulations in male Yorkshire pigs. Eight swine were randomized to receive 60 mg/kg of iron in either solid iron tablets or chewable multivitamins with iron. Serum iron, arterial blood gases, and episodes of vomiting were recorded over a ten‐hour period. Routine histologic evaluations of the esophagus, stomach, small intestine, large intestine, and liver were performed immediately after the study period. Pharmacokinetic analyses of area under the concentration‐time curve (AUC), time to peak concentration, and peak serum iron concentration were performed. Results: There was no significant difference between the serum iron levels except at three and four hours. There was a significant higher AUC in the chewable group compared with the solid group. Pathologic evaluation identified severe esophageal inflammation and focal erosion in the solid iron tablet group in two of the four animals, compared with no focal erosions and minimal esophageal inflammation in the chewable group. No significant change was identified in the liver, small intestine, or large intestine in either group. Conclusions: These results demonstrate increased local gastrointestinal toxicity following a large ingestion of solid iron tablets in a swine model, compared with chewable multivitamins with iron. Higher serum iron levels were identified in the animals that received chewable multivitamins with iron.
A Prospective Evaluation of the Electrocardiographic Manifestations of Hypothermia
Authors: Vassallo Susi U. , Delaney Kathleen A. , Hoffman Robert S. , Slater William , Goldfrank Lewis R.
Published: January 2008

Objective: To determine the effects of body temperature, ethanol use, electrolyte status, and acid‐base status on the electrocardiograms (ECGs) of hypothermic patients. Methods: Prospective, two‐year, observational study of patients presenting to an urban ED with temperature ≤95°F (≤35°C). All patients had at least one ECG obtained. Electrocardiograms were interpreted by a cardiologist blinded to the patient's temperature. J‐point elevations known as Osborn waves were defined as present if they were at least 1 mm in height in two consecutive complexes. Results: 100 ECGs were obtained in 43 patients. Presenting temperatures ranged between 74°F and 95°F (23.3°C‐35°C). Initial rhythms included normal sinus (n = 34), atrial fibrillation (n = 8), and junctional (n = 1). Osborn waves were present in 37 of 43 initial ECGs. Of the six initial ECGs that did not have Osborn waves present, all were obtained in patients whose temperatures were ≥90°F (≥32.2°C). For the entire group, the Osborn wave was significantly larger as temperature decreased (p = 0.0001, r = ‐0.441). The correlation between temperature and size of the Osborn wave was strongest in six patients with four or more ECGs (range r = ‐0.644 to r = ‐0.956, p = 0.001). No correlation could be demonstrated between the height of the Osborn waves and the serum electrolytes, including sodium, chloride, potassium, bicarbonate, BUN, creatinine, glucose, anion gap, and blood ethanol levels. Conclusions: The presence and size of the Osborn waves in hypothermic patients appear to be a function of temperature. The magnitude of the Osborn waves is inversely correlated with the temperature.
Use of a Geographic Information System to Determine Appropriate Means of Trauma Patient Transport
Authors: Lerner E. Brooke , Billittier Anthony J. , Sikora Jeremy , Moscati Ronald M.
Published: January 2008

Objective: To determine whether a geographic information system (GIS) and historical transport data can be used to create a map that identifies locations (zones) from which either ambulance or helicopter transport will result in shorter out‐of‐hospital times. Methods: A retrospective, cross‐sectional review of a trauma registry was conducted in a two‐county region served by a single trauma center. Data were gathered for all patients transported directly to the trauma center between 1993 and 1996. Incident locations and times from first 911 contact until arrival at the trauma center (out‐of‐hospital time) were extracted. A GIS was used to create a reference map with all incident locations plotted and given z‐coordinates corresponding to out‐of‐hospital time. Two contour surfaces were interpolated: one for all helicopter transports and one for all ground transports. Areas where the helicopter surface was lower than the ambulance surface were designated air zones since helicopter transport resulted in shorter out‐of‐hospital times. The remaining area was designated a ground zone since ambulance transport resulted in shorter out‐of‐hospital times. The mean out‐of‐hospital times were calculated for each mode of transport in both zones and were compared using a two‐tailed t‐test. Results: An air zone was identified beginning between 5 and 16 miles from the trauma center. Mean (±SD) out‐of‐hospital time from the air zone was 50 ± 9 minutes for helicopter transport (n = 54) and 63 ± 14 minutes for ambulance transport (n = 140). The difference between the means was 13 minutes (p < 0.000001; 95% CI = 8.95 to 17.05). Mean out‐of‐hospital time from the ground zone was 68 ± 16 minutes for helicopter transport (n = 122) and 32 ± 14 minutes for ambulance transport (n = 2,047). The difference between the means was 36 minutes (p < 0.000001; 95% CI = 33.59 to 38.41). Conclusions: A GIS and historical transport data can be used to create a map identifying locations from which either helicopter or ambulance transport will minimize out‐of‐hospital time. Inappropriate choice of transport mode is associated with increased out‐of‐hospital time.
Fast Track and the Pediatric Emergency Department: Resource Utilization and Patient Outcomes
Authors: Hampers Louis C. , Cha Susie , Gutglass David J. , Binns Helen J. , Krug Steven E.
Published: January 2008

Objective: To examine differences in the evaluation, management, and outcomes for patients seen in an on‐site “fast track” (FT) vs the main ED. Methods: Over a three‐month period, patients presenting to an urban pediatric ED were prospectively assessed. Patients included were: triaged as “nonurgent”; aged 2 months to 10 years; not chronically ill; and had fever, or complaint of vomiting, diarrhea, or decreased oral intake. Evening and weekend care was provided in the FT; at all other times these low‐acuity patients were seen in the ED. Seven days after the visit, families were interviewed by telephone. Results: Four hundred seventy‐nine and 557 patients were seen in the FT and ED, respectively. The patients in the two settings did not differ in age, clinical condition, race, or commercial insurance status. Patient mean test charges were 27 and 52 for the FT and ED, respectively (p < 0.01). Twenty‐four percent of the FT patients vs 41% of the ED patients had tests performed (p < 0.01). Average length of stay was 28 minutes shorter in the FT (95% CI = 19 to 36, p < 0.01). Follow‐up was completed for 480 of 755 families with telephones (64%). The FT and ED patients did not differ at follow‐up: 90% vs 88% had improved conditions (p = 0.53), 18% vs 15% had received unscheduled follow‐up care (p = 0.44), and 94% of the families in both groups were satisfied with the visit (p = 0.98). Conclusions: Compared with those in the main ED, the study patients seen in the FT had fewer tests ordered and had briefer lengths of stay. These findings were not explained by differences in patient ages, vital signs, or demographic characteristics. No difference in final outcomes or satisfaction was detected among the families contacted for follow‐up.
Systematic Reviews A Logical Methodological Extension of Evidence‐based Medicine
Authors: Gallagher E. John
Published: January 2008

Academic Emergency Medicine is interested in publishing systematic reviews (also known as meta‐analyses) containing explicit, quantitative compilations of valid, critically appraised evidence targeted at topics relevant to the science and practice of emergency medicine. This article presents a strategy for the performance and reporting of systematic reviews, based on established recommendations. A well‐performed systematic review of the literature may provide clinically relevant information otherwise unobtainable, and has potential to alter patient care. Systematic reviews are logical methodological extensions of evidence‐based medicine.
1998‐1999 SAEM Emergency Medicine Faculty Salary and Benefits Survey
Authors: Kristal Steven L. , Randall‐Kristal Karen A. , Thompson Bruce M. , Marx John A.
Published: January 2008

Objectives: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefits survey for all 1998 residency review committee (RRC)‐EM‐accredited programs using the SAEM fourth‐generation survey instrument. Responses were collected by SAEM and blinded from the investigators. Methods: Blinded program and individual faculty data were entered into a customized version of FileMaker Pro, a relational database program with a built‐in statistical package. Salary data were sorted by program region, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to the American Association of Medical Colleges (AAMC). Demographic data were analyzed with regard to numerous criteria, including department staffing levels, ED volumes, ED length of stay, department income sources, salary incentive components, and specific type and value of fringe benefits offered. Data were compared with those from previous SAEM studies. Results: Seventy‐three of 120 (61%) accredited programs responded, yielding usable data for 70 programs and 965 full‐time faculty among the four AAMC regions. Mean salaries were reported as follows: all faculty, 167,478; first‐year faculty, 140,616; programs reporting data to the AAMC, 161,794; programs not reporting data to the AAMC, 165,724. Mean salaries as reported by AAMC region: northeast, 167,876; south, 160,586; midwest, 190,957; west, 148,977. Conclusions: Reported salaries for full‐time EM residency faculty continue to rise. Significant regional differences in salaries have been present in all four SAEM surveys. Nonclinical hours are compensated at approximately one‐half the rate paid for clinical hours. The demographic data indicate that EM residency faculty are working at the upper extremes of numbers of patient encounters per physician, patient acuity levels, and department lengths of stay.
A Randomized, Clinical Trial Comparing Butylcyanoacrylate with Octylcyanoacrylate in the Management of Selected Pediatric Facial Lacerations
Authors: Osmond Martin H. , Quinn James V. , Sutcliffe Teresa , Jarmuske Mario , Klassen Terry P.
Published: January 2008

Objective: To compare two tissue adhesives, butylcyanoacrylate and octylcyanoacrylate, in the treatment of small (<4 cm) superficial linear traumatic facial lacerations in children. Methods: This was a randomized, clinical trial with parallel design. 94 children <18 years of age seen in the ED of a tertiary care pediatric hospital with a facial laceration suitable for tissue adhesive closure underwent laceration closure using either butylcyanoacrylate or octylcyanoacrylate. The primary outcome was the cosmetic result at three months rated from photographs by a plastic surgeon on a visual analog scale (VAS). Secondary outcomes included the time to perform the procedure, the perceived difficulty of the procedure, the pain perceived by the patient, and a wound evaluation score at ten to 14 days and three months. Results: Ninety‐four patients were randomized with 47 in each group. The two groups were similar for baseline demographic and clinical characteristics. There was no difference in the three‐month cosmesis VAS (median, 70.0 mm for n‐butyl‐2‐cyanoacrylate vs 67.5 mm for octylcyanocrylate, p = 0.84). There was no difference between the groups for time to complete the procedure (p = 0.88), parent/patient‐perceived pain of the procedure (p = 0.37), or physician‐perceived difficulty of the procedure (p = 0.33). Similarly, there was no difference between the groups for the percentage of early (p = 0.58) or late (p = 0.71) optimal wound evaluation scores. Conclusions: In the closure of small linear pediatric facial lacerations, octylcyanoacrylate is similar to butylcyanoacrylate in ease of use and early and late cosmetic outcomes. The superior physical properties of octylcyanoacrylate appear to add little benefit to the management of these selected lacerations. Physician preference and differing costs may dictate use for these small selected lacerations.
Time Delays in Accessing Stroke Care in the Emergency Department
Authors: Morris Dexter L. , Rosamond Wayne D. , Hinn Albert R. , Gorton Rebecca A.
Published: January 2008

Objective: To delineate components of delay within the hospital ED for patients presenting with symptoms of stroke. Methods: A prospective registry of patients presenting to the ED with signs or symptoms of stroke was established at a university hospital from July 1995 to March 1996. The ED arrival time, time to being seen by an emergency physician (EP), time to CT scan, and time to neurology consultation were obtained by medical record review. Results: The median delay (interquartile range) from ED arrival to being seen by an EP for the 170 eligible subjects was 0.42 (0.20‐0.75) hours. The median delay to CT scan was 1.88 hours (1.25‐2.67) and the median delay to neurology consultation was 2.42 hours (1.50‐3.48). Age, race, sex, and hospital discharge diagnosis had little influence on delay. Subjects arriving by emergency medical services (EMS) had a significantly shorter time to being seen by an EP (0.33 vs 0.50 hours) when compared with those who arrived by other means. Time to CT scan was shorter by 0.5 hours for patients arriving by EMS as well. These differences persisted when stratified by out‐of‐hospital delay times. Conclusions: These data suggest that arriving by EMS is associated with shorter times to being seen by an EP and receiving a CT scan. The influence of EMS on delays associated with rapid medical care of stroke patients reaches beyond the out‐of‐hospital transport phase.
Statistical Methodology
Authors: Young Kelly D. , Menegazzi James J. , Lewis Roger J.
Published: January 2008

Survival analysis is a group of statistical methods used to analyze data representing the time to an event of interest, e.g., the duration of survival after an out‐of‐hospital cardiac arrest or the length of time a patient stays in the ED. Survival analysis properly accounts for patients who are lost to follow‐up and for patients who have not yet experienced the event of interest at the end of the study's observation period (censored data). This article acquaints the reader with the terminology, methodology, and limitations of survival analysis. Specific methods discussed include life tables, the Kaplan‐Meier product limit estimate, the log‐rank test, and the multivariate Cox proportional hazards model.
Emergency Medicine Resident Research Requirements and Director Characteristics
Authors: Blanda Michelle , Gerson Lowell W. , Dunn Kathleen
Published: January 2008

Abstract. Objectives: To describe emergency medicine (EM) residency program research requirements, characterize research directors (RDs), and describe their research activities and productivity. Methods: A survey with questions addressing program research requirements, RDs' background, type of research productivity, time spent, and compensation was mailed to RDs at all Accreditation Council for Graduate Medical Education (ACGME)‐approved programs. Results: One hundred of 111 (90%) RDs responded; 54 of the 100 respondents were from university programs. Research is a formal requirement in 80% of EM programs. Writing a manuscript (35%) and major involvement in a project (31%) are the most common minimum requirements. University and community programs had similar research requirements and were equally likely to have delayed/withheld certificates. Eighty‐six percent of the RDs were male; 70% held this position for <5 years and 70% plan on being in the position for ≤5 additional years. More than half were junior faculty and 21 had completed a fellowship. Most (88%) did not serve in an associate RD position, and currently only 20 programs reported having this position. Fifty‐four percent had protected time. Median hour/week time allocations are: clinical—22, own research—10, other people's research—6, administration—5, and department administration—5. Factors associated with research productivity were senior rank (OR 6.87), having a research assistant (OR 4.78), protected time for their own research (OR 3.06), and reporting that extramural funding was considered in the RD's performance evaluation (OR 2.69). Conclusions: Most programs have established research requirements. Most RDs are junior faculty, have limited research training, expect a short tenure in the position, and have variable access to research resources. EM needs to foster an environment that will enable us to thrive in the academic community and create opportunity for residents to participate in meaningful research. This requires that all RDs have protected time, and that a greater proportion be at the associate or full professor level, have qualified research assistants, and receive periodic evaluation reviewing their ability to generate external funds. Appointment of associate RDs may improve research training and help ensure qualified RDs.
Lumbar Puncture First: An Alternative Model for the Investigation of Lone Acute Sudden Headache
Authors: Schull Michael J.
Published: January 2008

Subarachnoid hemorrhage (SAH) is a diagnosis often considered in patients presenting to the ED with acute sudden headaches, but with normal physical examinations. Standard of care today is for these patients to be investigated by noncontrast CT scan followed by lumbar puncture (LP) for negative CTs. However, given that most investigated patients have benign headaches, most of the CT and LP results are normal. The authors studied, by means of a theoretical analysis, the impact of an alternative diagnostic model, in which LP would be the first (and, in most cases, only) diagnostic test for patients suspected of SAH who meet lone acute sudden headache (LASH) criteria. Given reasonable assumptions, for every 100 patients investigated, the “LP‐first” model would result in 79 to 83 fewer CT scans and only seven to 11 additional LPs, as compared with traditional strategies. Among ED headache patients meeting LASH criteria, the authors believe use of this model could result in more efficient use of resources, minimal additional morbidity, and equal diagnostic accuracy for SAH.
A Clinical Trial of Propofol vs Midazolam for Procedural Sedation in a Pediatric Emergency Department
Authors: Havel Charles J. , Strait Richard T. , Hennes Halim
Published: January 2008

Abstract. Objective: To compare the effectiveness, recovery time from sedation, and complication rate of propofol with those of midazolam when used for procedural sedation in the pediatric emergency department (PED). Methods: A prospective, blinded, randomized, clinical trial comparing propofol and midazolam was conducted in the PED of a tertiary pediatric center. Eligible patients were aged 2‐18 years with isolated extremity injuries necessitating closed reduction. All patients received morphine for pain, then were randomized to receive propofol or midazolam for sedation. Vital signs, pulse oximetry, and sedation scores were recorded prior to sedation and every 5 minutes thereafter until recovery. Recovery time, time from cast completion to discharge, and other time intervals during the PED course and all sedation‐related complications were also recorded. Results: Between August 1996 and October 1997, 91 patients were enrolled. Demographic data, morphine doses, and sedation scores were similar between the propofol and midazolam groups. Mean ± SD recovery time for the propofol group was 14.9 ± 11.1 minutes, compared with 76.4 ± 47.5 minutes for the midazolam group, p < 0.001. Mild transient hypoxemia was the most significant complication, occurring in 5 of 43 (11.6%) patients given propofol and 5 of 46 (10.9%) patients given midazolam (odds ratio 1.08, 95% CI = 0.24 to 4.76). Conclusion: In this study, propofol induced sedation as effectively as midazolam but with a shorter recovery time. Complication rates for propofol and midazolam were comparable, though the small study population limits the power of this comparison. Propofol may be an appropriate agent for sedation in the PED; however, further study is necessary before routine use can be recommended.
Resting Sestamibi Imaging for the Prognosis of Low‐risk Chest Pain
Authors: Kosnik Joseph W. , Zalenski Robert J. , Shamsa Falah , Harris Richard , Mittner Jay , Kozlowski Jay , Di Carli Marcelo , Udelson James E.
Published: January 2008

Abstract. Objective: To assess the prognostic value of resting Tc‐99m sestamibi scanning for adverse cardiac events (ACEs) in ED chest pain patients with a low probability of acute cardiac ischemia (ACI). Methods: Sixty‐nine consenting, hemodynamically stable patients with chest pain and a nondiagnostic electrocardiogram received an injection of 25 mCi of sestamibi during or within two hours of active pain. Scans were interpreted locally by a nuclear cardiologist or radiologist. Interrater reliability was assessed. ACEs of myocardial infarction (MI), death, or revascularization were assessed during the index hospitalization and over a one‐year follow‐up period. Results: For ACEs, rest scanning with sestamibi had a sensitivity of 71% (95% CI = 0.33 to 0.97), a specificity of 92% (95% CI = 0.82 to 0.97), and an accuracy of 90% (95% CI = 0.87 to 0.99). The positive predictive value was 50% (95% CI = 0.19 to 0.82) and the negative predictive value was 97% (95% CI = 0.87 to 0.98). Sestamibi scanning was highly discriminating, with 62% of patients with positive scans but only 3% with negative scans having ACEs (p < 0.001, log rank test). Conclusion: In patients with low‐risk chest pain, sestamibi scanning has good specificity and moderate sensitivity for ACEs over a 12‐month period.
A Decision Guideline for Emergency Department Utilization of Noncontrast Head Computed Tomography in HIV‐infected Patients
Authors: Rothman Richard E. , Keyl Penelope M. , McArthur Justin C. , Beauchamp Norman J. , Danyluk Taras , Kelen Gabor D.
Published: January 2008

Abstract. Objective: To determine which neurologic signs or symptoms are predictive of new focal lesions on head CT in HIV‐infected patients. Methods: Prospective study with convenience sample enrollment of HIV‐infected patients who presented to a large inner‐city university‐based ED over an 11‐month period. Patients were assessed using a standardized neurologic evaluation to ascertain whether they had developed new or changed neurologic signs or symptoms. Patients with any new or changed neurologic findings had a head CT scan in the ED. The association between individual complaints or findings and new focal lesions on head CT was assessed by univariate analysis, and sensitivity, specificity, and positive predictive values were calculated. Stepwise logistic regression analysis was then carried out to estimate the relative risk for those variables independently associated with new focal lesions on CT scans. A decision guideline was developed incorporating those variables. Results: One hundred ten patients were identified as having new or changed neurologic signs or symptoms and had a head CT done in the ED. Twenty‐seven patients (24%) had focal lesions on head CT, of which 19 (18%) were identified as new focal lesions; eight of these (7%) demonstrated a mass effect. Clinical findings most strongly associated with new focal findings on head CT were: 1) new seizure, relative risk (RR) = 73.5, 95% CI = 6.2 to 873.0; 2) depressed or altered orientation, RR = 39.1, 95% CI = 4.6 to 330.0; and 3) headache, different in quality, RR = 27.0, 95% CI = 3.2 to 230.1. Use of these three findings as a screen for ordering head CT in the ED would have identified 95% (18/19) of the patients with new focal intracranial lesions, and resulted in a 53% reduction in the number of head CTs ordered in the ED. Inclusion of one additional parameter (prolonged headache, ≥3 days), would have resulted in identification of 100% of all new focal lesions, with a 37% reduction in the number of head CTs ordered. Among those patients with new focal findings, 74% required emergent management (i.e., seizure control, IV antibiotics, IV steroids or surgery). The most common intracranial lesion among patients with CD4 counts less than 200 cells/μL was toxoplasmosis, while cerebrovascular accidents (ischemic or hemorrhagic) were most common in those with CD4 counts greater than 200 cells/μL. Conclusion: Specific clinical signs and symptoms were associated with the presence of new intracranial lesions in a group of HIV‐infected patients who presented to the ED with neurologic complaints. These clinical findings can be incorporated into guidelines for determining the need for emergent head CT. Validation and widespread application of these guidelines could result in limiting the use of emergent neuroimaging to a more well‐defined HIV‐infected patient population.
Occupational Exposures to Blood among Emergency Medicine Residents
Authors: Lee Carol H. , Carter Wallace A. , Chiang William K. , Williams Cleopas M. , Asimos Andrew W. , Goldfrank Lewis R.
Published: January 2008

Abstract. Objectives: To investigate the epidemiologic characteristics of potentially infectious occupational exposures to blood among emergency medicine (EM) residents. Methods: A SAEM‐sponsored multiple‐choice survey was administered anonymously to all EM residents participating in the 1998 American Board of Emergency Medicine in‐service examination. Survey questions included resident demographics, use of universal precautions, frequency and types of exposures to blood, and exposure reporting. Residents who experienced at least one exposure were then asked to complete an additional set of questions referring only to their latest exposure. Mean values were calculated for each variable and differences between groups were compared by chi‐square analysis. Results: Three thousand one hundred sixty‐two surveys were distributed to the resident participants, and 2,985 surveys (94.4%) were returned. Of the participants, 56.1% reported at least one exposure to blood during their EM training. The frequency of this self‐reported exposure increased with advancing EM level of training (43% EM‐1, 58% EM‐2, 64% EM‐3, 76% EM‐4, p < 0.001). Of these residents, 36.6% always followed universal precautions, 54% frequently, and 9.4% sometimes, rarely, or never. Those individuals who “always” followed universal precautions reported significantly fewer exposures than those who did not (p < 0.005). The latest exposures were most commonly caused by a solid needle or sharp object (39.4%), by a hollow‐bore needle (30.6%), or by eye splashes (17.2%). Of these exposures, 71.7% occurred in the ED setting, and only 46.7% of these exposures were reported to health care providers. Conclusion: Emergency medicine residents are frequently exposed to blood, most commonly due to puncture injuries by sharp objects. The rate of exposure reporting is low, which may compromise appropriate postexposure counseling and prophylaxis.
Clinical Decision Making: An Emergency Medicine Perspective
Authors: Kovacs George , Croskerry Pat
Published: January 2008

Abstract. Clinical decision making (CDM) describes a form of qualitative inquiry that examines the thought processes involved in making medical decisions. A significant body of literature exists on the orderly “hypothetico‐deductive” model of clinical decision making. However, very little has been written on how CDM differs in the acute setting. This paper reviews the common methods of CDM and their relevance to emergency medicine (EM). The concept of diagnostic uncertainty and the utility of the diagnosis of unknown etiology in the disposition phase of the emergency patient visit are discussed. Finally, a unique EM perspective on clinical decision‐making errors is presented.
Complications of a Retrograde Intubation in a Trauma Patient
Authors: Wijesinghe H. Shawn , Gough John E.
Published: January 2008

Abstract. The authors report the case of an elder woman involved in a motor vehicle collision (MVC) requiring emergent intubation using the technique of retrograde intubation (RI). Since RI is a blind technique, potential complications arising from its use are numerous and may result in increased morbidity and mortality. Such was the case of this RI that involved incorrect placement of the endotracheal tube (ETT), resulting in suboptimal ventilation and increased morbidity. Additionally, this case illustrates how the failure to detect this error in multiple settings (ambulance, helicopter, emergency department) led to unnecessary and potentially deleterious procedures and significant delay in providing the basics of trauma care, oxygenation and ventilation. Although theoretical complications of RI have been addressed in the past, there have been very few published reports of actual complications. The emergency physician must be aware of difficult airways, options available to establish alternative airways, and methods to confirm appropriate placement of the ETT. The authors also discuss the indications, procedures, and complications involved in performing an RI.
Physician versus Computer Knowledge of Potential Drug Interactions in the Emergency Department
Authors: Langdorf Mark I. , Fox John C. , Marwah Rakesh S. , Montague Brian J. , Hart Michael M.
Published: January 2008

Abstract. Introduction: Proliferation of Food and Drug Administration—approved drugs makes it impossible for emergency medicine (EM) faculty to stay current on potential interactions between drugs, and with diseases, laboratory tests, and ethanol. A computer database may augment physician knowledge. Objectives: To compare the performance of EM faculty and an “expert” emergency physician (EP) with that of a criterion standard computer database in identifying potential drug interactions, and to report the incidence of drug—ethanol and drug—laboratory test interactions. Methods: This was a retrospective review of 276 emergency department charts for drug, ethanol, lab, and medical history. Evaluation by both EM faculty and an “expert” EP of patient history was done to identify potential interactions, and comparison with the Micromedex Drug‐Reax database for potential interactions (graded minor, moderate, or major) was made. Clinical significance of potential interactions was judged by a second EM faculty member. Results: Seventeen percent of the patients had potential drug—drug interactions, and 25% of these were judged to be clinically significant. Up to 52% of the patients had potential drug—ethanol interactions, while 38% of the patients could have potential drug—lab interactions. Sensitivity, specificity, and positive and negative predictive values of the EM faculty for potential drug—drug interactions compared with the computer were poor, at 14%, 58%, 6%, and 23%, respectively. The corresponding values for the “expert” EP were 25%, 86%, 26%, and 85%. The “expert” EP was statistically better than the EM faculty, but still less sensitive and predictive than the computer. Conclusions: A computer can aid the physician in avoiding potential drug interactions. Prospective validation of these findings should be done.
Acceptability of Emergency Department‐based Screening and Brief Intervention for Alcohol Problems
Authors: Hungerford Daniel W. , Pollock Daniel A. , Todd Knox H.
Published: January 2008

Abstract. Objectives: To adapt screening and brief intervention for alcohol problems (SBI) to a high‐volume emergency department (ED) setting and evaluate its acceptability to patients. Methods: Patients at a large public‐hospital ED were screened with the Alcohol Use Disorders Identification Test (AUDIT). Screen‐positive drinkers (AUDIT score ≥ 6) were provided brief, on‐site counseling and referral as needed. Three months later, project staff blinded to baseline measures reassessed alcohol intake, alcohol‐related harm, alcohol dependence symptoms, and readiness to change. Results: Of 1,034 patients approached, 78.3% (810) consented to participate (95% CI = 75.5% to 81.2%), and 21.2% (172) screened positive (95% CI = 18.4% to 24.0%). Of 88 patients with complete intervention data, 94.3% (83) accepted an intervention (95% CI = 89.5% to 99.2%), with acceptance rates ranging from 93% to 100% across four alcohol‐problem‐severity levels (p = 0.7). A majority (59.0%) set goals to decrease or stop drinking (95% CI = 48.4% to 69.6%). The group recontacted (n= 23) experienced statistically significant decreases in alcohol intake, alcohol‐related harm, and dependence symptoms, with measures decreasing for 68%, 52%, and 61% of the patients. Readiness to change also showed statistically significant improvement, with scores increasing for 43% of the patients. Moreover, two‐thirds of the patients (15/23) reported at follow‐up that SBI was a helpful part of their ED visit. Conclusions: High rates of consent and acceptance of counseling for alcohol problems by patients across a wide range of problem severity indicate that this protocol was acceptable to at‐risk patients in a public‐hospital ED. Improvements in alcohol‐related outcome measures at follow‐up were strong enough to warrant controlled studies of intervention efficacy.
Follow‐up Program for Emergency Department Patients with Gonorrhea or Chlamydia
Authors: Kelly John J. , Dalsey William C. , McComb Joseph , Njuki Fred
Published: January 2008

Abstract. Objectives: To study the performance of a centralized regional follow‐up program organized by a municipal department of health (DH) for female patients presenting to the emergency department (ED) with Neisseria gonorrhoeae and/or Chlamydia trachomatis, who are not diagnosed or treated at the time of presentation. Methods: This was a retrospective observational study of female patients seen in the ED with positive cervical specimens, and their subsequent treatment and follow‐up by the DH. Medical records were reviewed to determine the female patients seen in the ED who had positive specimens for N. gonorrhoeae or C. trachomatis. The DH followed up those not treated in the ED. Analysis of how long it took for these patients to be treated and the proportion lost to follow‐up was performed. Results: Of 2,121 specimens, 342 were positive for N. gonorrhoeae or C. trachomatis. Of the 342, 154 (45%) were recognized and appropriately treated in the ED. One hundred fifty‐nine of the 342 (46.5%) patients were discharged from the ED without treatment but were contacted by the DH and appropriate treatment was provided. The DH could not locate 23 (6.7%) patients, and four (1.2%) refused treatment. One died before treatment. Only 21 of the 159 were treated within nine days. Median time to treatment was 36 days. Conclusions: Centralized laboratory analysis and follow‐up by the DH for N. gonorrhoeae and C. trachomatis identified many female patients undiagnosed and untreated in the ED. The DH follow‐up program provided appropriate treatment to most female patients.
Reliability and Validity of a New Five‐level Triage Instrument
Authors: Wuerz Richard C. , Milne Leslie W. , Eitel David R. , Travers Debbie , Gilboy Nicki
Published: January 2008

Objectives: Triage is the initial clinical sorting process in hospital emergency departments (EDs). Because of poor reproducibility and validity of three‐level triage, the authors developed and validated a new five‐level triage instrument, the Emergency Severity Index (ESI). The study objectives were: 1) to validate the triage instrument against ED patients' clinical resource and hospitalization needs, and 2) to measure the interrater reliability (reproducibility) of the instrument. Methods: This was a prospective, observational cohort study of a population‐based convenience sample of adult patients triaged during 100 hours at two urban referral hospitals. Validation by resource use and hospitalization (criterion standards) and reproducibility by blinded paired triage assignments compared with weighted kappa analysis were assessed. Results: Five hundred thirty‐eight patients were enrolled; 45 were excluded due to incomplete evaluations. The resulting cohort of 493 patients was 52% female, was 26% nonwhite, and had a median age of 40 years (range 16‐95); overall, 159 (32%) patients were hospitalized. Weighted kappa for triage assignment was 0.80 (95% CI = 0.76 to 0.84). Resource use and hospitalization rates were strongly associated with triage level. For patients in category 5, only one‐fourth (17/67) required any diagnostic test or procedure, and none were hospitalized (upper confidence limit, 5%). Conversely, in category 1, one of twelve patients was discharged (upper confidence limit, 25%), and none required fewer than two resources. Conclusions: This five‐level triage instrument was shown to be both valid and reliable in the authors' practice settings. It reproducibly triages patients into five distinct strata, from very high hospitalization/resource intensity to very low hospitalization/resource intensity.
Conjoint Smoking and Drinking: A Case for Dual‐substance Intervention among Young Emergency Department Patients
Authors: Horn Kimberly , Gao Xin , Williams Janet , Helmkamp Jim , Furbee Mike , Manley William
Published: January 2008

Abstract.Objectives:To better understand conjoint smoking and drinking among young adult emergency department (ED) patients, the purposes of this investigation were: 1) to assess the prevalence of conjoint use; 2) to determine the factors associated with conjoint alcohol use and smoking; and 3) to address the implications for future ED‐based investigation of dual‐substance intervention.Methods:Data for this investigation were obtained from a battery of questionnaires administered to the routine‐care patients during an alcohol screening in the ED, which was part of a larger alcohol intervention study.Results:Study findings revealed that a majority of patients with self‐reported alcohol‐related problems were smokers. In fact, drinkers who smoked were likely to be pack‐a‐day smokers. Among the study sample, being female, having low education levels (e.g., high school education or less), having some emotional problems, and currently using marijuana were risk factors for conjoint smoking and drinking.Conclusions:Conjoint users were identifiable through brief screening. Given the prevalence of conjoint smoking and alcohol use among the ED sample and a specific set of risk factors, tailored intervention for alcohol and nicotine dependence may be an important and opportunistic clinical ED service.