bluuebunny/crossref_metadata_2025 huggingface dataset:
Incumbents' Interests and Gender Quotas
Authors: Fréchette Guillaume R. , Maniquet Francois , Morelli Massimo
Published: September 2008

The introduction of mandatory gender quotas in party lists is a reform that many countries have recently adopted or have been considering. The electoral system affects the incumbents' incentives to make such reforms, their details, and their effectiveness. We show that male incumbents can actually expect an increased incumbency advantage when gender quotas are introduced, if they are elected through single‐member district majority rule. On the other hand, no expectation of male advantage can reduce the incumbents' fear of being replaced if they are elected through closed‐list proportional representation. As France has both electoral systems, we validate the above argument using a formal model of constitutional design as well as an empirical analysis of the legislative elections in France, displaying the existence of male bias in the last three elections. We also show that parity may have Assembly composition effects and policy effects that vary with the electoral system.
Who Cheats? Who Loots? Political Competition and Corruption in Japan, 1947–1993
Authors: Nyblade Benjamin , Reed Steven R.
Published: September 2008

When do politicians resort to corrupt practices? This article distinguishes between two types of corruption by politicians: illegal acts for material gain (looting) and illegal acts for electoral gain (cheating). Looting generally involves a politician “selling” influence while cheating involves a politician “buying” votes. Individual‐level analyses of new data on financial scandals and election law violations in Japan show that the determinants of cheating differ from the determinants of looting. Most notably, political experience and electoral security increase the probability of looting, but electoral insecurity combined with intraparty competition increases the probability of cheating.
Semiparametric Transformation Models with Random Effects for Joint Analysis of Recurrent and Terminal Events
Authors: Zeng Donglin , Lin D. Y.
Published: September 2008

SummaryWe propose a broad class of semiparametric transformation models with random effects for the joint analysis of recurrent events and a terminal event. The transformation models include proportional hazards/intensity and proportional odds models. We estimate the model parameters by the nonparametric maximum likelihood approach. The estimators are shown to be consistent, asymptotically normal, and asymptotically efficient. Simple and stable numerical algorithms are provided to calculate the parameter estimators and to estimate their variances. Extensive simulation studies demonstrate that the proposed inference procedures perform well in realistic settings. Applications to two HIV/AIDS studies are presented.
Beyond Capital High: On Dual Citizenship and the Strange Career of “Acting White”
Authors: Fordham Signithia
Published: September 2008

In this article, I reflect on the strange career of the “burden of ‘acting White’ ” since it attracted widespread popular and academic attention over 20 years ago. I begin by noting that my original definition of “the burden of ‘acting White’ ” should not be confused with a prominent misconception of the problem as the “fear” of “acting White.” I then offer a revised definition that has emerged in the wake of the collision of meanings attributed to the Capital High study. At the core of the twists and turns this concept has taken is attempted identity theft: In exchange for what is conventionally identified as success, racially defined Black bodies are compelled to perform a White identity by mimicking the cultural, linguistic, and economic practices historically affiliated with the hegemonic rule of Euro‐Americans. Third, drawing on recent work on the impact of gender‐specific racial performances on Black males' and Black females' academic success, I analyze quantitative data from Capital High to explain the gender‐specific response patterns of male and female students to the dilemmas implicit in academic success. Finally, I suggest possible implications of the centrality of the burden of “acting White” for the academic performance of Black students and the identity of African Americans more generally.[burden of “acting White,” identity theft, racial insufficiency, gender insufficiency, Capital High, academic achievement]
Dimensions of Psychological Capital in a U.S. Suburb and High School: Identities for Neoliberal Times
Authors: Demerath Peter , Lynch Jill , Davidson Mario
Published: September 2008

In this article, we describe the identities of U.S. suburban high school students as they attempt to ensure their “market relevance” in a neoliberal era. The data are drawn from a four‐year ethnographic study of the construction of educational advantage conducted by a diverse five‐person research team. These identities were characterized by strong agentic beliefs, predispositions to exert control, deeply held attachments to individual success, highly developed self‐advocacy skills, precociously circumscribed aspirations, keen awareness of new forms of cultural capital, self‐consciously cultivated work ethics, and habituation to stress and fatigue. The study uncovered gender and racial differences in the acquisition of specific components of these identities, which are attributed in part to larger contextual factors, such as the subordination of the school's efforts to meet the needs of minority students to its broader goals of remaining competitive. Overall, we interpret these identity characteristics as components of psychological capital that these young people developed to manage risks: in particular, their ability to achieve “success” in a future characterized by acute competition, declining social support, and uncertainty.[identity, neoliberalism, social stratification, high school, United States]
Proper Depth of Placement of Oral Endotracheal Tubes in Adults Prior to Radiographic Confirmation
Authors: Roberts James R. , Spadafora Michael , Cone David C.
Published: September 2008

Objective: To determine whether a certain distance measurement on the oral endotracheal tube (ETT) at the corner of the mouth could reasonably ensure proper depth of placement in critically ill patients, without the immediate need for a confirming chest x‐ray (CXR).

Methods: A prospective observational cross‐sectional design was used to compare ETT mark distance and radiographic location of the ETT tip. The measurement marking on the ETT at the level of the corner of the mouth was noted at the time of intubation. The relationship of the tip of the ETT to the tracheal carina on the postintubation CXR was then determined. The ETT placement was deemed correct if the tip was at least 2 cm cephalad to the carina on the CXR.

Results: Of 83 intubated patients assessed, 52 were men and 31 women. The mean measurement on the ETT at the corner of the mouth was 22.2 cm for the women and 23.1 cm for the men. The mean distance from the tip of the ETT to the carina was 3.45 cm for the women and 4.13 cm for the men. Seventy‐five of the 83 patients (90.4%; 95% CI 81.9–95.7%) had correct ETT positions on the initial CXR. If the ETT position had been adjusted at the corner of the mouth to 21 cm for the women and 23 cm for the men, the ETT would have been in correct position for 81 of the 83 patients (97.6%; 95% CI 89.6–99.7%). This represents a significant improvement in tube placement (p < 0.025; the McNemar chi‐square).

Conclusion: Proper depth of ETT placement in the critically ill adult patient can be estimated by the technique of this study. In this adult patient population, corner‐of‐the‐mouth placement of the ETT using the 21‐cm tube mark for the women and the 23‐cm mark for the men would have led to proper placement for most patients.
Proceedings of the 7th Purdue Conference on Cardiac Defibrillation: A Database of Cardiac Arrhythmias
Authors: Panescu Dorin , Webster John G. , Tompkins Willis J. , Staley Richard L. , Johnson Jean , Schlageter Dave , Stratbucker Robert A.
Published: September 2008

Objective: To describe a database of cardiac arrhythmia recordings, useful for the development and testing of ECG rhythm processing or monitoring algorithms and devices.

Methods: The raw data were acquired within the Wisconsin‐Dane County emergency medical technician‐defibrillation program and contained emergency rhythm recordings of an average length of 30 minutes. The raw data were integrated into a software platform designed for the annotation and visualization of the recordings.

Results: Currently the database contains the following arrhythmia episodes: ventricular fibrillation (56), asystole (65), electromechanical dissociation (31), and other arrhythmias (42). The software, resident on personal computers, also can transmit any of the database recordings, through a digital‐to‐analog converter board, to a device under test.

Conclusions: The database technique described will provide a useful means of objectively assessing electronic devices for their ability to detect arrhythmias. The database is unique in that it contains lengthy episodes of arrhythmias. The database will be extended to include additional cases.
Combination Fentanyl and Diazepam for Pediatric Conscious Sedation
Authors: Pohlgeers Anthony P. , Friedland Leonard R. , Keegan‐Jones Lisa
Published: September 2008

Objectives: To evaluate the safety and to describe the use of combination IV diazepam and fentanyl in the pediatric emergency department (PED) as outpatient conscious sedation (CS) for orthopedic procedures.

Methods: A retrospective chart review of a standardized protocol for CS administered to 133 consecutive patients requiring CS for outpatient orthopedic procedures. The patients were continuously monitored for heart rate, respiratory rate, and arterial O2 saturation (SaO2) by pulse oximetry. The study was conducted at a large urban PED and regional referral center.

Results: A total of 133 children (mean age 8.5 years) received 138 orthopedic procedures. Mean (± SD) total diazepam dose was 0.12 ± 0.05 mg/kg; mean total fentanyl dose was 3.18 ± 1.04 μg/kg. Mean time intervals were 4.6 minutes from initial drug administration to start of procedure, 15.5 minutes to end of procedure, and 56 minutes to meeting criteria for release home. Complications included Sao2 < 90% for 15 patients (11%, 95% CI 6.4–17.4%), vomiting for one (0.74s. 95% CI 0.1–4.2%). and severe pruritus for one (0.7%, 95% CI 0.1–4.2%). An episode of Sao2 < 90% was associated with a higher initial mean fentanyl dose (2.60 vs 1.95 μg/kg; p = 0.0005). but was not associated with a higher initial mean diazepam dose (p = 0.28). Parented opioid use for pain management prior to CS was not associated with an increased risk for Sac), < 90% (p = 0.42). Heart rate, respiratory rate. and blood pressure were stable during the observational period. No patient required naloxone, flumazenil. artificial airway control. or admission to the hospital.

Conclusions: At the doses given in the study. the use of combination diazepam and fentanyl for outpatient CS of PED patients during orthopedic procedures was not associated with serious complications. A higher initial fentanyl dose was associated with episodes of SaO2 < 91%. Therefore, an initial dose of ≤2.0 μg/kg fentanyl titrated to effect is recommended.
Perimortem Cesarean Section: Case Reports and Recommendations
Authors: Lanoix Richard , Akkapeddi Vijay , Godfather Bruce
Published: September 2008

Per mortem cesarean section is rarely required in the ED. However, since trauma now represents a leading cause of no obstetric maternal death, emergency physicians (EPs) may more commonly be faced with the difficult decision of performing an emergency cesarean section. Two cases are described of severely traumatized pregnant patients for whom per mortem cesarean section in the ED led to birth of viable infants, with one long‐term survivor. The rationale and guidelines for the procedure are discussed, and it is emphasized that the EP should be thoroughly familiar with the procedure and prepared to perform it when indicated to enhance fetal (and potentially maternal) survival.
Multiple Resuscitation Regimens in a Near‐fatal Porcine Aortic Injury Hemorrhage Model
Authors: Stern Susan A. , Dronen Steven C. , Wang Xu
Published: September 2008

Objective: To compare early and delayed blood administrations in animals subjected to near‐fatal hemorrhage in the presence of a vascular injury and resuscitated to different mean arterial pressures (MAPs).

Methods: Fifty‐four immature swine with 4‐mm infrarenal aortic tears were bled to a pulse pressure of 5 torr and then resuscitated (estimated blood loss 40 to 45 mL/kg). Groups I, II, and III were resuscitated with shed blood at a rate of 2 mL/kg/min, followed by normal saline at a rate of 6 mL/kg/min. Groups IV, V, and VI received the same fluids in reverse order. The fluids were infused intermittently to maintain MAPs of 40, 60, and 80 torr. The animals were observed for 60 minutes or until death.

Results: The animals resuscitated to a MAP of 80 torr experienced significantly higher intraperitoneal hemorrhage volumes and mortality than did the animals intentionally maintained hypotensive, regardless of whether blood or normal saline was administered first. There was no significant difference in mortality or hemorrhage volumes between any of the groups intentionally maintained hypotensive. The animals maintained at a MAP of 60 torr were significantly less acidotic than were the animals resuscitated with the same fluid regimen but to a MAP of 40 torr. Early blood administration also minimized the acidosis associated with hypotensive resuscitation.

Conclusion: In this model of near‐fatal hemorrhage with a vascular injury, maintenance of the hypotensive state produced comparable improvements in one‐hour survival and reductions in hemorrhage volume regardless of whether blood or saline was administered first. Although hypotensive resuscitation resulted in improved outcome, it was associated with significant acidosis. This effect was minimized with moderate rather than severe underresuscitation and early blood administration.
Effect of Gender on the Emergency Department Evaluation of Patients with Chest Pain
Authors: Silbergleit Robert , McNamara Robert M.
Published: September 2008

Objective: To assess chest pain evaluation as reflected in the documentation of the evaluation process for women vs men in one emergency department (ED).

Methods: In this retrospective case series, patient charts were reviewed for documentation in accordance with a clinical policy for chest pain evaluation. Patient demographics and the frequencies of inclusion of the following items were determined: five descriptors of chest pain, associated symptoms, risk factors for coronary artery disease, receipt of physical examination, and receipt of ECG.

Results: Over a three‐month period, 132 men and 150 women were evaluated for chest pain and entered in the study. There was no significant difference in age between the men and the women overall, but in the subgroup of patients who were admitted to the hospital, the women were significantly older than the men by an average of five years (p = 0.04). Fifty‐five percent of all the patients were admitted to the hospital. The men were admitted to the hospital significantly more often than were the women (p = 0.01), with a relative risk of admission for women vs men of 0.76 (95% CI = 0.62–0.94). There was no significant difference between the men and the women for any of the process of evaluation items in the overall group or in the hospital‐admission and release‐home subgroups.

Conclusion: The authors' findings do not support the existence of a gender difference in ED chest pain evaluations, as reflected by documentation of the evaluation process. However, men were more likely to be admitted to the hospital for evaluation of coronary artery disease than were women.
Injuries Resulting from Bicycle Collisions
Authors: Frank Edmund , Frankel Pamela , Mullins Richard J. , Taylor Natasha
Published: September 2008

Objective: To review all bicycle crash‐related injuries reported to the Oregon Injury Registry for 1989 to compare patterns of injury and other features in adults vs children and adolescents.

Methods: A retrospective descriptive study was conducted using data from the Oregon Injury Registry. For 1989, this registry included all injury‐related deaths and approximately 75% of hospital admissions of 24 hours or more for injury in the State of Oregon. Deaths, helmet use, neurologic injuries, and concurrent ethanol use were evaluated for all patients and for the two age groups.

Results: There were 311 bicycle‐related injured patients in the registry for 1989; 122 (40%) were adults (age > 21 years) and 189 (60%) were children/adolescents (age < 21 years). Approximately 69% of both age groups were male. All of the 15 deaths involved male patients and most deaths [10/15 (67%)] involved injured adults. Bicycle vs motor vehicle collisions accounted for 14 (93%) deaths and 106 (34%) of all registry entries. While only 19 (15%) of the injured adults had elevated blood alcohol levels, half the adults who died had been intoxicated. Helmet use was rare with only 12 (4%) of all the injured riders known to have been helmeted; no rider who died was known to have been helmeted. Neurologic injuries were common. In children, 27 (14%) had sustained skull fractures, 36 (19%) intracranial injuries, and one (0.5%) a spinal injury. In adults, 13 (10%) had sustained skull fractures, 32 (26%) intracranial injuries, and three (2%) spinal injuries.

Conclusion: Although children account for 60% of the serious bicycle injuries in Oregon, adults account for 67% of the deaths. Helmet use is rare, brain injuries are frequent, and alcohol use appears to be a contributing factor in cycling deaths among adults. Public education efforts should be directed to both adult and pediatric populations, emphasizing safe cycling practices and helmet use.
High‐yield Selection Criteria for Cranial Computed Tomography after Acute Trauma
Authors: Madden Cynthia , Witzke Donald B. , Sanders Arthur B. , Valente John , Fritz Mark
Published: September 2008

Objective: To develop and prospectively evaluate criteria for selecting head‐injured patients requiring cranial CT.

Methods: A two‐phased prospective observational study design was implemented at a university ED. Physicians completed a form with 51 variables for 540 patients in Phase I. Ten high‐yield variables were identified and prospectively tested on 273 patients in Phase II. Prediction rule performance for identification of patients with abnormal CT scans was determined.

Results: The combined criteria had a sensitivity of 97% for CT‐scan abnormalities in Phase I; sensitivity was 96% in Phase II. Negative predictive values were 97% and 94%, respectively. Prevalence of disease in Phase I was 17%; prevalence in Phase II was 16%. Had the Phase I criteria been implemented during Phase II, 43 of 273 patients (16%) would not have been scanned, including two patients with positive results who did not require operative intervention.

Conclusions: Fifty‐one clinical variables from head‐injured patients were narrowed to ten of statistical significance and consistent interpretation for prospective evaluation. Patients with none of these criteria were found to be at low risk of having sustained significant head injury.
Colorimetric End–tidal CO2Detector for Verification of Endotracheal Tube Placement in Out–of–hospital Cardiac Arrest
Authors: Hayden Stephen R. , Sciammarella Joseph , Viccellio Peter , Thode Henry , Delagi Robert
Published: September 2008

Objective: To evaluate the ability of a disposable, colorimetric end–tidal CO2 detector to verify proper endotracheal (ET) tube placement in out–of–hospital cardiac arrest, and to correlate semiquantitative CO2 measurements with the rate of return of spontaneous circulation (ROSC).

Methods: Prospective, observational study using a convenience sample of intubated out–of–hospital cardiac arrest patients. A disposable, colorimetric end–tidal CO2 detector was attached to the ET tube after intubation. In the absence of a colorimetric change, the paramedics reassessed the tube placement and could reintubate the patient. Tube placement was verified at the hospital. Paramedics were instructed to contact the base station and report the colorimetric change upon hospital arrival. ROSC was defined as restoration of a self–sustaining pulse until hospital arrival.

Results: Between December 1990 and May 1993, ET tubes were placed in 566 victims of out–of–hospital cardiac arrest. 541 of the 566 intubations (95.6%) were associated with a color change. In one case with a color change and out–of–hospital clinical evidence of proper tube placement, the tube was determined to be in the esophagus at the hospital. Correct placement of the remaining 565 of 566 (99.8%) tubes was verified. Of the 566 patients who had a colorimetric change, 91 (16%) had ROSC vs one of 25 (4%) patients who did not have a color change. In one subgroup (n = 179), the degree of color change was highly associated with ROSC (p = 0.004).

Conclusions: A disposable, colorimetric end–tidal CO2 detector appears reliable in verifying proper ET tube placement in victims of out–of–hospital cardiac arrest. The degree of color change correlates with the probability of ROSC.
A Case–based Emergency Medicine Curriculum for Senior Medical Students
Authors: DeBehnke Daniel , Shepherd Dennis , Ma O. John
Published: September 2008

Objective: To determine the effects of a case–based, core content–oriented emergency medicine (EM) curriculum on the basic EM knowledge of senior medical students.

Methods: All senior medical students rotating through the Milwaukee County EM elective during the 1992–1993 academic year were assigned specific chapter readings from a case–oriented EM textbook. A course curriculum consisting of goals and objectives for each chapter and two to three representative cases for the discussion topic also was distributed to each student. Interspersed with the cases was a series of questions directed at pathophysiology, diagnosis, management, and disposition. The EM faculty and residents conducted case discussions three times per week. AH students completing the rotation were given a pretest at the beginning and a final examination at the end of the rotation. In addition, the students rated the textbook, coursebook, and lecture series at the end of the rotation using a five–point Likert scale.

Results: Seventy–five students rotated through the elective. The students showed a significant improvement in their EM knowledge base as judged by improvement in final examination scores compared with pretest scores (pretest score 62.2 ± 7.1%; final examination score 76.2 ± 6.3%; p < 0.0001). The mean change in scores was 14.8%, with a range of –1.6% to 34%. The students also rated the textbook, coursebook, and lecture series as effective, as shown by high median scores on a Likert scale.

Conclusions: A case–based EM curriculum coupled with ED clinical experience improves basic EM diagnostic and management knowledge of senior medical students.
Screening and Empiric Treatment for Syphilis in an Inner‐city Emergency Department
Authors: Ernst Amy A. , Farley Thomas A. , Martin David H.
Published: September 2008

Objective: To examine targeted screening and empiric treatment for syphilis in an urban ED.

Methods: Screening of emergency patients during previously arranged shifts from July 1991 through January 1992 in a university‐affiliated, inner‐city ED. Emergency patients who perceived that they had high‐risk factors for syphilis (i.e., cocaine or heroin use or sexual contact with a user of these substances) were compared with emergency patients denying high risk. All presumed high‐risk patients and alternate patients in the group who denied high risk (control group) were screened in the ED with the rapid plasma reagin (RPR) test. Empiric antibiotic treatment was initiated if the patient was RPR‐positive and gave no previous history of syphilis. In addition, serum was submitted to the state laboratory for VDRL and microhemagglutination‐Treponema pallidum (MHA‐TP) testing. Blinded serologic testing for HIV antibody was performed later on frozen serum.

Results: Of 806 patients presenting to the ED, 276 (34%) admitted to high‐risk behavior. Of 373 patients tested by RPR in the ED (216 high‐risk and 157 control patients), no significant difference was found between the high‐risk and the control patients in untreated syphilis [8 (4%) vs 4 (3%)] or positive MHA‐TP [47 (22%) vs 25 (16%)]. In the high‐risk group, the women were more likely than the men to be MHA‐TP‐positive (OR = 2.58, 95% CI 1.12–7.98, p = 0.04). Among the women, the MHA‐TP was more often positive for the high‐risk than for the control patients (34% vs 15%, OR = 2.27, 95% CI 1.12–4.67, p = 0.023). For the high‐risk group, seven (3%) new cases of syphilis were managed empirically. vs three (2%) new cases for the control group. HIV antibodies were detected in 16 of 212 (8%) high‐risk patients and five of 155 (3%) control subjects (p = 0.13).

Conclusion: This inner‐city ED population has a high frequency of positive syphilis and HIV serologies, regardless of acknowledged drug use risk factors. Therefore, in areas reporting high syphilis infection rates, consideration should be given to offering screening for syphilis to all emergency patients, along with establishment of adequate counseling and follow‐up.
Time to Equilibration of Oxygen Saturation Using Pulse Oximetry
Authors: Gruber Peter , Kwiatkowski Thomas , Silverrnan Robert , Flaster Edith , Auerbach Charles
Published: September 2008

Objective: To determine the time it takes for O2, saturation measured by pulse oximetry to equilibrate after a change is made in supplemental O2, administered by nasal cannula in patients with cardiac and pulmonary disease.

Methods: A prospective, observational study of a convenience sample of 51 patients treated in a university‐affiliated ED with nasal cannula O2. Patients were placed on and/or subsequently taken off O2 via nasal cannula set at 2 or 4L/min based on clinical indications. Oxygen saturation was measured at l‐minute intervals over a 30‐minute period using finger‐probe pulse oximetry. Of the 51 patients in the study, 43 were monitored while O2, treatment was initiated and 18 were monitored when it was discontinued.

Results: Most (95%) of the patients placed on O2, attained equilibration of O2, saturation within 3.5 minutes. Most (95%) of the patients taken off supplemental O2, attained equilibration of O2, saturation within 4.5 minutes.

Conclusion: The interval to equilibration of O2, saturation in patients receiving O2 by nasal cannula is considerably shorter than the 20–30 minutes generally suggested. Adequacy of O2, supplementation should be assessable much sooner than was previously taught.
Effect of Continuous Quality Improvement Methods on Reducing Triage to Thrombolytic Interval for Acute Myocardial Infarction
Authors: Krall Scott P. , IV Charles L. Reese , Donahue Lorraine
Published: September 2008

Objectives: To assess the timeliness of thrombolytic therapy in the ED for selected patients with acute myocardial infarction (AMI) following continuous quality improvement (CQI) interventions.

Methods: A retrospective, historical comparison study was performed of triage‐to‐thrombolytic time intervals for AMI patients using chart review for data collection. Patients treated after implementation of the CQI process vs a historical control group were compared. The patients with AMI who had received thrombolytics during the one‐year period prior to the CQI interventions and who had documentation of time intervals served as the control group. The patients treated during a four‐month period, beginning about one and a half years following introduction of the CQI interventions, served as the intervention group. Interventions included: a triage protocol, CQI review, and staff feedback.

Results: The mean triage‐to‐thrombolytic interval was longer for the control group (72 ± 25 vs 40.0 ± 22 min; p < 0.0001). The mean triage‐to‐ECG interval also was longer for the control group (16.5 ± 8.9 vs 8.5 ± 7.5 min; p < 0.0001). Most (79%) of the study group received thrombolytic therapy within 60 minutes, and 39% within 30 minutes, whereas 39% of the control group received thrombolytic therapy within 60 minutes, and 3% within 30 minutes.

Conclusion: The implementation of CQI techniques, including 100% chart review, intensive systems analysis, and staff feedback, had a positive effect on the timeliness of thrombolytic therapy for the ED patients who had AMI. As a result, most (79%) of the patients received therapy within the 60‐minute time window recommended currently by the American Heart Association.
Physical Diagnosis Skills of Physicians in Training: A Focused Assessment
Authors: Mangione Salvatore , Burdick William P. , Peitzman Steven J.
Published: September 2008

Objective: To assess the proficiency of emergency medicine (EM) trainees in the recognition of physical findings pertinent to the care of the critically ill patient.

Methods: Fourteen medical students, 63 internal medicine (IM) residents, and 47 EM residents from three university‐affiliated programs in Philadelphia were tested. Proficiency in physical diagnosis was assessed by a multimedia questionnaire targeting findings useful in emergencies or related to diseases frequently encountered in the ED. Attitudes toward diagnosis not based on technology, teaching practices of physical examination during EM training, and self‐motivated learning of physical diagnosis also were assessed for all the EM trainees.

Results: With the exception of ophthalmology, the EM trainees were never significantly better than the senior students or the IM residents. They were less proficient than the IM residents in cardiology, and not significantly different from the IM residents in all other areas. For no organ system tested, however, did they achieve less than a 42.9% error rate (range: 42.9–72.3%, median = 54.8%). There was no significant improvement in proficiency over the three years of customary EM training. The EM residents who had received supervised teaching in physical diagnosis during training achieved a significantly higher cumulative score. The EM residents attributed great clinical importance to physical diagnosis and wished for more time devoted to its teaching.

Conclusions: These data confirm the recently reported deficiencies of physical diagnosis skills among physicians in training. The results are particularly disturbing because they relate to EM trainees and concern skills useful in the ED. Physical diagnosis should gain more attention in both medical schools and residency programs.
Delayed Subluxation of an Occult Traumatic Odontoid Fracture in an Elderly Patient
Authors: Higgins George L.
Published: September 2008

The issue of whether a traumatic but occult cervical spine fracture can exist has generated significant debate in emergency medicine. The profound clinical and legal implications of missing an unstable cervical spine injury are well known to the emergency care provider. An elderly patient who satisfies all of the rigorous criteria for this type of injury is discussed. The patient experienced delayed subluxation of her acute odontoid fracture during a flexion/extension examination completed in the ED, with resultant development of cervical discomfort. Elderly victims of trauma with an appropriate mechanism of injury should be suspected of subtle or occult neck injuries.
Emergency Management of Blunt Testicular Trauma
Authors: Mulhall John P. , Gabram Sheryl G. A. , Jacobs Lenworth M.
Published: September 2008

Objective: Severe blunt testicular trauma is an infrequently reported consequence of injury, yet it is associated with significant sequelae. This case series evaluates the characteristics of patients with severe blunt testicular trauma, assesses the role of ultrasonography in their management, and offers an evaluation algorithm for use by both emergency and urology personnel.

Methods: A retrospective review was conducted of ten patients who had severe blunt testicular injuries referred for urologic evaluation over a seven‐year period at a level 1 trauma center. Attention was focused on ultrasonographic results, operative findings, and testicular salvage rates.

Results: With the exception of two motorcycle crash victims, patients presented in a delayed fashion (mean 3.5 days; range 1–5 days). Most (6/10) patients had true testicular rupture, all were explored urgently, and there was a 100% testicular salvage rate. Of the eight patients who had preoperative ultrasonographic examination, two were reported to show testicular rupture, but on exploration only one in fact had a tunica albuginea tear. Six patients had ultrasonographic examinations that revealed nonspecific abnormalities but failed to show testicular rupture; three had testicular rupture.

Conclusions: Ultrasonography cannot be relied on to accurately diagnose rupture of the testis in high‐risk patients. However, testicular rupture is universally associated with an abnormal ultrasonography scan, albeit commonly yielding nonspecific findings. A high level of suspicion is mandatory with high‐energy transfer mechanisms. Since a significant delay in presentation is not unusual, early exploration is warranted in the setting of high risk and provides an excellent chance of testicular salvage. Injuries associated with normal testicular ultrasonography may be managed conservatively.
Terbutaline vs Albuterol for Out‐of‐hospital Respiratory Distress: Randomized, Double‐blind Trial
Authors: Zehner William J. , Scott Jay M. , Iannolo Patsy M. , Ungaro Alan , Terndrup Thomas E.
Published: September 2008

Objective: To determine the efficacy and safety of single doses of subcutaneous terbutaline (terb) or nebulized albuterol (alb) during out‐of‐hospital treatment for respiratory distress from asthma or chronic obstructive pulmonary disease.

Methods: Patients aged >18 years who had respiratory distress were enrolled in a double‐placebo, double‐blind, randomized trial. Paramedics measured respiratory severity using an empiric score [respiratory rate, wheezing, speech, and peak expiratory flow rate (PEFR)], and the patients rated their own respiratory distress using a visual analog scale (VAS). The patients received 02 plus alb (2.5 mg) and saline injection (n = 40) or terb (0.25 mg) and saline aerosol (n = 43).

Results: The groups were similar with respect to age, gender, initial empiric scores (median score 9 for both groups), PEFRs (89 ± 84 L/min, mean ± SD, for alb vs 97 ± 84 L/min for terb), and respiratory distress VAS scores. Both groups showed significant improvement in their respiratory distress VAS scores by the time of ED arrival. The alb group had a greater improvement in respiratory distress VAS score than did the terb group (p < 0.05). Empiric scores, PEFR scores, and hospital admission frequencies were not significantly different. No complication was observed.

Conclusion: The out‐of‐hospital administration of either aerosolized alb or subcutaneous terb reduced respiratory severity. Albuterol provided greater subjective improvement in respiratory distress.
Jerry Mandell, Leukocyte Watcher, Searching for the Role of Cytokines in Infection
Authors: Gerard Marianne W. , Edlich Richard F.
Published: September 2008

The three primary goals of an academic physician should always remain: to heal, to teach, and to maintain a creative and resourceful scientific mind while continuously inspiring the quest for new knowledge and better ways of treating people. Gerald (Jerry) Mandell, MD, is an exemplary model of the academic physician/scientist (see photo). The following reflections on his academic career and achievements are offered in acknowledgment of his role as an inspirational teacher, caring physician, and innovative scientist whose contributions to medicine as a whole will have a profound effect on patient treatment.
Prospective Assessment of Presenting Serum Markers for Cardiac Risk Stratification
Authors: Hedges Jerris R. , Swanson J. Robert , Heeter Carol , Sherer Margaret
Published: September 2008

Objective:To quantify the association of initial ED serum cardiac markers with the risk for life‐threatening events (LEs) or need for lifesaving interventions (Lis) or administration of IV nitroglycerin.

Methods: A prospective, observational study was performed using a cohort of hemodynamically stable, hospitalized patients (age > 25 years) presenting with nontraumatic chest discomfort. Patients with ST‐segment elevation on their initial ECGs were excluded. Presenting serum samples were assayed for serum myoglobin and creatine kinase‐MB isomer (CK‐MB) using the Opus and Stratus systems. Target cases were defined as patients having LEs (e.g., cardiogenic shock, ventricular fibrillation, cardiac arrest), requiring Lis (e.g., intubation, cardioversion, pacing, reperfusion therapy), or needing IV nitroglycerin within 48 hours. Manufacturer's thresholds defined abnormal marker levels. Abnormal ECGs were defined using the Brush criteria.

Results: Of the 178 eligible patients, 44 (25%) were target cases. Most (55%) target cases had blood drawn for assays within four hours of chest discomfort onset. The relative risk and sensitivity of the serum markers and the ECG for target cases follow:

Of the seven patients with an LE/LI, six had blood drawn four hours or less after symptom onset; two LE/LI patients had abnormal myoglobin levels' no LE/LI patient had an abnormal CK‐MB level.

Conclusions: Isolated serum myoglobin and CK‐MB levels obtained at patient ED presentation were not strongly associated with the 48‐hour risk for LEs, Lis, or the use of IV nitroglycerin. Future studies of risk stratification should address the merits of serial serum marker measurements that extend up to 12 hours beyond patient symptom onset.
Emergency Department Do‐not‐attempt‐resuscitation Orders: Next‐of‐kin Response to the Emergency Physician
Authors: Balentine Jerry , Gaeta Theodore , Rao Narasinga , Brandon Bernadette
Published: September 2008

Objective:To evaluate the response by families of incompetent, chronically debilitated, and/or terminally ill patients who were contacted for do‐not‐attempt‐resuscitation (DNAR) status by an emergency physician (EP).

Methods: A prospective observational study was performed to assess next‐of‐kin willingness to support DNAR status for incompetent, chronically debilitated, and/or terminally ill patients. The families also were contacted by telephone follow‐up 48–72 hours after the ED visit. Upon follow‐up evaluation, the families were surveyed regarding prior DNAR instructions and their perceptions of the establishment of DNAR status in the ED. The study was conducted in an urban teaching hospital with an emergency medicine residency training program.

Results: Of the 71 patient families contacted, 60 (85%) of the patients had DNAR orders written in the ED. The families of these 60 patients had no negative response regarding contact by ED personnel. Of the

II (15%) patients whose families wished no DNAR order, only two families had negative responses to being contacted by the EP. In both cases the families had previously given detailed instructions to the chronic care facility.

Conclusion: The EP can play an important role in assisting the decision making process of families of incompetent, chronically debilitated, and/or terminally ill patients regarding institution of DNAR orders in the ED. Improved communication regarding existing DNAR orders with chronic care facilities might minimize the rare complaints received from families with preestablished DNAR orders.
Subcutaneous Lidocaine Does Not Affect the Success Rate of Intravenous Access in Children Less than 24 Months of Age
Authors: Sacchetti Alfred D. , Carraccio Carol
Published: September 2008

Objective: To determine whether subcutaneous lidocaine (SQL), when used to decrease the pain of IV catheter insertion, adversely affects IV access in children <24 months of age.

Methods: A historically controlled comparison of IV access successes with and without SQL in children <2 years of age was performed in a 30,000‐annual‐visit community hospital ED. On‐site data collected at the time of IV placement included: patient age, weight, hydration status, number of attempts, and location of attempts. All patients had IV attempts made by the same emergency physician.

Results: A total of 110 children, mean age 9.6 ± 6.9 months, were included in the study analysis. Of the 110, 70 had an IV catheter placed with no pretreatment, while 40 had SQL pretreatment. The average number of attempts for all patients was 1.36 ± 0.73, with 83 (75%) performed successfully in 1 attempt and 101 (91%) within 2 attempts. The mean numbers of attempts were similar for the control and SQL groups: 1.34 vs 1.40, respectively (p = 0.68), as were the proportions successful in 1 attempt (77% vs 73%; p = 0.58) and within 2 attempts (91% vs 90%; p = 0.84).

Conclusion: SQL use prior to an IV attempt in children 2 years of age does not impact vascular access. A secondary finding was that vascular access with and without SQL in infants and small children generally can be accomplished in 1 attempt.
Comparison of Staples vs Suturing for Securing Central Venous Catheters
Authors: Hightowel David , March Juan , Ausband Steve , Brown Lawrence H.
Published: September 2008

Objective: To determine whether skin staples can be used to secure central venous catheters as effectively as does suturing.

Methods: A prospective, randomized trial of techniques to secure a central venous catheter was performed in a medical school human anatomy laboratory using human cadavers. Central lines were secured to the upper left thorax using either standard suture material (000 silk) or skin staples (5.7 mm ± 3.8 mm). Once secured, an upward force was applied to the hub of the catheter perpendicular to the skin. The amount of force needed to break the catheter hub free of the skin was measured in kg. A total of 10 measurements were made for each of 3 methods for securing the catheters (2 sutures, 2 staples, 4 staples). In addition, the site of catheter breakage was recorded.

Results: Those catheter hubs secured by 2 sutures required a mean force of 3.1 ± 0.5 kg to cause breakage, and the break always occurred at the suture. Those hubs secured by 2 staples gave way at 3.0 ± 0.3 kg (p = NS), while those secured with 4 staples gave way at 4.5 2 ±.4 kg (p < 0.05). Although 1 hub did break, in all other stapled cases, the break occurred at the staple.

Conclusions: Based on this cadaver model, use of staples appears to be as effective as suturing for securing central venous catheters. Further studies of safety and time for placement are needed.
Glucagon and Phenylephrine Combination vs Glucagon Alone in Experimental Verapamil Overdose
Authors: Stone C. Keith , Thomas Stephen H. , Koury Shaheed I. , Low Ronald B.
Published: September 2008

Objective: To evaluate glucagon and phenylephrine in combination as a treatment for the hemodynamic effects of verapamil overdose.

Methods: Pentobarbital–anesthetized and instrumented dogs were overdosed using a previously developed verapamil overdose model (15 mg/kg IV over 30 minutes). The animals were maintained and observed for 90 minutes or until death. Cardiac output (CO), heart rate (HR), and mean arterial pressure (MAP) were monitored. Following the 30–minute verapamil infusion (toxicity), the control animals received no treatment; the glucagon animals received a 5–mg glucagon bolus and a drip of 5 mg/90 minutes; and the glucagon/ phenylephrine animals received the same glucagon therapy plus a phenylephrine drip titrated to 180 (μg/ min over 15 minutes. The groups were compared using analysis of variance: the experimental variables were group and time; the response variables were changes from toxicity for the hemodynamic parameters. Post–hoc comparisons were done with a set at 0. 05.

Results: A significant change in CO was seen in the glucagon group (Δ = 2. 6 L/min) and the glucagon/ phenylephrine group (Δ = 1. 9 L/min) compared with the control group (Δ = 0. 8 L/min). The change in CO was significantly larger for the glucagon animals compared with the glucagon/phenylephrine animals. The change in MAP for the glucagon/phenylephrine group (Δ = 24 mm Hg) was significant compared with the control group (Δ = 14 mm Hg). The MAP change for the glucagon group (Δ = 19 mm Hg) was not significantly different from that of either the control or the glucagon/phenylephrine group. The change in glucagon HR (Δ = 6 beats/min) was significant compared with the control group (Δ = –4 beats/min) and the glucagon/phenylephrine group (Δ = –4 beats/min).

Conclusion: The glucagon/phenylephrine therapy improved MAP compared with the control, but reduced CO and HR compared with glucagon alone. Glucagon/phenylephrine therapy is not as effective as glucagon alone in reversing the hemodynamic effects of experimental verapamil overdose.
Rate of Patient Workups by Non–Emergency Medicine Residents in an Academic Emergency Department
Authors: Stone C. Keith , Stapczynski J. Stephan , Thomas Stephen H. , Koury Shaheed I.
Published: September 2008

Objective: To quantify the number of patients seen per hour by non–emergency medicine (non–EM) residents in a university hospital ED.

Methods: This retrospective observational study was performed in a university hospital ED and level I trauma center. The facility had no EM residency, but was staffed with 24–hour EM faculty coverage. A computerized tracking system was searched for the number of patients seen by each of 93 non–EM residents for 12 nonconsecutive months. The ED schedule for each month was used to calculate the number of hours worked by each resident. From these figures, the number of patients seen per hour by each resident was calculated.

Results: The postgraduate years of training of the residents were as follows: 78 (84%) were PGY1, ten (11%) were PGY2, and five (5%) were PGY3. All the residents combined saw a mean 0. 95 ± 0. 20 patients/ hour, with a range from 0. 58 to 1. 75 patients/hour. There was no significant difference between the numbers of patients seen when compared by specialty using the Tukey–Kramer test (α = 0. 05).

Conclusion: The rate at which non–EM residents work up patients is consistent with previously reported rates for EM residents.
Communicating Information to Patients: The Use of Cartoon Illustrations to Improve Comprehension of Instructions
Authors: Delp Chris , Jones Jeffrey
Published: September 2008

Objective: To evaluate the effect of cartoon illustrations on patient comprehension of and compliance with ED release instructions.

Methods: A prospective, randomized, controlled study of consecutive patients who presented to the ED of a community teaching hospital with lacerations necessitating wound repair during a three‐month study period. At ED release, the patients were randomly assigned to receive wound care instructions with or without cartoon illustrations. Three days later, the patients were followed up by telephone. A blinded investigator asked a series of questions designed to test the patient's recall of, understanding of, and compliance with wound care instructions.

Results: A total of 234 patients were successfully contacted by telephone; 105 (45%) had been given ED release instructions with cartoons, 129 (55%), without cartoons. There was no significant difference in age, gender, level of education, or satisfaction with the ED visit between the two groups. The patients given cartoon instructions were more likely to have read the instructions (98% vs 79%, p < 0. 001), were more likely to answer all wound care questions correctly (46% vs 6%, p < 0. 001), and were more compliant with daily wound care (77% vs 54%, p < 0. 01). Subset analysis of those patients who had less than a high school education (n = 57) demonstrated even larger differences between the two treatment groups in terms of comprehension of and compliance with ED release instructions.

Conclusion: Cartoon illustrations are an effective strategy for conveying information and may improve patient compliance with ED release instructions.