bluuebunny/crossref_metadata_2025 huggingface dataset:
Health care resource utilization in patients with active epilepsy
Authors: Kurth Tobias , Lewis Barbara E. , Walker Alexander M.
Published: December 2009

Purpose:  To evaluate health care resource utilization (HRU) in active epilepsy.

Methods:  Thomson‐Reuters insurance databases included 14 million persons in 2005–2007. We extracted information for individuals with insurance claims suggestive of epilepsy. Using iterative expert classification, we sorted patients by type of epilepsy. For each type we calculated prevalence and HRU. A distance analysis identified closely similar types, and a principal components analysis revealed dimensions of variation in HRU.

Results:  The prevalence of active epilepsy was 3.4 per 1,000. Most common diagnoses among 46,847 patients were generalized convulsive epilepsy (33.3%) and complex partial seizures (24.8%). Patients averaged 10 physician visits per year, 24 diagnostic tests/procedures per year, >30 drug dispensings per year, and <1 emergency room (ER) visit per year, the minority of each of these being related to epilepsy. Female patients generally had more HRU, and HRU increased with age. Patients were hospitalized most frequently for disorders other than epilepsy. HRU was similar for most epilepsy types, excepting grand mal status, epilepsia partialis continua, and infantile spasms. The first principal components of HRU variation was nonepilepsy HRU, followed by components of epilepsy‐related medications, other epilepsy/emergency care, and epilepsy visits/diagnostic procedures.

Discussion:  The prevalence of active epilepsy in the United States is substantially less than the prevalence of any history of recurrent seizure. Nonepilepsy‐related HRU dominated HRU in epilepsy patients and was the principal source of variation. There is a core set of epilepsy diagnoses, the HRU patterns of which are indistinguishable, whereas patients with grand mal status, epilepsia partialis continua, and infantile spasms all have distinct patterns. To provide more specific insights into the economic impact of the condition, studies of HRU in epilepsy should make a distinction about epilepsy‐related and unrelated care.
Prognosticating acute symptomatic seizures using two different seizure outcomes
Authors: Leung Howan , Man Celeste B. L. , Hui Andrew C. F. , Kwan Patrick , Wong Ka S.
Published: December 2009

Purpose:  This study examined the profiles and prognosis of first acute symptomatic seizure (ASS). Because seizure recurrences may occur in the setting of a persisting or reemerging acute symptomatic cause or in the setting of an unprovoked seizure, we documented the prognosis of ASS in terms of acute symptomatic seizure (AS) or unprovoked seizure (US) recurrence.

Methods:  We conducted a prospective study of patients with suspected seizures between April 2004 and December 2005. Patients were classified according to medical history taking, routine clinical evaluation, and expert adjudication, and they were followed for a minimum of 2 years or until death. The Kaplan‐Meier method and univariate/multivariate statistical analysis were used to determine prognosis.

Results:  One hundred five patients with first‐ever ASS were identified. For many, first ASS was associated with status epilepticus (29.5%), multiple‐onset (>1 seizure within 24 h on day of presentation) (35.2%), and multiple etiologies (22.9%), with a mortality of 30% at 2 years (Kaplan‐Meier method). Using AS as outcome, the risk of recurrence following an ASS was 32% at 2 years [mean time to recurrence 20.5 days with epileptiform electroencephalography (EEG) being an independent predictor; p = 0.005, odds ratio (OR) 16, 95% confidence interval (CI) 4.09–62.7]. Using US as outcome, the risk of recurrence following an ASS was 12% at 2 years.

Discussion:  Although ASS did not associate with a high rate of US recurrence, we demonstrated that ASS was often followed by another AS. This may have implication for short‐ to medium‐term antiepileptic agent therapy, especially when the acute symptomatic cause takes a long time to treat, is prone to reemergence, or is irreversible.
Involvement of the thalamocortical network in TLE with and without mesiotemporal sclerosis
Authors: Mueller Susanne G. , Laxer Kenneth D. , Barakos Jerome , Cheong Ian , Finlay Daniel , Garcia Paul , Cardenas‐Nicolson Valerie , Weiner Michael W.
Published: December 2009

Purpose:  The thalamus plays an important role in seizure propagation in temporal lobe epilepsy (TLE). This study investigated how structural abnormalities in the focus, ipsilateral thalamus and extrafocal cortical structures relate to each other in TLE with mesiotemporal sclerosis (TLE‐MTS) and without hippocampal sclerosis (TLE‐no).

Methods:  T1 and high‐resolution T2 images were acquired on a 4T magnet in 29 controls, 15 TLE‐MTS cases, and 14 TLE‐no. Thalamus volumes were obtained by warping a labeled atlas onto each subject’s brain. Deformation‐based morphometry was used to identify regions of thalamic volume loss and FreeSurfer for cortical thickness measurements. CA1 volumes were obtained from high‐resolution T2 images. Multiple regression analysis and correlation analyses for voxel‐ and vertex‐based analyses were performed in SPM2 and FreeSurfer.

Results:  TLE‐MTS had bilateral volume loss in the anterior thalamus, which was correlated with CA1 volume and cortical thinning in the mesiotemporal lobe. TLE‐no had less severe volume loss in the dorsal lateral nucleus, which was correlated with thinning in the mesiotemporal region but not with extratemporal thinning.

Discussion:  The findings suggest that seizure propagation from the presumed epileptogenic focus or regions close to it into the thalamus occurs in TLE‐MTS and TLE‐no and results in circumscribed neuronal loss in the thalamus. However, seizure spread beyond the thalamus seems not to be responsible for the extensive extratemporal cortical abnormalities in TLE.
Examining the prevalence of epilepsy and delivery of epilepsy care in Ireland
Authors: Linehan Christine , Kerr Mike P. , Walsh Patricia N. , Brady Gerry , Kelleher Cecily , Delanty Norman , Dawson Frances , Glynn Mike
Published: December 2009

Purpose:  To examine the prevalence of epilepsy and delivery of epilepsy care in Ireland.

Methods:  A multiple case ascertainment methodology was employed examining five nationwide data sources. Data were obtained via (1) a nationwide population‐based health survey, (2) secondary data analysis of all reimbursements for prescriptions of antiepilepsy medication nationwide from 2002 to 2005, (3) a nationwide survey of primary care community‐based physicians, (4) a nationwide survey of specialist care hospital‐based neurologists, and (5) secondary data analysis of inpatient discharges from acute hospitals nationwide for persons with a diagnosis of epilepsy between 2000 and 2005.

Results:  The findings indicate that nationwide approximately (1) 10 per 1,000 persons (n = 31,000) 18 years and older have self‐reported lifetime prevalence of epilepsy, (2) 8.3–9 per 1,000 (approximately 33,000–36,000) persons 5 years and older are being treated for epilepsy using antiepilepsy medication, (3) the typical general practitioner provides care to an average of 13 patients with active epilepsy and epilepsy in remission with treatment, (4) specialist care is provided on a weekly basis to approximately 442 persons with active epilepsy and epilepsy in remission with treatment, and (5) approximately 67 discharges for persons with a primary or secondary diagnosis of epilepsy are reported from acute hospitals weekly.

Discussion:  This study is distinguished as the first nationwide prevalence study of epilepsy in Europe and provides previously unavailable data on this population in Ireland. Moreover, this study illustrates the merits of secondary data analysis of existing sources when access to clinical sources for the purpose of identifying epidemiologic samples is limited.
Rapid and transient response of soil respiration to rain
Authors: Lee Xuhui , Wu Hui‐Ju , Sigler Jeffrey , Oishi Christopher , Siccama Thomas
Published: December 2009

The influence of rainstorm on soil respiration of a mixed forest in southern New England, USA was investigated with eddy covariance, rain simulation and laboratory incubation. Soil respiration is shown to respond rapidly and instantaneously to the onset of rain and return to the prerain rate shortly after the rain stops. The pulse‐like flux, most likely caused by the decomposition of active carbon compounds in the litter layer, can amount to a loss of 0.18 t C ha−1 to the atmosphere in a single intensive storm, or 5–10% of the annual net ecosystem production of midlatitude forests. If precipitation becomes more variable in a future warmer world, the rain pulse should play an important part in the transient response of the ecosystem carbon balance to climate, particularly for ecosystems on ridge‐tops with rapid water drainage.
Geriatric Oncology and Primary Care: Promoting Partnerships in Practice and Research
Authors: Rose Julia Hannum , O'Toole Elizabeth E. , Koroukian Siran , Berger Nathan A.
Published: December 2009

This supplement is a compilation of original work that was presented at an interdisciplinary conference on “Geriatric Oncology and Primary Care: Promoting Partnerships in Practice and Research” held in Cleveland, Ohio, April 3 to 4, 2008. An audience of 77 clinicians and researchers attended this conference, primarily coming from Ohio and adjacent states. Articles are organized around a conceptual framework to consider primary and shared care roles of primary care physicians (PCPs) and oncologists in the care of older patients with cancer and their families. Articles in Section One focus on evidence‐based clinical practice and recommendations. Section Two includes articles on original psychosocial and health services research that inform this topic. Papers in this conference were developed in recognition of the greater prevalence and growing incidence of cancer in older adults; the unique geriatric expertise and practice considerations essential to the prevention and control of cancer in older adults; the important and effective roles that PCPs may play in such care; and the need to develop shared care models that foster collaboration between PCPs and oncologists, from cancer prevention through long‐term survivorship and end‐of‐life care of older adults. Models of shared care between oncologists and PCPs should be tested and compared for optimal care of older patients with cancer and their families. Potential implications of ideally shared care include more‐informed patient‐centered decision‐making, better adherence to treatment, improved match between older patient goals and treatments, and thus better outcomes.
Shared Care in Geriatric Oncology: Primary Care Providers' and Medical/Oncologist's Perspectives
Authors: Owusu Cynthia , Studenski Stephanie A.
Published: December 2009

Existing literature lends support to the benefit of shared care in the management of chronic diseases, but there are limited data on the feasibility, cost‐effectiveness, or benefits of shared care in oncology. A recent conference organized by the Aging and Cancer Program of the Case Comprehensive Cancer Center sought to explore the perceptions of physicians and other allied health professionals who attended the conference about shared care in the acute management of older patients with cancer using a case history presentation and an anonymous audience response system. Analyses of the audience response indicated that shared responsibility and enhanced information exchange in addition to the current level of communication between providers involved in the acute management of older patients with cancer is desirable. Studies exploring the feasibility and benefits of a shared care model in the management of older patients with cancer are needed.
Targeting Cancer Prevention and Screening Practices for Older Adults
Authors: Byers Tim
Published: December 2009

Although most cancers occur in persons aged 65 and older, objective information about the benefits of prevention, screening, and treatment are substantially lacking for older adults, because they have been largely excluded from randomized controlled trials. Proper inference about risks and benefits of cancer prevention and screening in older adults therefore requires proper interpretation of observational data. This article addresses two specific approaches to improving understanding of observational data on cancer prevention and screening in advanced age: the use of measures of risk differences (rather than relative risk) to assess varying effects of risk factors with advancing age and the use of trends over time as surrogates for screening effects. Two factors that are likely to affect cancer reduction trends in older adults in years to come are then discussed: the compression of mortality from cancers diagnosed, but not cured, at younger ages and ageism by patients, providers, and families.
Geriatric Assessment in Oncology Practice
Authors: Hurria Arti
Published: December 2009

There is no standard tool for assessing the “functional age” of an older adult with cancer, although it is widely recognized that chronological age does not capture the heterogeneous physiological and functional status of older adults. Integrating a “geriatric assessment” into oncology research and clinical practice would help fill this void. Geriatric assessment covers factors that predict morbidity and mortality in older adults, including functional status, comorbidity, cognition, psychological state, nutritional status, and social support. This assessment provides a broader overall understanding of individual characteristics that affect life expectancy. In addition, this assessment identifies areas of vulnerability in older adults for which further evaluation or intervention is indicated. This article will address the utility of a geriatric assessment in oncology practice, review data that attest to the benefits of the assessment, and issue a call for further research into how this assessment can be integrated into oncology care. Doing so will help develop targeted interventions and optimize cancer outcomes in this rapidly growing population.
When Cancer in Older Adults Is Undermanaged: The Breast Cancer Story
Authors: Silliman Rebecca A.
Published: December 2009

Age is the most important risk factor for breast cancer; age is also a risk factor for undermanagement of breast cancer. One thousand eight hundred fifty‐nine women aged 65 and older with early‐stage breast cancer were studied, and it was found that undermanagement is a risk factor for recurrence and for dying of breast cancer. Although conservative treatment is probably warranted in patients with tumors having excellent prognostic characteristics and in women with limited life expectancies, standard treatment is needed for the majority of older women if the disproportionate burden of breast cancer in this age group is to be reduced. Better strategies are needed for identifying those most likely to benefit from standard treatment and from systematic surveillance for recurrence. In this regard, collaboration between oncologists and primary care physicians is essential for achieving high‐quality care and outcomes in this vulnerable group of patients.
Current Practices and Perspectives on Breast Cancer Screening and Treatment in Older Women with Dementia
Authors: Smyth Kathleen A.
Published: December 2009

OBJECTIVES: To explore the nature of breast cancer screening and treatment decisions in older women with dementia.

DESIGN: Thematic analysis of semistructured telephone interviews.

SETTING: Alzheimer's Disease Research Center Registry.

PARTICIPANTS: Twenty‐three family caregivers (CGs) of women with dementia (WWD).

MEASUREMENTS: Semistructured questions regarding CGs' perceptions of current and predementia beliefs held by the WWD about the importance of regular screening mammograms, CGs' views about the importance of obtaining regular screening mammograms for the WWD and whether dementia stage of the WWD influenced these views, and CGs' view of what level of treatment would be appropriate if WWD they were caring for were to be diagnosed with breast cancer.

RESULTS: In CGs of women with mild to moderate (but not severe) dementia, mammogram importance ratings reflected perceived predementia importance levels (generally high). Most CGs of women with mild to moderate dementia planned to continue screening regardless of dementia severity of the WWD, but CGs of women with severe dementia at the time of the interview did not generally consider screening important. Physician recommendations were frequently found to influence screening practices. CGs' views on appropriate treatment if the WWD developed breast cancer varied widely except in the case of severe dementia, in which case comfort care was consistently preferred.

CONCLUSION: Breast cancer screening and treatment in dementia are active areas for healthcare decision‐making, and supportive interventions involving physicians, CGs, and WWD are needed.
Assessment and Interpretation of Comorbidity Burden in Older Adults with Cancer
Authors: Koroukian Siran M.
Published: December 2009

OBJECTIVES: To evaluate the associations between comorbidities, functional limitations, geriatric syndromes, treatment patterns, and outcomes in a population‐based cohort of older patients diagnosed with colorectal cancer and receiving home health care.

DESIGN: Retrospective study.

SETTING: Data from the Ohio Cancer Incidence Surveillance System, Medicare claims and enrollment files, and the home health care Outcome and Assessment Information Set.

PARTICIPANTS: Ohio residents diagnosed with incident colorectal cancer in 1999 to 2001 and receiving home health care in the 30 days before or after cancer diagnosis (N=957).

MEASUREMENTS: Outcome measures included receipt of cancer treatment and survival through 2005.

RESULTS: Not having surgery was associated negatively with comorbidities but positively with functional limitations and geriatric syndromes. Receipt of chemotherapy was negatively associated with comorbidities and functional limitations. The presence of two or more geriatric syndromes was significantly associated with unfavorable survival outcomes when analyzing overall survival and disease‐specific survival (DSS). Having limitations in two or more activities of daily living was associated with unfavorable overall survival but not with DSS. Comorbity was associated with favorable DSS at borderline level of statistical significance but not with overall survival.

CONCLUSION: The findings highlight the importance of incorporating functional limitations and geriatric syndrome data in geriatric oncology outcomes studies.
Differences in Oncologist Communication Across Age Groups and Contributions to Adjuvant Decision Outcomes
Authors: Step Mary M. , Siminoff Laura A. , Rose Julia H.
Published: December 2009

The objective of this study was to assess potential age‐related differences in oncologist communication during conversations about adjuvant therapy decisions and subsequent patient decision outcomes. Communication was observed between a cross‐section of female patients aged 40 to 80 with early‐stage breast cancer (n=180) and their oncologists (n=36) in 14 academic and community oncology practices in two states. Sources of data included audio recordings of visits, followed by post‐visit patient interviews. Communication during the visit was assessed using the Siminoff Communication Content and Affect Program. Patient outcome measures included self‐reported satisfaction with decision, decision conflict, and decision regret. Results showed that oncologists were significantly more fluent and more direct with older than middle‐aged patients and trended toward expressing their own treatment preferences more with older patients. Satisfaction with treatment decisions was highest for women in their 50s and 60s. Decision conflict was significantly associated with more discussion of oncologist treatment preferences and prognosis. Decision regret was significantly associated with patient age and education. Older adults considering adjuvant therapy may find that oncologists' communication accommodations to perceived deficiencies in older adult cognition or communication challenge their decision‐making involvement. Oncologists should carefully assess patient decision‐making preferences and be mindful of accommodating their speech to age‐related stereotypes.
Cancer Treatment in Older Adults: Implications for Psychosocial Research
Authors: Given Barbara , Given Charles W.
Published: December 2009

The purpose of this article is to describe areas in need of psychosocial research for older adults who are currently receiving cancer treatment. Areas in which there are gaps in knowledge related to psychosocial research are outlined. Topics discussed for future research include comorbidity, physical function, cognitive status, frailty, and geriatric syndromes. In addition, the need for intervention to support patients and family caregivers is outlined. There are numerous areas of concern to older patients with cancer receiving treatment that warrant further study. Research is needed to identify ways to support patients and families at the time of cancer treatment so that they can make informed decisions and actively participate in cancer treatment.
A Model for the Shared Care of Elderly Patients with Cancer
Authors: Cohen Harvey Jay
Published: December 2009

A model of care for elderly patients with cancer is suggested that incorporates the concept of shared care by various disciplines but in particular the oncologist and primary care provider or geriatrician. Degrees of participation will vary over time, depending upon the needs of the patient and family.
New hemostatic agents in the combat setting
Authors: Cox E. Darrin , Schreiber Martin A. , McManus John , Wade Charles E. , Holcomb John B.
Published: December 2009

BACKGROUND: Hemorrhage is a leading cause of potentially preventable death in both civilian and military trauma patients. Animal data have shown that hemostatic bandages reduce hemorrhage and improve survival. This article reports recent clinical observations regarding the efficacy and evolution of use of two new hemostatic bandages employed in the global war on terrorism.

METHODS: We performed a retrospective cohort review of soldiers treated with either the QuikClot or HemCon hemostatic bandages between April and October 2006. Hemostatic dressings were placed on wounds either in the field or at the combat support hospital (CSH).

RESULTS: During the 6‐month study period, 1691 trauma patients were admitted to the CSH. Fifty uses of hemostatic dressings in 44 patients (2.6% of admissions) were identified. Forty patients were treated with HemCon dressings, three patients with QuikClot, and one with both QuikClot and HemCon. Eighteen percent of the dressings were used in the field, predominantly on extremity wounds (7/8). In contrast, most dressings used in the CSH were for truncal wounds (26/36 patients). Hemostatic dressings were applied to extremity wounds in prehospital and hospital settings, either alone or in conjunction with tourniquets. In surviving patients (95%), the treating surgeon determined that the hemorrhage was either stopped or greatly decreased by use of hemostatic dressings. Two of the four patients treated with QuikClot had burns from exothermic reactions, while no adverse reactions were noted with HemCon.

CONCLUSIONS: Hemostatic agents stop or decrease bleeding. Whereas HemCon appears to be safe, QuikClot may produce superficial burns. These new hemostatic agents have a place in the surgical armamentarium to assist in controlling internal hemorrhage from truncal and pelvic hemorrhage, especially during damage‐control surgery.
Thromboembolic complications following trauma
Authors: McLaughlin Daniel F. , Wade Charles E. , Champion Howard R. , Salinas Jose , Holcomb John B.
Published: December 2009

BACKGROUND: Some studies have reported an increased incidence of thomboembolic complications following trauma.

STUDY DESIGN AND METHODS: We performed a literature review and queried the National Trauma Data Bank to more closely examine the incidence of a variety of thromboembolic complications following injury.

RESULTS: Thromboembolic events are rare, but occur at a greater rate in more severely injured patients. It is unclear, however, whether the incidence of thromboembolic complications in trauma patients is on the rise overall. Differences in study populations, particularly injury severity scores, as well as different methods of screening, diagnosis, prophylaxis, and treatment have led to extreme differences in reported rates.

CONCLUSION: While recent research has added to the body of knowledge, continued efforts focusing on risk stratification, diagnosis, screening, prophylaxis, and treatment are necessary to rationally understand the spectrum of thrombotic complications.
Soft Tissue Infections and Emergency Department Disposition: Predicting the Need for Inpatient Admission
Authors: Sabbaj Alfredo , Jensen Brett , Browning Mary Ann , Ma O. John , Newgard Craig D.
Published: December 2009

Objectives:  Little empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This study’s objective was to generate a clinical decision rule to predict the need for greater than 24‐hour hospital admission for patients presenting to the ED with soft tissue infection.

Methods:  This was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24‐hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression.

Results:  A total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24‐hour admission. Using CART, the strongest predictors of >24‐hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37°C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients.

Conclusions:  Although we were unable to generate a high‐sensitivity decision rule to identify ED patients with soft tissue infection requiring >24‐hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24‐hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections.
Kaizen: A Method of Process Improvement in the Emergency Department
Authors: Jacobson Gregory H. , McCoin Nicole Streiff , Lescallette Richard , Russ Stephan , Slovis Corey M.
Published: December 2009

Introduction:  Recent position statements from health care organizations have placed a strong emphasis on continuous quality improvement (CQI). CQI finds many of its roots in kaizen, which emphasizes small, low‐cost, low‐risk improvements. Based on the successful Kaizen Programs at organizations such as Toyota, the authors thought the emergency department (ED) would be an ideal environment to benefit from such a program.

Objectives:  The authors sought to create a CQI program using a suggestion‐based model that did not require a large time commitment, was easy to implement, and had the potential to empower all physicians in the department. It would not take the place of other improvement efforts, but instead augment them. The hypothesis was that such a program would foster sustainable engagement of emergency physicians in system improvement efforts and lead to a continuous stream of low‐cost implementable system improvement interventions.

Methods:  A CQI program was created for the physician staff of the Department of Emergency Medicine at Vanderbilt University Medical Center, focusing on a suggestion‐based model using kaizen philosophy. Lectures teaching kaizen philosophy were presented. Over the past 4 years, a methodology was developed utilizing a Web‐based application, the Kaizen Tracker, which aids in the submission and implementation of suggestions that are called kaizen initiatives (KIs). The characteristics of the KIs submitted, details regarding resident and faculty participation, and the effectiveness of the Kaizen Tracker were retrospectively reviewed.

Results:  There were 169, 105, and 101 KIs placed in the postimplementation calendar years 2006, 2007, and 2008, respectively. Seventy‐six percent of KIs submitted thus far have identified a “process problem.” Fifty‐three percent of KIs submitted have led to operational changes within the ED. Ninety‐three percent of the resident physicians entered at least one KI, and 73% of these residents submitted more than one KI. Sixty‐nine percent of the attendings entered at least one KI, and 89% of these attendings submitted more than one KI.

Conclusions:  Over the past 4 years, the Kaizen Program at Vanderbilt has been widely and frequently used within the ED. It has resulted in over 400 changes in our adult ED system and has met the challenge of using CQI to drive ED improvements. There are limitations to this study, including the fact that its impact on patient outcomes remains unknown. However, this Kaizen Program may be an excellent tool for other departments to assist with quality improvement and should be studied with a multicenter prospective approach.
Use of the Visual Analog Scale to Rate and Monitor Severity of Nausea in the Emergency Department
Authors: Meek Robert , Kelly Anne‐Maree , Hu Xue Feng
Published: December 2009

Objectives:  The objective was to describe the association between verbal descriptors of nausea severity and visual analog scale (VAS) ratings in an undifferentiated emergency department (ED) population and to calculate the minimum clinically significant difference (MCSD) in VAS rating of nausea severity in this population.

Methods:  A prospective observational study was conducted at three EDs on a convenience sample of stable, consenting adult patients presenting with nausea as part of their symptom complex. Data included demographics, adjectival description of nausea severity (none, mild, moderate, or severe), and VAS rating (standard 100‐mm line) at enrollment, 30 minutes, and 60 minutes. At 30 and 60 minutes they were also asked to describe any change in nausea severity from the previous rating (“a lot less,”“a little less,”“the same,”“a little more,”“a lot more”). The MCSD was defined as the average VAS change when a patient reported “a little less” or “a little more” nausea.

Results:  A total of 247 patients provided 693 matched adjectival ratings and VAS scores. Median age was 45 years, and 100 (40%) were male. The median VAS measures for none, mild, moderate, and severe nausea were 2, 23, 53, and 83 mm, respectively. VAS distributions in the verbal categories were statistically different from each other (Spearman rank correlation coefficient = 0.90; p < 0.0001). The MCSD was 22 mm (95% CI = 20 to 24 mm).

Conclusions:  There is very good correlation between verbal descriptors of nausea and VAS ratings. The MCSD for VAS nausea ratings in an ED population is 22 mm.
Using a Discrete‐event Simulation to Balance Ambulance Availability and Demand in Static Deployment Systems
Authors: Wu Ching‐Han , Hwang Kevin P.
Published: December 2009

Objectives:  To improve ambulance response time, matching ambulance availability with the emergency demand is crucial. To maintain the standard of 90% of response times within 9 minutes, the authors introduce a discrete‐event simulation method to estimate the threshold for expanding the ambulance fleet when demand increases and to find the optimal dispatching strategies when provisional events create temporary decreases in ambulance availability.

Methods:  The simulation model was developed with information from the literature. Although the development was theoretical, the model was validated on the emergency medical services (EMS) system of Tainan City. The data are divided: one part is for model development, and the other for validation. For increasing demand, the effect was modeled on response time when call arrival rates increased. For temporary availability decreases, the authors simulated all possible alternatives of ambulance deployment in accordance with the number of out‐of‐routine‐duty ambulances and the durations of three types of mass gatherings: marathon races (06:00–10:00 hr), rock concerts (18:00–22:00 hr), and New Year’s Eve parties (20:00–01:00 hr).

Results:  Statistical analysis confirmed that the model reasonably represented the actual Tainan EMS system. The response‐time standard could not be reached when the incremental ratio of call arrivals exceeded 56%, which is the threshold for the Tainan EMS system to expand its ambulance fleet. When provisional events created temporary availability decreases, the Tainan EMS system could spare at most two ambulances from the standard configuration, except between 20:00 and 01:00, when it could spare three. The model also demonstrated that the current Tainan EMS has two excess ambulances that could be dropped. The authors suggest dispatching strategies to minimize the response times in routine daily emergencies.

Conclusions:  Strategies of capacity management based on this model improved response times. The more ambulances that are out of routine duty, the better the performance of the optimal strategies that are based on this model.
Variation in the Type, Rate, and Selection of Patients for Out‐of‐hospital Airway Procedures Among Injured Children and Adults
Authors: Newgard Craig D. , Koprowicz Kent , Wang Henry , Monnig Aaron , Kerby Jeffrey D. , Sears Gena K. , Davis Daniel P. , Bulger Eileen , Stephens Shannon W. , Daya Mohamud R. ,   the ROC Investigators
Published: December 2009

Objectives:  The objective was to compare the type, rate, and selection of injured patients for out‐of‐hospital airway procedures among emergency medical services (EMS) agencies in 10 sites across North America.

Methods:  The authors analyzed a consecutive patient, prospective cohort registry of injured adults and children with an out‐of‐hospital advanced airway attempt, collected from December 1, 2005, through February 28, 2007, by 181 EMS agencies in 10 sites across the United States and Canada. Advanced airway procedures were defined as orotracheal intubation, nasotracheal intubation, supraglottic airway, or cricothyrotomy. Airway procedure rates were calculated based on age‐specific population values for the 10 sites and the number of injured patients with field physiologic abnormality (systolic blood pressure of ≤90 mm Hg, respiratory rate of <10 or >29 breaths/min, Glasgow Coma Scale [GCS] score of ≤12). Descriptive measures were used to compare patients between sites.

Results:  A total 1,738 patients had at least one advanced airway attempt and were included in the analysis. There was wide variation between sites in the types of airway procedures performed, including orotracheal intubation (63% to 99%), supraglottic airways (0 to 27%), nasotracheal intubation (0 to 21%), and cricothyrotomy (0 to 2%). Use of rapid sequence intubation (RSI) varied from 0% to 65%. The population‐adjusted rates of field airway intervention (by site) ranged from 1.2 to 22.8 per 100,000 adults and 0.2 to 4.0 per 100,000 children. Among trauma patients with physiologic abnormality, some sites performed airway procedures in almost 50% of patients, while other sites used these procedures in fewer than 10%. There was also large variation in demographic characteristics, physiologic measures, mechanism of injury, mode of transport, field cardiopulmonary resuscitation, and unadjusted mortality among airway patients.

Conclusions:  Among 10 sites across North America, there was wide variation in the types of out‐of‐hospital airway procedures performed, population‐based rates of airway intervention, and the selection of injured patients for such procedures.
Variation in fish assemblages across dry‐season pools in a Mediterranean stream: effects of pool morphology, physicochemical factors and spatial context
Authors: Pires D. F. , Pires A. M. , Collares‐Pereira M. J. , Magalhães M. F.
Published: December 2009

Pires DF, Pires AM, Collares‐Pereira MJ, Magalhães MF. Variation in fish assemblages across dry‐season pools in a Mediterranean stream: effects of pool morphology, physicochemical factors and spatial context. Ecology of Freshwater Fish 2010: 19: 74–86. © 2009 John Wiley & Sons A/S

Abstract –  Knowledge of patterns of refuge use by fish is critical for maintaining biodiversity in drought‐prone streams. In this study, the fish assemblages of 21 dry‐season pools in a Mediterranean stream were characterised and related to three sets of factors reflecting pool morphology, physicochemistry and spatial context. Fish were associated with the three sets of variables, with variation partitioning indicating that overall species richness and abundance were primarily related to pool morphology but relative species abundances were mainly associated with physicochemical contexts. In general, species richness was the highest but overall fish abundance was the lowest in large pools. Pools well shaded by riparian canopy held the highest richness and abundance of native fish, but relative species abundances and assembly structure varied among pools contingent on canopy cover, substrate composition and spatial location. These results suggested that conservation of fish diversity in Mediterranean streams requires networks of pools with diverse sizes and physicochemical contexts.
Nesting in an uncertain world: information and sampling the future
Authors: Schmidt Kenneth A. , Whelan Christopher J.
Published: November 2009

Seasonal fecundity is strongly influenced by the number of nests attempted (including renests following nest failure) in a season. This number is often assumed to be set by the length of the breeding season or through some predetermined maximum. Instead, the decision to renest likely results from a cost–benefit analysis honed by natural selection where the ultimate components of fitness, i.e. reproduction and survival, tradeoff with one another. Moreover, reproductive decision making should not occur in an information‐vacuum. In a world where habitat quality (i.e. likelihood of nest success) is uncertain females should use nest failures to update the probability their renest nest will succeed, and this estimate in turn can affect the decision to renest. We develop a model of renesting behavior based on these conceptual ideas using the framework of statistical decision theory (SDT) and the process of Bayesian updating. We assume that renesting incurs 1) a cost to future reproductive success and 2) a reduction in expected reproductive success for each successive replacement nest. We show, all else equal, birds should curtail renesting with (1) increased residual reproductive success, (2) increased cost to future reproduction, (3) declines in current reproduction with successive attempts, and (4) increasing nest predation rates. We also explore several ecological implications of the model. First, uncertainty in habitat quality and the process of information updating, based on nest outcomes, link changes in the quality or proportion of one habitat type to the behavior in the other habitat. Second, females may use their estimate of habitat quality, based on a sample of nesting attempts, to decide whether to return or disperse to a new site between years. We compare this to the win‐stay: lose‐switch rule for dispersal and discuss the implications for population dynamics.
The effect of visiting zoos on human health and quality of life
Authors: SAKAGAMI Taketo , OHTA Mitsuaki
Published: December 2009

The increased mental stress of daily life and aging of the population are serious matters in Japan. There are many studies regarding the effects of human‐animal interactions on mental and physical human health, whereas there are few studies examining the effects of visiting zoos. To determine the effect of visiting zoos on human health and quality of life, two different zoos were visited by 70 participants in Experiment 1 and 163 participants in Experiment 2. In this study we administered the WHO QOL‐26 questionnaire in Japanese to assess the psychological scales of participants, and blood pressures and pulse rates were measured to assess their physical scales. We also used pedometers to count the number of steps taken during zoo visits. Both zoo visits decreased blood pressure and participants demonstrated more than 6000 steps during each visit. The quality of life sub‐scale scores were improved after zoo visits.
Is Marriage More Than Cohabitation? Well‐Being Differences in 30 European Countries
Authors: Soons Judith P. M. , Kalmijn Matthijs
Published: December 2009

The study aims to assess, first, whether there is a gap in well‐being between unmarried cohabitants and the married, second, if selection factors can explain this so‐called cohabitation gap, and third, if the size of the cohabitation gap differs across countries and how this can be explained. We use pooled data from young adults (18–44) in 3 rounds of the European Social Survey (N ≅ 31, 500). Multilevel regression analyses show that there is a moderate cohabitation gap that can be partly explained with the selection factors material resources and religiosity. Country differences were clear and could partly be explained with the level of institutionalization: In countries where cohabitation is more accepted and more prevalent, the cohabitation gap is smaller.
Giving to the Good and the Needy: Parental Support of Grown Children
Authors: Fingerman Karen , Miller Laura , Birditt Kira , Zarit Steven
Published: December 2009

Parents may provide many types of support to their grown children. Parents age 40 to 60 (N = 633) reported the support they exchange with each child over age 18 (N = 1,384). Mothers and fathers differentiated among children within families, but provided emotional, financial, and practical help on average every few weeks to each child. Offspring received most assistance when they (a) had greater needs (because of problems or younger age) or (b) were perceived as more successful. Parents received more from high achieving offspring. Findings support contingency theory; parents give more material and financial support to children in need. Motivation to enhance the self or to assure support later in life may explain support to high achieving offspring.
Family Change and Continuity in Iran: Birth Control Use Before First Pregnancy
Authors: Abbasi‐Shavazi Mohammad Jalal , Philip Morgan S. , Hossein‐Chavoshi Meimanat , McDonald Peter
Published: December 2009

Using data from the 2002 Iran Fertility Transition Survey, we examined birth control use between marriage and first pregnancy. We focused on the post‐1990 increase in birth control use and develop two explanations. The first posits that birth control use reflects a new marriage form, the conjugal marriage, which places a heightened value on the spousal relationship while deemphasizing the centrality of parenthood. A second explanation stresses the use of a new resource, effective birth control, within an Iranian‐Islamist view of marriage. Key to this explanation is the role of the state—Iranian political/religious actors encourage early marriage and the use of birth control. Although the explanations could be complementary, evidence provides more support for the latter.
Employer‐Supported Child Care: Who Participates?
Authors: Morrissey Taryn W. , Warner Mildred E.
Published: December 2009

Child‐care vouchers are becoming more common and can provide child‐care assistance to a wide spectrum of the population. There is little empirical research, however, on which workers participate in their employer's child‐care programs. In this exploratory study, employees with children at 1 large university completed questionnaires to gather information on their child‐care arrangements and their experience with the employer's child‐care voucher program (N = 949). Results indicate that the employees who were most in need of child‐care assistance in terms of family structure, job type, and child‐care expenses were more likely to receive vouchers. Federal policy limiting the structure of employer‐sponsored voucher programs appeared to present barriers to participation for certain groups of employees.
The oleic acid complexes of proteolytic fragments of α‐lactalbumin display apoptotic activity
Authors: Tolin Serena , De Franceschi Giorgia , Spolaore Barbara , Frare Erica , Canton Marcella , Polverino de Laureto Patrizia , Fontana Angelo
Published: November 2009

The complexes formed by partially folded human and bovine α‐lactalbumin with oleic acid (OA) have been reported to display selective apoptotic activity against tumor cells. These complexes were named human (HAMLET) or bovine (BAMLET) alpha‐lactalbumin made lethal to tumor cells. Here, we analyzed the OA complexes formed by fragments of bovine α‐lactalbumin obtained by limited proteolysis of the protein. Specifically, the fragments investigated were 53–103 and the two‐chain fragment species 1–40/53–123 and 1–40/104–123, these last being the N‐terminal fragment 1–40 covalently linked via disulfide bridges to the C‐terminal fragment 53–123 or 104–123. The OA complexes were obtained by mixing the fatty acid and the fragments in solution (10‐fold and 15‐fold molar excess of OA over protein fragment) or by chromatography of the fragments loaded onto an OA‐conditioned anion exchange column and salt‐induced elution of the OA complexes. Upon binding to OA, all fragments acquire an enhanced content of α‐helical secondary structure. All OA complexes of the fragment species showed apoptotic activity for Jurkat tumor cells comparable to that displayed by the OA complex of the intact protein. We conclude that the entire sequence of the protein is not required to form an apoptotic OA complex, and we suggest that the apoptotic activity of a protein–OA complex does not imply specific binding of the protein.
Morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south Indian adults: With special relevance to surgical cricothyroidotomy
Authors: Prithishkumar Ivan J , David Suresh S
Published: December 2009

Objective:  To measure the working dimensions of the cricothyroid membrane in the adult south Indian population and to establish the association between the working dimensions and the appropriate endotracheal tube size for the purpose of cricothyroidotomy.

Methods:  Cross‐sectional evaluation of 50 fresh adult autopsy cases (35 men, 15 women) in a medical university teaching hospital in South India.

Results:  Age ranged from 17.0 to 83.0 years. Working dimensions of the membrane in neutral position of neck, in men: width = 8.41 ± 2.11 mm, height = 6.57 ± 1.87 mm; in women: width = 6.30 ± 1.29 mm, height = 5.80 ± 1.56 mm. Depth of the subglottic larynx at the level of cricoid cartilage: men = 20.73 ± 1.97 mm, women = 15.62 ± 1.71 mm. Distance of the lower border of cricothyroid membrane from suprasternal notch in neutral position of neck, in men = 5.18 ± 1.76 cm, women = 4.72 ± 1.55 cm; in passively extended neck, men = 7.86 ± 1.25 cm, women = 8.05 ± 1.28 cm. Regression equations have been derived to determine endotracheal tube size for cricothyroidotomy, based on distance between sternal notch and chin, and height of the individual (P < 0.05).

Conclusions:  Working dimensions are smaller in the Indian group compared with western publications. Endotracheal tubes ranging from size 3.0 to 6.0 might be used for cricothyroidotomy in the adult south Indian population.