bluuebunny/crossref_metadata_2025 huggingface dataset:
Community–wide Emergency Department Visits by Patients Suspected of Drug–seeking Behavior
Authors: Zechnich Andrew D. , Hedges Jerris R.
Published: September 2008

Objective: To measure community–wide ED use by patients at high risk for drug–seeking behavior.

Methods: A retrospective, observational study was performed to analyze a cohort of university hospital ED patients seen January 1 to June 30, 1990, for specific pain–related diagnoses (i.e., ureteral colic, toothache, back pain, abdominal pain, or headache) and either independently identified on at least one other local hospital's “patient alert” list or having a drug–related death during 1990. Patients with terminal illnesses were excluded. The frequency of ED (and affiliated urgent care clinic) visits and hospital admissions were determined for January 1 to December 31, 1990, at seven local hospitals. Detailed, supplemental chart review was performed for visits to three of these hospitals from 1990 to 1992.

Results: Thirty patients were identified as being at risk for drug–seeking behavior (mean age: 34.3 years; range: 21–55 years; 50% males). We identified 379 visits for this cohort (86% ED visits, 9.8% urgent care visits, 4.7% hospital admissions), for an average of 12.6 visits (range: 2–33) per patient per year. On average, each patient visited 4.1 (range: 1–7) different hospitals and used 2.2 (range: 1–6) different aliases. Two patients died of drug overdose. Supplemental chart review revealed 28 episodes (among 17 different patients) in which a patient was told that he or she “would receive no further ‘narcotics’” from that facility; these patients subsequently received controlled substances from another hospital in 93% of these instances and from the same facility in 71%.

Conclusions: Patients identified as being at high risk for drug–seeking behavior have high community–wide ED visit rates. Improving communication between and within hospitals may help identify patients who could benefit from more consistent community–wide care and appropriate treatment for addiction.
Variance Cardiography for Emergency Department Evaluation of Chest Pain Patients
Authors: Spadafore Joseph C. , Lieber James G. , Vasilenko Peter
Published: September 2008

Objective: To determine the test performance of 24–lead variance cardiography (VC), an ECG technique that measures QRS morphologic variability, for ED evaluation of chest pain associated with coronary artery disease (CAD).

Methods: A prospective, single–blind study of VC was performed in a community teaching hospital ED. All chest pain patients (>30 years of age) who, after initial emergency physician evaluation, were believed to have pain of potential cardiac etiology and were admitted to the hospital were eligible. Exclusion criteria included obvious noncardiac etiology for discomfort, bundle–branch block, atrial fibrillation, and incomplete subsequent cardiac evaluation. After initial evaluation and stabilization, VC was obtained. The numerical output of VC was a CAD index (CADI). Serum myoglobin and creatine kinase (CK)–MB levels were obtained at the time of presentation and after one, two, and six hours. Hospital records were reviewed to determine final diagnosis and in–hospital evaluation results.

Results: Fifty–two of 75 eligible patients had complete data. Final diagnoses were as follows: 27/52 (52%), noncardiac; 13/52 (25%), acute myocardial infarction (AMI); and 12/52 (23%), unstable angina due to CAD. Twenty–three percent (12/52) of the patients had CADIs < 75. Eleven of these were found to have noncardiac origins for their chest pain. The twelfth patient had a 12–lead ECG revealing AMI and had been given thrombolytic therapy with subsequent reperfusion prior to VC. Using a CADI < 75 as the cutoff for a negative study, VC alone had a negative predictive value of 92%, a sensitivity of 96%, a positive predictive value of 60%, and a specificity of 41%.

Conclusion: A CADI < 75, in addition to clinical impression and initial ECG, may identify chest pain patients who do not have significant CAD. Further prospective assessment of VC is warranted.
Serial Myoglobin Levels for Patients with Possible Myocardial Infarction
Authors: Davis Charles P. , Barrett Kevin , Torre Paul , Wacasey Kevin
Published: September 2008

Objectives: To determine the sensitivity and specificity of a new myoglobin assay for acute myocardial infarction (AMI), considering both the total amount of serum myoglobin and its percentage change over 2 hours.

Methods: A prospective, observational test performance study for the recognition of AMI was done using serial myoglobin assays of 42 admitted chest pain patients at a large, urban teaching hospital ED. Myoglobin testing was performed at presentation (time 0) and at 1 and 2 hours after arrival. A myoglobin level >100 g/L (ng/mL) or a change >50% from baseline (increase or decrease) any time during the 2–hour period was considered positive. Patients and their physicians were blinded to the myoglobin results. The managing clinician's final diagnosis of the presenting event was used as the diagnostic criterion standard.

Results: The sensitivity of the myoglobin technique for detection of AMI in the first hours in the ED was 13/14 (93%; 95% CI: 66–100%). The 1 patient who had a false‐negative test had evidence of AMI on the ECG and an initially abnormal creatine kinase‐MB (CK‐MB) assay. The specificity was 22/28 (79%; 59–92%). However, of the 6 patients who had “false‐positive” myoglobin tests, all had serious illness: significant cardiac disease (n = 4), in‐hospital death (n = 1), or deep venous thrombosis (n = 1).

Conclusion: Myoglobin level determinations are sensitive tests to detect AMI during the first 2 hours of a patient's stay in the ED and may complement current clinical tools.
An Emergency Medicine Approach to Violence throughout the Life Cycle
Authors: Muelleman Robert L. , Reuwer John , Sanson Tracy G. , Gerson Lowell , Woolard Bert , II Arthur H. Yancy , Bernstein Edward ,   for the SAEM Public Health and Education Committee
Published: September 2008

This document by the SAEM Public Health and Education Committee outlines the public health impact of interpersonal violence as it pertains to acute emergency care. This paper provides an overview of violence through the life cycle (i.e., child abuse, youth violence, intimate violence, and elderly abuse). It also makes specific recommendations regarding the role emergency physicians can play in reducing violence through medical education, research, surveillance, public education, advocacy, and clinical practice.
Blood Cultures in Adult Patients Released from an Urban Emergency Department: A 15‐month Experience
Authors: Sturmann Kai M. , Bopp James , Molinari Diane , Akhtac Saadia , Murphy Jane
Published: September 2008

Objective: To determine the frequency of positive blood cultures obtained from adult patients with potential occult bacteremia released from an urban ED and how often these positive cultures alter the subsequent patient course or management.

Methods: This retrospective case series study was conducted at the ED of a large, urban teaching hospital. The study population consisted of a convenience sample of adult patients who presented to the ED with evidence of fever or other clinical conditions suggesting the possibility of bacteremia. The records of all patients who had blood cultures done and who were not admitted to an inpatient service were reviewed. Follow‐up was obtained for all patients for whom culture results were positive. A substantial influence on the medical management or clinical course by a (noncontaminant) positive blood culture result was defined as a positive result that directly led to: further diagnostic testing, hospital admission, initiation or alteration of antibiotic therapy, or a different diagnosis. Culture‐positive patients who were noncompliant with requested ED follow‐up were included in this estimate. An estimate of the laboratory charges per diagnosis of bacteremia also was derived.

Results: Only 24 of 1,350 patients (1.8% of the study population; 95% CI 1.1–2.5%) had true‐positive blood cultures. Only 7 patients (0.52% of the population; 95% CI 0.14–0.90%) potentially had their medical management affected by the positive blood culture results. Based on the laboratory charges associated with all blood cultures for this patient group, the cost per clinically significant positive blood culture result was $11,570.

Conclusions: The prevalence of bacteremia was 1.8% among the released patients who had blood cultures obtained in the ED. Furthermore, only 0.52% of the patients had positive blood cultures that potentially affected their medical management. Further study is warranted to identify specific criteria for selecting ambulatory patients for whom the use of blood cultures may be cost‐effective.
Subarachnoid Hemorrhage Diagnosis: Lumbar Puncture Is Still Needed When the Computed Tomography Scan Is Normal
Authors: Sidman Robert , Connolly Emily , Lemke Thomas
Published: September 2008

Objectives: To determine the sensitivity of third‐generation CT scanners for diagnosed nontraumatic subarachnoid hemorrhage (SAH) and to assess the impact of symptom duration on sensitivity.

Methods: A retrospective chart review was performed in a university‐affiliated tertiary care hospital with an annual ED volume of >100,000 patients. The target population was all patients who presented to the ED from January 1991 to September 1994 with symptoms suggestive of SAH and who had a final diagnosis of nontraumatic SAH based on either a positive CT scan or positive spinal fluid analysis. Patients referred from outside facilities were included if they had a CT done at the study site. All CT scans were done using third‐generation scanners. Official CT scan reports were used to categorize scans as positive or negative.

Results: There were 140 patients identified with SAH, with a mean age of 56 years (range 10–88). The sensitivity of CT in the diagnosis of nontraumatic SAH when performed at or before 12 hours of symptom duration was 100% (80/80), and 81.7% (49/60) after 12 hours of symptom duration (95% CI 95–100% and 69.5–90.4%, respectively; p < 0.0001). Eleven of the 140 patients had a negative CT and positive spinal fluid analysis, yielding an overall sensitivity of 92.1% (129/140).

Conclusion: The sensitivity of third‐generation CT scans for SAH decreases with time from the onset of symptoms. In this sample population, CT was able to detect all patients scanned ^12 hours after symptom onset. Although the study demonstrated good sensitivity of CT scan reports for SAH when the scan was performed after S12 hours of symptom onset, additional real‐time experience is needed to better define the potential risk of a missed SAH should this population not receive the customary lumbar puncture examination in the setting of a negative CT scan.
The Frequency of Unsuspected Minor Illness or Injury in Intoxicated Patients
Authors: Biros Michelle H.
Published: September 2008

Objective: To determine the frequency of unsuspected minor illness or injury in a group of patients frequently seen in the ED for acute intoxication.

Methods: The medical records of the 20 patients seen most frequently in the ED for acute intoxication in 1993 were reviewed for the number of ED visits for intoxication, the number of associated documented episodes of minor trauma or illness, the extent of ED workup of discovered illness or injury, and patient disposition from the ED.

Results: The 20 study patients were evaluated in the ED 1,858 times in 1993 for acute intoxication, a mean of 92.5 visits/patient (±26.6). The most frequent injury was minor trauma above the neck, occurring a mean of 9 times (±3.6) in each of the study patients during 1993. Evaluation included repeated neurologic examinations and frequent radiography of the cervical spine (n = 80), skull (n = 5), facial bones (n = 6), and mandible (n = 5). A limited number of head CT scans also were done (n = 8). The most frequent minor illnesses were gastritis (n = 7), managed with hydration, and mild hypothermia (n = 6), managed with passive rewarming.

Conclusions: The incidence of unsuspected minor illness or injury in this patient group was substantial. While most unsuspected medical problems had little clinical significance, some were potentially dangerous, and some necessitated hospitalization (e.g., hypothermia, hematemesis, and respiratory depression).
Flunitrazepam and Its Involvement in Date or Acquaintance Rape
Authors: Anglin Deirdre , Spears Kelvin L. , Hutson H. Range
Published: September 2008

An estimated 1 in 4 women in the United States will be raped in their lifetimes. Approximately 75% of all rapes are date or acquaintance rapes. Recently the illegal use of flunitrazepam (Rohypnol), a benzodiazepine, as a prelude to the assault has been reported. Flunitrazepam readily dissolves, and once in solution, is colorless, odorless, and tasteless. The predominant clinical manifestations are drowsiness, impaired motor skills, and anterograde amnesia. Due to the amnestic effects of flunitrazepam, historical clues of the rape event are difficult to obtain. Patients with a complaint of sexual assault who appear intoxicated or have anterograde amnesia should be suspected of unknowingly ingesting flunitrazepam. In addition to adhering to standard rape protocols, a urine specimen should be analyzed for flunitrazepam metabolites using gas chromatography/mass spectrometry. If the hospital, local, or forensic laboratory is unable to analyze for flunitrazepam, Hoffmann‐La Roche Inc., the manufacturer of Rohypnol, should be contacted. Hoffmann—La Roche has a mechanism for definitive testing for flunitrazepam, at no cost, for health care providers, rape treatment centers, and law enforcement agencies. A network of organizations is attempting to reduce the abuse of flunitrazepam in association with date rape.
Role of Pilot Instrument Proficiency in the Safety of Helicopter Emergency Medical Services
Authors: Wuerz Richard C. , O'Neal Rick
Published: September 2008

Objectives: To determine whether instrument‐proficient pilots would more safely manage a flight into unplanned instrument meteorologic conditions (IMC) than would nonproficient pilots.

Methods: A controlled experimental study was performed using a full‐motion helicopter simulator. Participants were emergency medical services (EMS) pilots with commercial licenses and previous simulator experience who were blinded to the study design and hypothesis. During a simulated EMS mission, cloud ceiling and visibility were decreased until IMC prevailed, and pilot actions were recorded. Data included the altitude at which the aircraft entered IMC, and whether the pilots maintained control of the aircraft, flew within aviation standards (i.e., bank angle, airspeed), and safely landed.

Results: Twenty‐eight pilots (13 instrument‐proficient, 15 nonproficient) participated; they had a median of 6,300 hours of helicopter experience. Two pilots crashed, both from the nonproficient group. The instrument‐proficient pilots lost control less often (15% vs 67%, p < 0.05), maintained instrument standards more often (77% vs 40%, p < 0.05), and entered IMC at a higher altitude (689 feet vs 517 feet, p < 0.05) compared with the nonproficient pilots. Instructor comments indicated that the nonproficient pilots made more errors than did the instrument‐proficient pilots.

Conclusions: Instrument‐proficient pilots more safely manage an unexpected encounter with IMC. Helicopter EMS programs should strongly consider maintaining instrument proficiency to enhance safety.
Early Stroke Recognition: Developing an Out‐of‐hospital NIH Stroke Scale
Authors: Kothari Rashmi , Hall Kent , Brott Thomas , Broderick Joseph
Published: September 2008

Objective: To develop an abbreviated and practical neurologic scale that could assist emergency medical services or triage personnel in identifying patients with stroke.

Methods: A prospective, observational, cohort study was performed at university‐based EDs. Participants were 74 patients treated in a thrombolytic stroke trial and 225 consecutive non‐stroke patients evaluated during 4 random 12‐hour shifts in the ED. Scores on the NIH Stroke Scale were obtained for all patients by physicians. Items of this scale were modified and recoded to a binomial (normal or abnormal) scale. Serial univariate analyses using χ2 were performed to rank items. Recursive partitioning was then performed to develop the decision rule for predicting the presence of stroke.

Results: Three items identified 100% of patients with stroke: facial palsy, motor arm, and dysarthria. An Abbreviated NIH Stroke Scale based on these items had a sensitivity of 100% and a specificity of 92%. A proposed Out‐of‐hospital NIH Stroke Scale consisting of facial palsy, motor arm, and a combination of dysarthria and best language items (abnormal speech) had a sensitivity of 100% and a specificity of 88%.

Conclusion: Using the derivation data set, a proposed Out‐of‐hospital NIH Stroke Scale had a high sensitivity and specificity for identifying patients with stroke when performed by physicians in this group of 299 ED patients. Prospective studies of other health care professionals using the scale in the out‐of‐hospital arena are needed.
The Effect of Injection Speed on the Pain of Lidocaine Infiltration
Authors: Krause Richard S. , Moscati Ronald , Filice Michael , Lerner E. Brooke , Hughes David
Published: September 2008

Objective: To determine whether reducing the speed of injection is effective in reducing injection pain for buffered and unbuffered lidocaine solutions.

Methods: A prospective, single‐blind, randomized, crossover, laboratory study was performed. Adult volunteers were recruited from ED staff at an urban teaching hospital to serve as subjects. Twenty‐nine subjects each received 4 1‐mL injections into the dorsum of the hands. Each subject received fast and slow injections of buffered and unbuffered lidocaine. Subjects rated the pain of each injection on a 100‐mm visual analog scale (VAS). Mean pain scores for each intervention were compared using analysis of variance.

Results: The mean pain VAS score for fast injection of buffered lidocaine was 14.1 mm. For slow buffered injection, the mean pain score was 11.4 mm (p = 0.98). For unbuffered lidocaine, the means were 28.7 mm for fast injection and 22.2 mm for slow injection (p = 0.40).

Conclusions: Reducing injection speed did not produce a statistically significant change in injection pain for either buffered or unbuffered solutions.
Victimization from Physical Violence in Pennsylvania: Prevalence and Health Care Use
Authors: Forjuoh Samuel N. , Kinnane Janet M. , Coben Jeffrey H. , Deanvater Stephen R. , Songer Thomas J.
Published: September 2008

Objectives: To determine the prevalence of interpersonal physical violence (IPV) among Pennsylvania adults, to identify the personal characteristics of the victims, and to determine their health care use for resulting injuries.

Methods: Population‐based data describing physical violence were obtained through a statewide telephone survey of 3,620 Pennsylvania adults selected from households by random‐digit dialing in 1994. The prevalence and 95% confidence interval (95% CI) of victimization from IPV along with ED or other medical care facility use for IPV‐related injuries were computed by several personal characteristics. Logistic regression was used to compare victims of IPV and their levels of health care use.

Results: The prevalence of reported victimization from IPV was 5.6% (95% CI = 4.9, 6.3). Significantly more victimization was reported by males, persons aged 18–29 years, those employed, and unmarried persons. The proportion of victims who reported to have gone to an ED or other medical care facility for IPV‐related injury treatment was 12.9%. Significantly more persons with annual household incomes <$20,000 reported health care use for injuries resulting from IPV than did those with incomes of ≥$20,000 (OR = 3.98; 95% CI = 1. 27, 12.48). Health care use for injuries was not found to be related to gender, age. race, employment, or marital status.

Conclusions: This population‐based study of health care use for IPV‐related injuries found that victims of physical violence in Pennsylvania were not only young and unmarried men, but also employed. Health care use for resulting injuries was greater among persons with lower incomes.
Faculty Development in Emergency Medicine
Authors: Jouriles Nicholas J. , Kuhn Gloria J. , Moorhead John C. , Ray V. Gail , Rund Douglas A.
Published: September 2008

Faculty development is an important, multifaceted topic in academic medicine. In this article, academic emergency physicians discuss aspects of faculty development, including: 1) a department chair's method for developing individual faculty members, 2) the traditional university approach to promotion and tenure, 3) faculty development in a new department, and 4) personal development.
The Effects of Combined Intravenous and Inhaled Steroids (Beclomethasone Dipropionate) for the Emergency Treatment of Acute Asthma
Authors: Guttman Alex , Afilalo Marc , Colacone Antoinette , Kreisman Harvey , Dankoff Jerrald ,   Asthma ED Study Group
Published: September 2008

Objective: To compare the efficacy of high‐dose inhaled steroids in conjunction with IV steroids with that of IV steroids alone in the emergency treatment for acute asthma.

Methods: A double‐blind, placebo‐controlled, randomized trial was conducted on 60 ED patients presenting with acute asthma. All patients received nebulized salbutamol, and IV methylprednisolone, 80 mg at baseline and 40 mg at 6 hours. In addition to the above therapy, the experimental group received beclomethasone dipropionate (BDP) 7 mg over 8 hours via a metered‐dose inhaler (MDI) attached to a holding chamber, while the control group received a placebo administered in the same fashion. Patients were treated on the protocol for 12 hours with the primary outcome measure being the change in % predicted FEV1.

Results: Of 60 patients, 30 were randomized to BDP (age: 42 ± 16 years; FEV1: 0.97 ± 0.42 L) and 30 were randomized to placebo (age: 37 ± 18 years; FEV1: 0.98 ± 0.35 L). Spirometry and dyspnea measured by the Borg Scale improved significantly in both groups compared with baseline (p < 0.001). Changes in spirometry measures, dyspnea, and vital signs did not differ between treatment groups over the 12 hours of study (p > 0.05).

Conclusion: Inhaled BDP added to the standard regimen of IV methylprednisolone, and β‐agonist did not further improve flow rates or dyspnea scores measured for up to 12 hours after presentation to the ED.
Color Doppler Ultrasonography by Emergency Physicians for the Diagnosis of Acute Deep Venous Thrombosis
Authors: Jolly B. Tilman , Massarin Elizabeth , Pigman E. Cary
Published: September 2008

Objectives: To assess the feasibility of emergency physicians' (EPs') performing color‐flow Doppler ultra‐sonographic vascular studies in the ED to diagnose deep venous thrombosis (DVT), after a modest training program.

Methods: A retrospective observational review was performed of the performance of color‐flow Doppler ultrasonographic vascular studies by EPs. Prior to the study period, venous Doppler studies were not available at off‐hours. Two attending EPs were trained by the hospital's vascular laboratory by observing studies and then performing 25–30 studies successfully. They were then available to examine all patients presenting to the ED at off‐hours who were suspected of having DVT. Patients were admitted or released from the ED based on the examination results. All patients were to have formal vascular laboratory studies the next day. The study was performed at a university hospital ED and evaluated all patients who underwent off‐hour examinations from January 1993 to February 1994. The examiners were aware of the clinical scenario. Results: Of 23 eligible patients, 15 completed the protocol with a follow‐up next‐day study. Based on the follow‐up study, the ED examination was 100% sensitive (7 true positives) and 75% specific (6 true negatives). The 2 false‐positive studies were for patients with old DVT. The 8 patients without follow‐up studies were not included in the analysis, although 4 of these patients had negative studies and unremarkable clinical outcomes.

Conclusions: These preliminary findings suggest that Doppler ultrasonographic studies of the lower extremity veins by EPs can be used to make admission decisions when formal studies are not available. Confirmatory studies should be performed. EPs may overread acute thrombosis in the setting of old venous disease. Issues of cost and logistics remain to be resolved.
Multiphasic Anaphylaxis: An Uncommon Event in the Emergency Department
Authors: Brady William J. , Luber Samuel , Carter C. Thomas , Guertler Andrew , Lindbeck George
Published: September 2008

Objective: To determine the rate of clinically significant recurrence of symptoms in patients treated for anaphylaxis in the ED.

Methods: Retrospective chart review of out‐of‐hospital, ED, and hospital records over a 4.5‐year period (July 1991 to December 1995) at a university hospital ED with an annual patient volume of 60,000. Subjects were ED anaphylaxis patients with ≥2 of the following 3 organ systems involved: cutaneous, respiratory, and cardiovascular. The major outcome criterion was recurrence of symptoms after ED release. Recurrences were sought at the primary treatment hospital and at surrounding hospitals (radius of 75 miles from the primary institution) within a 7‐day period from the initial visit. Review of the state death registry also was made to verify the absence of out‐of‐hospital deaths.

Results: The medical records of 1,261 allergic reaction patients were reviewed, with 67 (5.3%) cases of anaphylaxis identified. Symptoms and signs in patients during the ED phase included: dyspnea, 42 (63%); pruritus, 38 (57%); emesis, 27 (41%); throat/chest tightness, 25 (37%); orthostatic complaints, 12 (18%); urticaria, 47 (70%); circulatory shock, 32 (48%); upper airway angioedema, 7 (33%); stridor, 11 (16%); and bronchospasm, 20 (30%). Of the 67 patients, 93% had immediate resolution and remained asymptomatic for a mean time of 4.2 hours in the ED. Protracted reaction occurred in 5 cases (3 using β‐adrenergic blocking agents). For 19 (28%) patients admitted to hospital, the mean hospital length of stay was 63 hours. Only 2 (3%) recurrent cases were identified, both manifested solely by urticaria.

Conclusion: Recurrent anaphylactic reactions were rare, occurring in 3% of cases and without life threat in this patient population. Selective outpatient management of patients with severe anaphylactic reactions that promptly respond to therapy with complete, rapid resolution may be reasonable. Further study of this medical emergency is required to develop criteria to guide the choice of an outpatient disposition.
Herbal Preparation Use among Urban Emergency Department Patients
Authors: Hung Oliver L. , Shih Richard D. , Chiang William K. , Nelson Lewis S. , Hoffman Robert S. , Goldfrank Lewis R.
Published: September 2008

Objective: To determine the prevalence of herbal preparation use among patients presenting to an urban teaching hospital ED.

Methods: A prospective anonymous survey on herbal preparation use was performed. Consecutive, acutely ill or injured adult (≥8 years old) ED patients were offered the survey over a 1‐month period. The survey also asked for information related to patient age, ethnicity, gender, employment, education, cigarette smoking history, ethanol consumption, use of illicit drugs, chief complaint, and HIV status.

Results: Of 2,473 eligible subjects, 623 (25%) participated. The overall reported prevalence of herbal preparation use among the participants was 21.7%. Women were more likely to use herbal preparations than men (28.5% vs 17.2%, p = 0.013). Prevalence rates in different ethnic populations were: whites, 18.2%; Hispanics, 13.9%; blacks, 26.4%; and Asians, 36.8%. Asians had a significantly higher use rate than the other ethnic groups (p = 0.039). Neither HIV positivity, educational level, employment status, nor age was significantly associated with herbal preparation use. The most commonly reported herbal preparations were goldenseal tea, garlic, and ginger. Several of the herbal preparations reported as used by patients in this study have been associated with severe systemic toxicity in the medical literature.

Conclusion: Although the survey response rate was low, the prevalence of herbal preparation use among acutely ill or injured patients presenting to this urban ED remains significant. A directed history toward specific herbal preparation use may provide relevant pharmacologic information and uncover cases of herbal‐preparation‐induced toxicity.
Research Subject Enroller Program: A Key to Successful Emergency Medicine Research
Authors: Cobaugh Daniel J. , Spillane Linda L. , Schneider Sandra M.
Published: September 2008

Objective: To describe the successful use and impact of individuals paid to enroll clinical research subjects in support of emergency medicine (EM) research.

Program Description: Paramedics and college students were hired to identify/enroll subjects in EM research studies 14 hours/day, 7 days/week. Potential subjects were identified by monitoring emergency medical services radios, routine rounding in the ED, and communication with the ED attending and charge nurse. Enrollers were trained in phlebotomy, obtaining ECGs, obtaining consent in appropriate studies, and post‐ED follow‐up. They supported ED prospective studies and multicenter clinical trials, as well as departmental surveys and retrospective studies. Survey support included mailing list development, mailing completion, survey database design, and data entry.

Program Outcomes: Over 18 months, 17 prospective studies and 8 surveys/retrospective studies were completed. 2,175 subjects were enrolled in prospective studies and 6,500 surveys/retrospective reviews were completed. In the year prior to enroller program initiation, <100 subjects were enrolled in 3 departmental studies.

Conclusion: Use of paid, clinical research subject enrollers supports successful recruitment of study subjects and the completion of EM research studies.
Morganella morganii: A Newly Reported, Rare Cause of Neonatal Sepsis
Authors: Salen Philip N. , Eppes Stephen
Published: September 2008

This case report reviews the clinical course of an 11‐day‐old boy who developed late‐onset neonatal sepsis secondary to a rare neonatal pathogen, Morganella morganii. This gram‐negative enteric bacterium, within the Enterobacteriaceae family, has most commonly been a nosocomial pathogen in debilitated, postsurgical patients. Like many other Enterobacteriaceae, M. morganii has an inducible β‐lactamase and is resistant to multiple antibiotics. When caring for neonates with culture‐proven M. morganii sepsis, the authors recommend administering both a third‐generation cephalosporin and an aminoglycoside to ensure that both antibiotics are bactericidal and to reduce the induction of resistance.
Analysis of Factors Affecting U.S. Emergency Physician Workforce Projections
Authors: Holliman C. James , Wuerz Richard C. , Hirshberg Alan J. , Force SAEM Workforce Task
Published: September 2008

Objectives: To use existing data sources to refine prior estimates of the U.S. emergency medicine (EM) workforce and to estimate effects of proposed changes in the U.S. health care system on the EM workforce. Methods: Relevant data were extracted from the American College of Emergency Physicians (ACEP) 1995 Membership Activity Report, the American Medical Association (AMA) publication “1995/96 Physician Characteristics and Distribution in the U.S.,” the American Hospital Association (AHA) 1994 hospital directory, a written survey of each state's medical licensing board and state medical society, and the American Board of Emergency Medicine (ABEM) annual activity report for 1995. These data were used to project workforce supply and demand estimates applicable to workforce models.

Results: None of the available information sources had complete data on the number and distribution of emergency physicians (EPs) currently practicing in the United States. Extrapolating the limited reliable statewide EP numbers to make nationwide projections reveals a shortage of EPs needed to fully staff the nation's existing EDs. At least 22 states had an average ratio of <5 EPs per existing ED. Additional national projections incorporating a decreasing number of U.S. EDs indicate that the current annual number of EM residency graduates will not eliminate the deficit of EPs for at least several decades, given that projected numbers of retiring EPs annually will soon equal the total annual EM residency graduate production. Conclusions: Although the current data on EPs in practice in the United States are incomplete, the authors project a relative shortage of EPs. More accurate and complete information on the numbers and distribution of EPs in America is needed to improve workforce projections.
The Relationship Between Emotional Resources and Emotional Labor: An Exploratory Study
Authors: Liu Yongmei , Prati L. Melita , Perrewé Pamela L. , Ferris Gerald R.
Published: September 2008

The study examines the effects of a subtype of personal resources (i.e., emotional resources) on emotional labor strategies. We examined 2 variables, emotional intelligence and negative affectivity, as proxies for emotional resources. Largely consistent with predictions, results indicated that individuals with a high level of emotional resources (indicated by high emotional intelligence) are more likely than others to deep act, and individuals with comparatively low emotional resources (indicated by high negative affectivity) are more likely than others to surface act. The differential effects of surface acting and deep acting on strain and job satisfaction were examined. Depressed mood was found to mediate the relationship between surface acting and job satisfaction.
Clinical Correlates of Dispositional Forgiveness
Authors: Webb Marcia , Colburn Trina A. , Heisler Dawn , Call Steve , Chickering Sarah A.
Published: September 2008

The present study examined relationships between the variables of depression, shame, guilt, psychological maltreatment, and dispositional forgiveness. The methodology included the completion of questionnaires by 280 university and community college participants. Results indicated that all factors of dispositional forgiveness were negatively related to depression, to shame, and to all factors of psychological maltreatment. Partial correlations further revealed positive associations between guilt and dispositional forgiveness. Hierarchical multiple regression analyses demonstrated the unique contribution of psychological maltreatment to dispositional forgiveness beyond that of depression, shame, and guilt. Implications of results for clinical practice and future research are discussed.
Norming and Performing: Using Microworlds to Understand the Relationship Between Team Cohesiveness and Performance1
Authors: Fullagar Clive J. , Egleston David O.
Published: September 2008

The current study used a microworld simulation to investigate the direction of the relationship between group cohesiveness and performance. The study involved ten 4‐person teams who undertook 12 sessions of an air traffic control simulation. Performance and cohesiveness data were collected at each 1‐hr session. Using hierarchical linear modeling, group performance was found to predict group cohesiveness and not vice‐versa. These findings are discussed with respect to previous research and popular theories of group development.
Does reactivity to stress cosegregate with subclinical psychosis? A general population twin study
Authors: Lataster T. , Wichers M. , Jacobs N. , Mengelers R. , Derom C. , Thiery E. , Van Os J. , Myin‐Germeys I.
Published: September 2008

Objective:  This study assessed the relationship between stress reactivity (trait 1) and psychosis (trait 2) across genetically related persons (cross‐twin, cross‐trait design) to examine whether stress reactivity is an uncontaminated and unconfounded familial marker of psychosis risk.

Method:  Reactivity to stress and subclinical psychotic experiences were assessed in 289 female, general population twin‐pairs. Cross‐trait, within‐twin associations investigating the association between stress reactivity and subclinical psychotic experiences in each person, were calculated. In addition, cross‐trait, cross‐twin associations were calculated to assess whether stress reactivity in one twin was moderated by subclinical psychotic experiences in the co‐twin.

Results:  Cross‐trait, within‐twin analyses showed significant associations between stress reactivity and subclinical psychotic experiences in each person. In addition, the cross‐trait cross‐twin analyses showed that stress reactivity in twin 1 was significantly moderated by subclinical experiences in the co‐twin.

Conclusion:  The results suggest that the psychosis phenotype cosegregates with increased emotional reactivity to stress in daily life.
Subjective and objective sleep among depressed and non‐depressed postnatal women
Authors: Dørheim S. K. , Bondevik G. T. , Eberhard‐Gran M. , Bjorvatn B.
Published: September 2008

Objective:  Women sleep less in the postnatal period and it has been suggested that mothers diagnosed with depression alternatively could be suffering from the effects of chronic sleep deprivation.

Method:  From a population‐based study, we recruited 42 women, of whom 21 scored ≥10 on the Edinburgh Postnatal Depression Scale. Sleep was registered by the Pittsburgh Sleep Quality Index (PSQI), sleep diaries and actigraphy 2 months after delivery.

Results:  There were significant differences in subjective sleep measured retrospectively by the PSQI between depressed and non‐depressed women. In contrast, there were no significant differences in sleep measured prospectively by sleep diaries and actigraphy. Both depressed and non‐depressed women had impaired sleep efficiency (82%) and were awake for about 1.5 h during the night. Primipara had worse sleep, measured by actigraphy, compared with multipara.

Conclusion:  Measured objectively and prospectively, women with depression did not have worse sleep than non‐depressed women.
Changes in serum interleukin‐6, C‐reactive protein and thrombomodulin levels under periodontal ultrasonic debridement
Authors: Ushida Yuka , Koshy Geena , Kawashima Yoko , Kiji Makoto , Umeda Makoto , Nitta Hiroshi , Nagasawa Toshiyuki , Ishikawa Isao , Izumi Yuichi
Published: September 2008

Aim: This study aimed to compare the effect of single‐visit full‐mouth mechanical debridement (FMD) and quadrant‐wise mechanical debridement (QMD) on the levels of serum interleukin (IL)‐6, C‐reactive protein (CRP) and soluble thrombomodulin.

Material and Methods: Thirty‐six subjects with chronic periodontitis were randomly allocated to three groups: undergoing QMD, single‐visit FMD with povidone iodine or with water. Serum IL‐6 and soluble thrombomodulin were measured by enzyme‐linked immunosorbent assay, and serum CRP was measured by the latex‐enhanced nephelometric method.

Results: Serum IL‐6 level increased significantly immediately after debridement in all the three groups, with this increase being greatest in the full‐mouth groups. However, the increase in the full‐mouth groups was not significantly higher than that of quadrant‐wise group. In the quadrant‐wise group, serum IL‐6 level decreased significantly 1 month after debridement compared with baseline. Serum‐soluble thrombomodulin decreased significantly in the full‐mouth groups but not in the quadrant‐wise group. Changes in CRP level were not significant at baseline or after debridement in all the three groups.

Conclusions: FMD increased serum IL‐6 and reduced serum‐soluble thrombomodulin to a greater extent than QMD, suggesting that the former technique has stronger transient effects on systemic vascular endothelial functions than the latter.
Smoking behaviour and attitudes to periodontal health and quit smoking in patients with periodontal disease
Authors: Martinelli Elizabeth , Palmer Richard M. , Wilson Ron F. , Newton J. Tim
Published: September 2008

Objective: The aim of this study was to assess oral health‐related beliefs and attitudes, health behaviour of smokers in relation to the Transtheoretical Model (TTM) of behaviour change, willingness to have smoking cessation provided together with periodontal treatment.

Material and Methods: Postal questionnaire was sent to 500 referred patients. Part 1 looked at attitudes and beliefs about periodontal disease, Part 2 aimed at current smokers focused on the TTM and smoking cessation.

Results: Response rate was 56% (n=277); 67% females, 33% males. Mean age was 44.9 years (SD 12.45); 24.5% current smokers, 30.3% past smokers, 45.5% never smokers. Fewer smokers reported “bleeding gums” (p=0.027), but more smokers reported “having loose teeth” (p=0.016). The TTM stages of change indicated that 31% of current smokers were in pre‐contemplation of quitting smoking, 46% were in contemplation and 23% were in preparation. Twenty‐three percent of the past smokers were in action and 77% in maintenance. Smokers showed differences in the “self‐re‐evaluation” (p=0.001) and “self‐liberation” (p=0.015) processes of change depending on their stage of change (pre‐contemplation or preparation). Nearly half (49%) of the current smokers who wanted to quit requested smoking cessation to be provided alongside their periodontal treatment.

Conclusion: A large proportion of periodontal patient smokers may be considering quitting, and nearly half requested provision of smoking cessation intervention in conjunction with the periodontal treatment.
Cholelithiasis in thalassemia major
Authors: Origa Raffaella , Galanello Renzo , Perseu Lucia , Tavazzi Dario , Domenica Cappellini M. , Terenzani Laura , Forni Gian Luca , Quarta Giovanni , Boetti Tatiana , Piga Antonio
Published: September 2008

Objectives:  Aim of this study was to evaluate prevalence and characteristics of cholelithiasis in a large population of patients with thalassemia major (TM).

Methods:  Data from 858 consecutive patients with transfusion‐dependent thalassemia at five major Italian centers were analyzed. In these centers, a complete abdomen ultrasonography is performed yearly after the beginning of the transfusion regimen. The role of co‐inheriting Gilbert’s syndrome genotype was investigated studying the promoter region of the UGT1‐A1 gene by automated sequencing.

Results:  Thirty percent of TM patients had gallstones. The Gilbert’s genotype [homozygosity for (TA)7 motif at UGT1A promoter gene], influenced both the prevalence of cholelithiasis and the age at which it developed.

Conclusions:  Cholelithiasis has a remarkable frequency and precocity in patients with TM and especially in those with (TA)7/(TA)7 UGT1‐A1 genotype. An early biliary ultrasonography is recommended from childhood and a closer follow‐up in patients with thalassemia and associated Gilbert’s syndrome may be indicated.
MT3/QR2 melatonin binding site does not use melatonin as a substrate or a co‐substrate
Authors: Boutin Jean A. , Marcheteau Estelle , Hennig Philippe , Moulharat Natacha , Berger Sylvie , Delagrange Philippe , Bouchet Jean‐Paul , Ferry Gilles
Published: September 2008

Abstract: Quinone reductase 2 (QR2, E.C. 1.10.99.2) is implicated in cell reactive oxygen species production. The catalytic activity of this enzyme is inhibited by 1 μmof melatonin. QR2 was identified as the third melatonin binding site (MT3). It is of major importance to understand the exact roles of melatonin and QR2 in oxidative stress. A fascinating possibility that melatonin could serve as a co‐substrate or substrate of QR2 was hypothesized recently. In the current investigation, nuclear magnetic resonance studies of the QR2 catalytic reaction were performed, the results led us to conclude that, whatever the conditions, melatonin is not cleaved off to form N1‐acetyl‐N2‐formyl‐5‐methoxykynurenine by a catalytically active QR2, very strongly indicating that melatonin is neither a substrate nor a co‐substrate of this enzyme. Further studies are needed in order to better understand the relationship between MT3/QR2, melatonin and redox status of the cells, in order to better explain the anti‐oxidant activities of melatonin at pharmacological concentrations (>1 μm).
Pitfalls in the design and analysis of paediatric clinical trials: a case of a ‘failed’ multi‐centre study, and potential solutions
Authors: Van Der Lee Johanna H , Tanck Michael WT , Wesseling Judit , Offringa Martin
Published: September 2008

Aim: To increase awareness of possible pitfalls in the design and analysis of a multi‐centre randomized clinical trial and to give an overview of alternative study designs and their consequences for power analyses in case of limited availability of trial participants.

Methods: Investigation of the assumptions in the power calculation and re‐analysis of the original data of a ‘failed’ trial on the effect of dexamethasone on the duration of mechanical ventilation in young children with respiratory syncytial virus infection. Use of ‘boundaries approach’ is explored using the data from this trial. A comprehensive overview of the various modern solutions for the design of a subsequent trial in this field is given.

Results: Two frequent major deficiencies of trial design and data analysis are reviewed in depth, i.e. too optimistic assumptions for the sample size calculation and failure to adjust for centre effects.

Conclusion: Critical review of trial assumptions and if necessary sample size recalculation based on an internal pilot by a data monitoring committee is recommended to maximize the probability of obtaining conclusive results.
Fluorescence studies of the replication initiator protein RepA in complex with operator and iteron sequences and free in solution
Authors: Diederix Rutger E. M. , Dávila Cristina , Giraldo Rafael , Lillo M. Pilar
Published: September 2008

RepA, the replication initiator protein from the Pseudomonas plasmid pPS10, regulates plasmid replication and copy number. It is capable of autorepression, in which case it binds as a dimer to the inverted repeat operator sequence preceding its own gene. RepA initiates plasmid replication by binding as a monomer to a series of four adjacent iterons, which contain the same half‐repeat as found in the operator sequence. RepA contains two domains, one of which binds specifically to the half‐repeat. The other is the dimerization domain, which is involved in protein–protein interactions in the dimeric RepA–operon complex, but which actually binds DNA in the monomeric RepA–iteron complex. Here, detailed fluorescence studies on RepA and an N‐(iodoacetyl)aminoethyl‐8‐naphthylamine‐1‐sulfonic acid‐labeled single‐cysteine mutant of RepA (Cys160) are described. Using time‐resolved fluorescence depolarization measurements, the global rotational correlation times of RepA free in solution and bound to the operator and to two distinct iteron dsDNA oligonucleotides were determined. These provide indications that, in addition to the monomeric RepA–iteron complex, a stable dimeric RepA–iteron complex can also exist. Further, Förster resonance energy transfer between Trp94, located in the dimerization domain, and N‐(iodoacetyl)aminoethyl‐8‐naphthylamine‐1‐sulfonic acid‐Cys160, located on the DNA‐binding domain, is observed and used to estimate the distance between the two fluorophores. This distance may serve as an indicator of the orientation between both domains in the unbound protein and RepA bound to the various cognate DNA sequences. No major change in distance is observed and this is taken as evidence for little to no re‐orientation of both domains upon complex formation.