bluuebunny/crossref_metadata_2025 huggingface dataset:
Occipital Nerve Blocks: Effect of Symptomatic Medication
Authors: Tobin Joshua A. , Flitman Stephen S.
Published: November 2009

Objective.— To explore the effect of symptomatic medication overuse (SMO) and headache type on occipital nerve block (ONB) efficacy.

Methods.— We conducted a chart review of all of the ONBs performed in our clinic over a 2‐year period.

Results.— Of 108 ONBs with follow‐up data, ONB failed in 22% of injections overall. Of the other 78%, the mean decrease in head pain was 83%, and the benefit lasted a mean of 6.6 weeks. Failure rate without SMO was 16% overall, and with SMO was 44% overall (P < .000). In those who did respond, overall magnitude and duration of response did not differ between those with and those without SMO. Without SMO, ONB failure rate was 0% for postconcussive syndrome, 14% for occipital neuralgia, 11% for non‐intractable migraine, and 39% for intractable migraine. With SMO, failure rate increased by 24% (P = .14) in occipital neuralgia, by 36% (P = .08) for all migraine, and by 52% (P = .04) for non‐intractable migraine.

Conclusions.— SMO tripled the risk of ONB failure, possibly because medication overuse headache does not respond to ONB. SMO increased ONB failure rate more in migraineurs than in those with occipital neuralgia, possibly because migraineurs are particularly susceptible to medication overuse headache. This effect was much more pronounced in non‐intractable migraineurs than in intractable migraineurs.
Expert Opinion: What Causes Migraine: Which Physician Explanation Do Patients Prefer and Understand?
Authors: Evans Randolph W. , Evans Rochelle E.
Published: November 2009

Background.— Although “What causes migraine,” is one of the most common questions migraineurs ask their physicians, little is known about what response physicians provide, whether migraineurs believe it is important that they be provided information, or which explanation is most informative.

Methods.— Seven migraine specialists were personally contacted and a convenience sample of 23 neurologists were surveyed at a meeting to obtain a range of explanations. Four explanations were selected and edited. One hundred consecutive patients seen in a general neurology practice participated in the study.

Results.— The mean response on a 5‐point Likert scale to the statement, “It is important to provide patients an explanation of what causes migraine,” of 15 neurologists surveyed at a meeting was 4.3 (5 = strongly agree). One hundred consecutive patients participated in the study with a mean age of 39.1 years and 87 females. The mean response to the question, “How important is it for a physician to provide you with an explanation of what causes migraine?” was 4.7 on a 5‐point Likert scale (5 = very important). The explanation preferred by most (56) of the subjects was the longest (245 words) with the fewest (4) choosing the briefest (25 words).

Conclusions.— This study suggests that neurologists and migraineurs believe that it is very important for a physician to provide them with an explanation of what causes migraine. An explanation that may be most informative may contain information in lay terms about the pathophysiology and the many triggers. The physician can provide explanations verbally, through handouts, or by referral to internet sites. Better patient understanding of what causes migraine may improve treatment adherence and patient satisfaction.
Psychiatric comorbidity and suicidal behavior in epilepsy: A community‐based case–control study
Authors: Stefanello Sabrina , Marín‐Léon Letícia , Fernandes Paula T. , Li Li M. , Botega Neury J.
Published: November 2009

Purpose:  To provide information about psychiatric comorbidity and suicidal behavior in people with epilepsy compared to those without epilepsy from a community sample in Brazil.

Methods:  An attempt was made to evaluate all 174 subjects with epilepsy (cases) identified in a previous survey. For every case identified, an individual without epilepsy (control) matched by sex and age was selected in the same neighborhood. A structured interview with validated psychiatric scales was performed. One hundred and fifty‐three cases and 154 controls were enrolled in the study.

Results:  People with epilepsy had anxiety more frequently [39.4% vs. 23.8%, odds ratio (OR) 2.1, 95% confidence interval (CI) 1.2–3.5; p = 0.006], depression (24.4% vs. 14.7%, OR 1.9, 95% CI 1.01–3.5; p = 0.04), and anger (55.6% vs. 39.7%, OR 1.9, 95% CI 1.2–3.1; p = 0.008). They also reported more suicidal thoughts [36.7% vs. 23.8%, OR 1.8, 95% CI 1.1–3.1; p = 0.02), plans (18.2% vs. 3.3%, OR 2.0, 95% CI 1.0–4.0; p = 0.04), and attempts (12.1% vs. 5.3%, OR 2.4, 95% CI 1.1–3.2, p = 0.04) during life than controls.

Conclusions:  These findings call attention to psychiatric comorbidity and suicidal behavior associated with epilepsy. Suicide risk assessment, mental evaluation, and treatment may improve quality of life in epilepsy and ultimately prevent suicide.
Profiles of psychosocial outcome after epilepsy surgery: The role of personality
Authors: Wilson Sarah J. , Wrench Joanne M. , McIntosh Anne M. , Bladin Peter F. , Berkovic Samuel F.
Published: November 2009

Purpose:  We have previously found that the developmental time frame of epilepsy onset influences adult personality traits and subsequent adjustment to intractable seizures. In the same cohort of patients we now investigate the influence of these factors on psychosocial outcome after surgical treatment.

Methods:  Fifty‐seven adult patients with focal epilepsy were prospectively assessed before and after surgery. Measures of psychosocial outcome included mood, health‐related quality of life (HRQOL), and psychosocial adjustment, collected longitudinally at 1‐, 3‐, and 12‐months after surgery.

Results:  Patients with high neuroticism and low extraversion were predisposed to greater depression after surgery. More than 70% of patients with high neuroticism also reported disrupted family dynamics and difficulties adjusting to seizure freedom. The latter was associated with changes in self‐identity that increased over time. Patients with epilepsy onset before or during the self‐defining period of adolescence reported the greatest perceived self‐change after surgery that had positive effects for HRQOL.

Discussion:  Psychosocial outcome after epilepsy surgery appears intrinsically linked to a change in self and a transition from chronically sick to well. The development of personality traits and self‐identity in the context of habitual seizures can impact psychosocial outcome and the extent of self‐change reported after surgery, and paradoxically, can concur more beneficial effects.
Using the Internet to recruit patients for epilepsy trials: Results of a New Zealand pilot study
Authors: Bergin Peter S. , Ip Tony , Sheehan Robert , Frith Richard W. , Sadleir Lynette G. , McGrath Nicole , Ranta Annemarei , Walker Elizabeth B.
Published: November 2009

Purpose:  We created a database that could be accessed via the Internet by any neurologist or pediatric neurologist in New Zealand. The database was designed to facilitate recruitment of patients for investigator‐driven drug trials.

Methods:  We established an epilepsy database, and invited neurologists and pediatric neurologists throughout New Zealand to register patients via the Internet when they were uncertain of the optimal management. Details regarding seizure type and frequency, epilepsy syndrome, etiology, drug history, and investigations were collected. We produced an algorithm to select patients who had failed to respond to a single antiepileptic drug (AED). These patients were randomized immediately via the Internet to receive a different drug. Participants were not reimbursed.

Results:  The pilot study recruited patients from mid‐June to December 2007. Sixteen neurologists participated; neurologists were based in eight different cities. One hundred thirty‐seven patients were registered, of whom 113 were considered suitable for drug trials. Thirty‐five patients who had used a single antiepileptic drug AED were enrolled, and 14 of these were successfully randomized online to a different drug. Follow‐up information was entered via the Internet for all 108 patients who were seen again during the following year.

Discussion:  We have demonstrated that patients can be recruited for trials and randomized from routine clinics via the Internet. Trials could compare AEDs or look at other aspects of epilepsy management. An international pilot study is planned. Neurologists are invited to enroll patients with epilepsy, who would be suitable for randomized controlled trials, into a Web‐based register.
Topiramate overdose: A case report of a patient with extremely high topiramate serum concentrations and nonconvulsive status epilepticus
Authors: Brandt Christian , Elsner Heike , Füratsch Nora , Hoppe Matthias , Nieder Esther , Rambeck Bernhard , Ebner Alois , May Theodor W.
Published: November 2009

We report the case of a 21‐year‐old man with idiopathic generalized epilepsy who ingested about 8,000 mg of topiramate (TPM) in a suicide attempt. On admission to the hospital he had a nonconvulsive status epilepticus and received 4 mg lorazepam i.v. He recovered rapidly despite an initial TPM concentration of 144.6 μg/ml. To our knowledge, this is the first report of a patient who survived such a high TPM concentration. The case indicates that nonconvulsive status epilepticus could be a manifestation of TPM intoxication.
Ictal affective symptoms in temporal lobe epilepsy are related to gender and age
Authors: Toth Vanda , Fogarasi Andras , Karadi Kazmer , Kovacs Norbert , Ebner Alois , Janszky Jozsef
Published: November 2009

Purpose: We systematically analyzed the video‐recorded and patient‐reported, as well as positive and negative ictal affective symptoms (IAS) in temporal lobe epilepsy (TLE). Our aim was to assess (1) frequency, (2) gender effect, (3) lateralizing significance, (4) localizing value, and (5) prognostic significance in epilepsy surgery of IAS in patients with video‐registered seizures.

Methods: We reviewed ictal video recordings of 184 patients (99 women, aged 16–63). All patients had surgery for intractable TLE with video‐recorded complex partial seizures (CPS) due to temporal lobe lesions visualized by high‐resolution magnetic resonance imaging (MRI). Affective auras (AAs) were categorized into two groups: positive or negative.

Results: We registered AAs in 18% of patients: positive in 3%, negative in 15%. We saw ictal affective behavior (IAB) in 22% of patients; 10% had positive, whereas 14% had negative IAB. Two patients had both positive and negative IAB. AAs showed an association with IAB in case of fear expression versus fear auras (p = 0.018). IAB, especially negative IAB, occurred more often in women than in men. Patients with negative IAB were younger than others. We could not demonstrate an association between IAS and the localization, lateralization, or hemispheric dominance. Surgical outcome did not associate with IAS.

Discussion: Patient‐reported and video‐recorded negative—but not positive—affective signs are related to each other. Video‐recorded negative AAs occur more often in women and young patients.
Assessment of Precious Metal Flows During Preprocessing of Waste Electrical and Electronic Equipment
Authors: Chancerel Perrine , Meskers Christina E.M. , Hagelüken Christian , Rotter Vera Susanne
Published: November 2009

The manufacturing of electronic and electrical equipment (EEE) is a major demand sector for precious and special metals with a strong growth potential. Both precious and special metals are contained in complex components with only small concentrations per unit. After the use‐phase, waste electronic and electrical equipment (WEEE) is an important source of these “trace elements.” Their recycling requires appropriate processes in order to cope with the hazardous substances contained in WEEE and to recover efficiently the valuable materials. Although state‐of‐the‐art preprocessing facilities are optimized for recovering mass‐relevant materials such as iron and copper, trace elements are often lost. The objective of this article is to show how a substance flow analysis (SFA) on a process level can be used for a holistic approach, covering technical improvement at process scale, optimization of product life cycles, and contributing to knowledge on economy‐wide material cycles. An SFA in a full‐scale preprocessing facility shows that only 11.5 wt.% of the silver and 25.6 wt.% of the gold and of the palladium reach output fractions from which they may potentially be recovered. For copper this percentage is 60. Considering the environmental rucksack of precious metals, an improvement of the recycling chain would significantly contribute to the optimization of the product life cycle impact of EEE and to ensuring the long‐term supply of precious metals.
How Can We Improve the Accuracy of Screening Instruments?
Authors: Johnson Evelyn S. , Jenkins Joseph R. , Petscher Yaacov , Catts Hugh W.
Published: November 2009

Screening for early reading problems is a critical step in early intervention and prevention of later reading difficulties. Evaluative frameworks for determining the utility of a screening process are presented in the literature but have not been applied to many screening measures currently in use in numerous schools across the nation. In this study, the accuracy of several Dynamic Indicators of Basic Early Literacy Skills (DIBELS) subtests in predicting which students were at risk for reading failure in first grade was examined in a sample of 12,055 students in Florida. Findings indicate that the DIBELS Nonsense Word Fluency, Initial Sound Fluency, and Phoneme Segmentation Fluency measures show poor diagnostic utility in predicting end of Grade 1 reading performance. DIBELS Oral Reading Fluency in fall of Grade 1 had higher classification accuracy than other DIBELS measures, but when compared to the classification accuracy obtained by assuming that no student had a disability, suggests the need to reevaluate the use of classification accuracy as a way to evaluate screening measures without discussion of base rates. Additionally, when cut scores on the screening tools were set to capture 90 percent of all students at risk for reading problems, a high number of false positives were identified. Finally, different cut scores were needed for different subgroups, such as English Language Learners. Implications for research and practice are discussed.
Response to Intervention Screening and Progress–Monitoring Practices in 41 Local Schools
Authors: Mellard Daryl F. , McKnight Melinda , Woods Kari
Published: November 2009

This study describes response to intervention (RTI) screening and progress–monitoring instruments and procedures in 41 local school settings. For screening the schools most often used published reading assessments or commercial products; a three–times–per–year screening schedule was most prevalent. For progress monitoring schools most often relied on published reading assessments; a weekly progress monitoring schedule was most prevalent. The variability between local school practices is discussed with regard to efficiency, equity, and viability of RTI.
Special Education Teacher Education: A Perspective on Content Knowledge
Authors: Greer Diana L. , Meyen Edward L.
Published: November 2009

The passage of No Child Left Behind and the Individuals with Disabilities Education Act has strengthened the conditions for instructional accountability for all learners. The standards–based approach promulgated by curriculum and state assessments is central to the accountability of conditions in today's schools; however, national and state data continue to document a performance gap between students with learning disabilities (LD) and their nondisabled peers. Building on 5 years of experience in developing and testing the Blending Assessment with Instruction Program in mathematics, we present three basic principles that are essential to ensuring that students with LD achieve curriculum standards: (1) instruction must be aligned with curriculum standards, (2) teachers’ content knowledge is essential to translating curriculum standards into aligned instruction, and (3) instructional methodology should receive greater attention during teacher preparation.
Executive Function Coaching for College Students with Learning Disabilities and ADHD: A New Approach for Fostering Self–Determination
Authors: Parker David R. , Boutelle Karen
Published: November 2009

Given growing numbers of college students with attention deficit/hyperactivity disorder (ADHD) and/or learning disabilities (LD), it is important to understand why these students choose ADD (“executive function”) coaching to enhance their academic success when more traditional forms of campus support already offer this help. Fifty–four undergraduates with ADHD and/or LD participated in a study of their experiences with coaching. To better understand students’ perspectives on the manner in which coaching helped them minimize executive function challenges while addressing academic goals, a purposive sample of seven of these students participated in two interviews. All seven described highly self–determined approaches to goal attainment that they associated with coaching. These students also reported that, in contrast to traditional campus services, coaching focused primarily on supporting their emerging autonomy, helping them develop and manage their executive function skills and promoting their self–efficacy and confidence about future success. Findings are linked to recommendations for additional research and service delivery options.
Categorization of the hemodynamic response to hemodialysis: The importance of baroreflex sensitivity
Authors: CHESTERTON Lindsay J. , SELBY Nicholas M. , BURTON James O. , FIALOVA Jana , CHAN Cian , MCINTYRE Chris W.
Published: November 2009

Intradialytic hypotension (IDH) remains an important cause of morbidity and mortality in hemodialysis (HD) patients. The baroreflex arc is under autonomic control and regulates blood pressure. This study aimed to investigate the contribution of impaired baroreflex sensitivity (BRS) to the pathophysiology of IDH. Thirty‐four chronic HD (12 IDH‐prone, 22 IDH‐resistant) patients underwent BRS measurement during HD with relative blood volume monitoring. During analysis, patients were separated into four age‐matched groups according to resting BRS≥4.5 ms/mmHg and hemodynamic stability. Resting BRS was extremely heterogenous (geometric mean BRS 5.78±1.41 [range 1.76–41.41] ms/mmHg). Relative blood volume reduction was well matched in all groups (mean reduction in relative blood volume for all patients −6.74%±0.86%, P>0.05). Thirty‐seven episodes of IDH occurred in the IDH prone, reduced BRS group. Patients with impaired resting BRS and prone to IDH had markedly different responses to HD as compared to the preserved BRS group, but the total peripheral resistance response was significantly lower than in the IDH‐resistant patients (15.9%±2.1% vs. 42.4%±3.0%, respectively, P<0.001). In those patients prone to IDH and with impaired resting BRS, percentage reduction in cardiac output at the end of HD highly correlated with reduction in relative blood volume (r=0.94, P=0.006). Hypotension during dialysis may be an important source of recurrent cardiac injury and early recognition of those patients prone to relative symptomatic and asymptomatic hypotension remains important. Impaired resting BRS and recognition of a suboptimal peripheral pressor response, appear to predict those patients most likely to undergo hemodynamic instability and may assist in the pursuit of this elusive goal.
Growing up Charismatic: Morality and Spirituality among Children in a Religious Community
Authors: Csordas Thomas J.
Published: November 2009

AbstractThe intersection of two questions about human experience is the starting point for this article. The first question has to do with the problem of how charisma can be successfully transferred to the second generation of a prophetic community. The second question has to do with how children come to be, and to act as, moral and spiritual beings. These questions converge in a particular way in the ethnographic setting of The Word of God Community: it is founded on a charismatic spirituality closely intertwined with a moral imperative, such that its viability depends on reproduction of that morality and spirituality among children of the founding generation. Data come from interviews with 38 children across three age groups (5–7, 10–12, and 15–17 years), conducted over a four‐week period subsequent to a community schism, which left members in a state of reflection, self‐examination, and openness. We focus on children's responses to a series of culturally specific vignettes designed to present various dilemmas of moral reasoning. In this highly charged context moral and spiritual life are based on an active engagement characterized by dynamic and contested processes, and it is through these processes that individuals make meaning out of and reconstruct the moral code of their culture. [childhood and adolescence, religion, Catholic Charismatic Renewal, Pentecostalism, morality, spirituality, intentional communities]
La Vida Matizada: Time Sense, Everyday Rhythms, and Globalized Ideas of Work
Authors: Syring David
Published: November 2009

This article explores three instances of the frictions and negotiations that are sparked by specific transnational encounters with global capitalist temporality. Capitalist ideas about the proper ways to organize time and labor have long dominated global practices. Such ideas simultaneously force acceptance of a limited model of the proper relationships between work and everyday life. This article provides ethnographic descriptions of the work rhythms of three men in interconnected contexts—those of an indigenous Saraguro (Ecuador) man, the experience of a migrant Saraguro man who works in industrial agriculture in the United States, and the author's experience as an academic.
Street Life under a Roof
Authors: Margaretten Emily
Published: November 2009

This article offers a story about community formation right along the sidelines of the streets. It traces the transitory movements of youth in South Africa, their sojourns from the streets to shelters and places of their own making. Blending personal narratives with ethnographic description and analyses, this article illustrates a crossing over of moments in which abandonment and abuse give rise to instances of companionship, care, and cohabitation.
Mothers of Solitude: Childlessness and Intersubjectivity in the Upper Zambezi
Authors: Silva Sónia
Published: November 2009

Drawing on normative cultural forms and interpersonal encounters, I seek to convey the sense of sadness and devastation associated with childlessness in the Upper Zambezi, and to interpret that sense as a pathology of severed intersubjectivity. I also argue that as irremediable as this pathology might seem, elderly childless women may momentarily revert to personhood through compassion, itself experienced as the restoration of intersubjective ties. The conditions of personhood and nonpersonhood, in addition to being structural and processual, are emotional, performative, and intersubjective as well.
Partial Intra‐Aortic Occlusion Improves Perfusion Deficits and Infarct Size Following Focal Cerebral Ischemia
Authors: Noor Raza , Wang Chen Xu , Todd Kathryn , Elliott Cameron , Wahr Joyce , Shuaib Ashfaq
Published: November 2009

Reperfusion with intravenous tissue plasminogen activator (tPA) has been the goal of therapy for acute ischemic stroke; however, tPA is contraindicated in many patients, has low recanalization rates in major occlusions, and carries a substantial risk of symptomatic intracerebral hemorrhage. In the present study, we hypothesized that partial intra‐aortic occlusion of the abdominal aorta would increase salvage of ischemic penumbra and reduce infarct volume after focal embolic stroke in rats. We examined the effects of aortic occlusion on infarct volume, expression and activation of matrix metalloprotease‐9, and hemorrhagic transformation with or without treatment with tPA. We then examined the effects of aortic occlusion on perfusion deficits following embolic occlusion. Results showed that partial aortic occlusion significantly reduces brain infarction volume with or without treatment with tPA after focal ischemia, but does not increase risk for hemorrhagic transformation or matrix metalloprotease‐9 expression and activation. Partial intra‐aortic occlusion also reduces perfusion deficits after focal cerebral ischemia as compared to control. The present study shows that partial intra‐aortic occlusion significantly decreases infarction volume and perfusion deficits following ischemic injury in an embolic model of cerebral ischemia. Moreover, combination treatment with tPA and partial intra‐aortic occlusion further reduces infarction volume without any increase in hemorrhagic transformation.
Acceptance of Rapid HIV Screening in a Southeastern Emergency Department
Authors: Freeman Arin E. , Sattin Richard W. , Miller Kelly M. , Dias James K. , Wilde James A.
Published: November 2009

Objectives:  The objective was to assess the acceptance of an emergency department (ED) human immunodeficiency virus (HIV) screening program based on the Centers for Disease Control and Prevention (CDC) recommendations for routine HIV screening in health care settings.

Methods:  Rapid HIV screening was offered on an opt‐out basis to patients aged 13 to 64 years presenting to the ED by trained HIV counselors. Patients were excluded if they had a history of HIV, were physically or mentally incapacitated, did not understand their right to opt‐out, or did not speak English or Spanish. Statistical analyses, including logistic regression, were performed to assess the associations between the demographics of patients offered testing and their test acceptance or refusal.

Results:  From March 2008 to January 2009, a total of 5,080 (91%) of the 5,585 patients offered the HIV test accepted, and 506 (9%) refused. White and married patients were less likely to accept testing than those who were African American and unmarried (p < 0.001). Adult patients were almost twice as likely to accept testing as pediatric patients (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.50 to 2.53). As age increased among pediatric patients, testing refusal decreased (OR = 0.71; 95% CI = 0.59 to 0.85), and as age increased among adult patients, testing refusal increased (OR = 1.17; 95% CI = 1.12 to 1.22). Two percent of persons accepting the test were considered high risk. Males were more likely to report high‐risk behavior than females (OR = 1.83; 95% CI = 1.23 to 2.72).

Conclusions:  The opt‐out approach results in high acceptance of routine HIV screening. Widespread adoption of the CDC’s recommendations, although feasible, will require significant increases in resources.
An Interdisciplinary Initiative to Reduce Radiation Exposure: Evaluation of Appendicitis in a Pediatric Emergency Department With Clinical Assessment Supported by a Staged Ultrasound and Computed Tomography Pathway
Authors: Ramarajan Naresh , Krishnamoorthi Rajesh , Barth Richard , Ghanouni Pejman , Mueller Claudia , Dannenburg Bernard , Ewen Wang N.
Published: November 2009

Objectives:  In the emergency department (ED), a significant amount of radiation exposure is due to computed tomography (CT) scans performed for the diagnosis of appendicitis. Children are at increased risk of developing cancer from low‐dose radiation and it is therefore desirable to utilize CT only when appropriate. Ultrasonography (US) eliminates radiation but has sensitivity inferior to that of CT. We describe an interdisciplinary initiative to use a staged US and CT pathway to maximize diagnostic accuracy while minimizing radiation exposure.

Methods:  This was a retrospective outcomes analysis of patients presenting after hours for suspected appendicitis at an academic children’s hospital ED over a 6‐year period. The pathway established US as the initial imaging modality. CT was recommended only if US was equivocal. Clinical and pathologic outcomes from ED diagnosis and disposition, histopathology and return visits, were correlated with the US and CT. ED diagnosis and disposition, pathology, and return visits were used to determine outcome.

Results:  A total of 680 patients met the study criteria. A total of 407 patients (60%) followed the pathway. Two‐hundred of these (49%) were managed definitively without CT. A total of 106 patients (26%) had a positive US for appendicitis; 94 (23%) had a negative US. A total of 207 patients had equivocal US with follow‐up CT. A total of 144 patients went to the operating room (OR); 10 patients (7%) had negative appendectomies. One case of appendicitis was missed (<0.5%). The sensitivity, specificity, negative predictive value, and positive predictive values of our staged US‐CT pathway were 99%, 91%, 99%, and 85%, respectively. A total of 228 of 680 patients (34%) had an equivocal US with no follow‐up CT. Of these patients, 10 (4%) went to the OR with one negative appendectomy. A total of 218 patients (32%) were observed clinically without complications.

Conclusions:  Half of the patients who were treated using this pathway were managed with definitive US alone with an acceptable negative appendectomy rate (7%) and a missed appendicitis rate of less than 0.5%. Visualization of a normal appendix (negative US) was sufficient to obviate the need for a CT in the authors’ experience. Emergency physicians (EPs) used an equivocal US in conjunction with clinical assessment to care for one‐third of study patients without a CT and with no known cases of missed appendicitis. These data suggest that by employing US first on all children needing diagnostic imaging for diagnosis of acute appendicitis, radiation exposure may be substantially decreased without a decrease in safety or efficacy.
Violence Prevention in the Emergency Department: Future Research Priorities
Authors: Houry Debra , Cunningham Rebecca M. , Hankin Abigail , James Thea , Bernstein Edward , Hargarten Stephen
Published: November 2009

The 2009 Academic Emergency Medicine Consensus Conference working group session participants developed recommendations and research questions for violence prevention in the emergency department (ED). A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) promote and facilitate the collection of standardized information related to violence victimization and perpetration in ED settings; 2) develop and validate brief practical screening instruments that can identify those at risk for perpetration of violence toward others or toward self; 3) develop and validate brief practical screening instruments that can identify victims at risk for violent reinjury and mental health sequelae; and 4) conduct efficacy, translational, and dissemination research on interventions for violence prevention. The work group emphasized the critical need and role of ED‐based research to impact surveillance and prevention of future violence‐related injury.
Mental Health and Emergency Medicine: A Research Agenda
Authors: Larkin Gregory Luke , Beautrais Annette L. , Spirito Anthony , Kirrane Barbara M. , Lippmann Melanie J. , Milzman David P.
Published: November 2009

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED‐initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real‐world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.
Public Health in the Emergency Department: Overcoming Barriers to Implementation and Dissemination
Authors: McKay Mary Pat , Vaca Federico E. , Field Craig , Rhodes Karin
Published: November 2009

This article is the outcome of a consensus building workshop entitled, “Overcoming Barriers to Implementation and Dissemination” convened at the 2009 Academic Emergency Medicine Consensus Conference, ‘‘Public Health in the ED: Surveillance, Screening, and Intervention.” The participants were asked to address potential methods for overcoming barriers to the dissemination and implementation in the emergency department (ED) of evidenced‐based practices to improve public health. The panel discussed three broad areas of interest including methods for disseminating evidence‐based practices, barriers encountered during the process of implementation, and the importance of involvement in activities outside the ED including engagement in policy development and improvement. Four recommendations were discussed in detail and consensus was reached. The recommendations included 1) researchers and advocates should disseminate findings through multiple forums beyond peer‐reviewed publications when an ED‐based public health intervention has enough evidence to support integration into the routine practice of emergency care; 2) local barriers to implementation of public health interventions should be recognized and well understood from multiple perspectives prior to implementation; 3) innovation must be put into place and adapted based on local institutional context and culture as barriers and the best methods for overcoming them will vary across institutions; and 4) use of legislation, regulation, and incentives outside of the ED should support and strengthen ED‐based interventions. For each area of interest, research dimensions to extend the current understanding of methods for effectively and efficiently implementing evidence‐based public health interventions in the ED were discussed and consensus was achieved.
SBIRT in Emergency Care Settings: Are We Ready to Take it to Scale?
Authors: Bernstein Edward , Bernstein Judith A. , Stein Jack B. , Saitz Richard
Published: November 2009

This article summarizes a panel discussion on “SBIRT in the emergency care setting: are we ready to take it to scale?” Dr. Edward Bernstein commented on the historical developments of emergency department (ED) screening, brief intervention (BI), and referral to treatment (SBIRT) research, practice, and knowledge translation. Dr. Jack Stein addressed SBIRT grant program progress to date, the reimbursement stream, SBIRT lessons learned, and unanswered questions. Dr. Richard Saitz reviewed the limitations of the evidence for alcohol and drug ED screening and BI and cautioned on the danger of proceeding to practice and broad dissemination without evidenced based on randomized controlled trials with sufficient sample size and clinically important outcomes.
Tobacco Screening Multicomponent Quality Improvement Network Program: Beyond Education
Authors: Kimmel Sharon , Smith Suzanne L. , Sabino Judith N. , Gertner Eric , Dostal Julie , Greenberg Marna Rayl
Published: November 2009

Objectives:  Due to the addictive nature of the disease and interrelated societal influences on the behavior of tobacco use, repeated interventions are often required before people successfully stop using tobacco. Our objective was to implement a multicomponent clinical intervention initiative enabling health care providers to effectively screen for tobacco use. We also sought to describe changes in emergency medicine providers’ documentation of cessation advice to tobacco users.

Methods:  The intervention was conducted at three emergency departments (EDs) and four clinics at a community‐based teaching hospital and health network. Health care providers with the opportunity to identify and counsel tobacco‐using patients in ambulatory health care settings were the study population. The authors initiated a quality improvement initiative for tobacco screening that employed a multicomponent strategy to facilitate systemic changes that support 100% tobacco use identification, documentation, and counseling. Baseline, posteducation, and post–wrap‐around documented screening rates were compared within each site across the intervention. Cumulative ED baseline, posteducation, and post–wrap‐around rates of provider advice to tobacco users were compared across the intervention. Percentage of possible available gain was calculated in consideration of a 100% ceiling effect. Statistical analysis was performed using SPSS and MetStat. Descriptive statistics and Pearson’s chi‐square cell frequency were used to analyze and compare sites. Fisher’s exact test was used to compare those tests with a chi‐square cell frequency of five or less. The statistical tests used for pre‐/postintervention percentage comparisons by site had power between 80% and 90%, detecting differences of 10% and 20% or more at a 0.05 level of significance.

Results:  Significant increases in posteducation screening rates for all ED sites complemented significant increases in ED post–wrap‐around intervention screening rates. Significant increases in ED provider documented cessation advice were also noted.

Conclusions:  This initiative successfully changed tobacco screening behavior of health care providers at all sites. It was particularly successful in the ED, typically an environment less likely to be conducive to preventive health interventions.
Alcohol, Tobacco, and Other Drugs: Future Directions for Screening and Intervention in the Emergency Department
Authors: Cunningham Rebecca M. , Bernstein Steven L. , Walton Maureen , Broderick Kerry , Vaca Federico E. , Woolard Robert , Bernstein Edward , Blow Fred , D’Onofrio Gail
Published: November 2009

This article is a product of a breakout session on injury prevention from the 2009 Academic Emergency Medicine consensus conference on “Public Health in the ED: Screening, Surveillance, and Intervention.” The emergency department (ED) is an important entry portal into the medical care system. Given the epidemiology of substance use among ED patients, the delivery of effective brief interventions (BIs) for alcohol, drug, and tobacco use in the ED has the potential to have a large public health impact. To date, the results of randomized controlled trials of interventional studies in the ED setting for substance use have been mixed in regard to alcohol and understudied in the area of tobacco and other drugs. As a result, there are more questions remaining than answered. The work group developed the following research recommendations that are essential for the field of screening and BI for alcohol, tobacco, and other drugs in the ED. 1) Screening—develop and validate brief and practical screening instruments for ED patients and determine the optimal method for the administration of screening instruments. 2) Key components and delivery methods for intervention—conduct research on the effectiveness of screening, brief intervention, and referral to treatment (SBIRT) in the ED on outcomes (e.g., consumption, associated risk behaviors, and medical psychosocial consequences) including minimum dose needed, key components, optimal delivery method, interventions focused on multiple risk behaviors and tailored based on assessment, and strategies for addressing polysubstance use. 3) Effectiveness among patient subgroups—conduct research to determine which patients are most likely to benefit from a BI for substance use, including research on moderators and mediators of intervention effectiveness, and examine special populations using culturally and developmentally appropriate interventions. 4) Referral strategies—a) promote prospective effectiveness trials to test best strategies to facilitate referrals and access from the ED to preventive services, community resources, and substance abuse and mental health treatment; b) examine impact of available community services; c) examine the role of stigma of referral and follow‐up; and d) examine alternatives to specialized treatment referral. 5) Translation—conduct translational and cost‐effectiveness research of proven efficacious interventions, with attention to fidelity, to move ED SBIRT from research to practice.
Research Using Emergency Department–related Data Sets: Current Status and Future Directions
Authors: Hirshon Jon Mark , Warner Margaret , Irvin Charlene B. , Niska Richard W. , Andersen Daniel A. , Smith Gordon S. , McCaig Linda F.
Published: November 2009

The 2009 Academic Emergency Medicine consensus conference focused on “Public Health in the ED: Surveillance, Screening and Intervention.” One conference breakout session discussed the significant research value of health‐related data sets. This article represents the proceedings from that session, primarily focusing on emergency department (ED)‐related data sets and includes examples of the use of a data set based on ED visits for research purposes. It discusses types of ED‐related data sets available, highlights barriers to research use of ED‐related data sets, and notes limitations of these data sets. The paper highlights future directions and challenges to using these important sources of data for research, including identification of five main needs related to enhancing the use of ED‐related data sets. These are 1) electronic linkage of initial and follow‐up ED visits and linkage of information about ED visits to other outcomes, including costs of care, while maintaining deidentification of the data; 2) timely data access with minimal barriers; 3) complete data collection for clinically relevant and/or historical data elements, such as the external cause‐of‐injury code; 4) easy access to data that can be parsed into smaller jurisdictions (such as states) for policy and/or research purposes, while maintaining confidentiality; and 5) linkages between health survey data and health claims data. ED‐related data sets contain much data collected directly from health care facilities, individual patient records, and multiple other sources that have significant potential impact for studying and improving the health of individuals and the population.
The Clinical Impact of Health Behaviors on Emergency Department Visits
Authors: Bernstein Steven L.
Published: November 2009

Modifiable health behaviors are an important cause of visits to emergency departments (EDs). Substance use, unsafe sexual behavior, interpersonal violence, unintentional injury, and other risky behaviors account for a large proportion of ED volume, as well as up to 40% of all deaths in the United States. While emergency physicians commonly treat the illnesses and injuries caused by these behaviors, additional opportunities exist to screen, intervene, refer, and initiate treatment for patients with these health risks. This article reviews the epidemiology and clinical impact of risky health behaviors on ED visits and suggests strategies for creating a research agenda in these areas.
IGHV3‐21 gene usage is associated with high TCL1 expression in chronic lymphocytic leukemia
Authors: Mansouri Mahmoud R. , Sevov Marie , Åleskog Anna , Jondal Mikael , Merup Mats , Sundström Christer , Osorio Lyda , Rosenquist Richard
Published: November 2009

T‐cell leukemia/lymphoma protein 1 (TCL1) was recently shown to display an expression pattern in chronic lymphocytic leukemia (CLL) corresponding to molecular subtypes, where poor‐risk patients demonstrated higher expression levels. Here, we examined the mRNA expression pattern of TCL1 in 144 patients with CLL, including 67 immunoglobulin heavy‐chain variable (IGHV) mutated, 58 IGHV unmutated and 19 patients with IGHV3‐21 usage. A higher TCL1 expression level was detected in patients with CLL with unmutated vs. mutated IGHV genes (P < 0.001), whereas no difference was demonstrated within the IGHV3‐21 cohort (i.e., mutated vs. unmutated and stereotyped vs. non‐stereotyped complementarity determining region 3). The IGHV3‐21 subgroup displayed high TCL1 mRNA expression, differing significantly from other IGHV mutated cases (P < 0.001), although 11/19 had mutated IGHV genes. Furthermore, high TCL1 expression levels were associated with significantly shorter overall survival (P < 0.001). Altogether, we show that TCL1 mRNA expression may predict clinical outcome in CLL and that the IGHV3‐21 subset, regardless of mutational status, displays high TCL1 expression.
Kasabach–Merritt phenomenon: a single centre experience
Authors: Ryan Clodagh , Price Vicotria , John Philip , Mahant Sanjay , Baruchel Sylvain , Brandão Leonardo , Blanchette Victor , Pope Elena , Weinstein Miriam
Published: November 2009

Objective:  Kasabach–Merritt phenomenon (KMP) can lead to life‐threatening bleeding, and its optimum treatment has not been established. We review the experience of managing KMP in a single institution.

Methods:  A retrospective chart review on all children with KMP treated at the Hospital for Sick Children, Toronto, over an 18 yr period was carried out.

Results:  All 15 patients had profound thrombocytopenia and hypofibrinogenemia at presentation, half had bleeding symptoms, and three had cardiac failure. All patients received corticosteroids. Five responded to steroids alone, given for an average of 13 wk, increasing platelets to >20 × 109/L at a mean of 6.2 d and fibrinogen >1 g/dL at 25.6 d. Ten patients received at least one other therapeutic modality in addition to steroids, including vincristine, interferon, anti‐platelet agents and pentoxifylline. Five patients received vincristine, for a mean of 6 wk, with two patients responding. Eight patients received interferon, for a mean of 4 months, with two patients responding. Overall, the mean time to increasing platelets >20 × 109/L was 56 d, to >150 × 109/L was 88 d and fibrinogen >1 g/dL 49 d. Ten patients showed a partial response to embolisation, with a mean of 2.8 procedures performed. Thrombotic complications occurred in 7%. Twelve patients remain alive, with relapse in six patients, all treated successfully. One patient died, and two patients have been lost to follow‐up.

Conclusion:  KMP is a rare condition, with significant morbidity and mortality. The therapeutic approach should include a multidisciplinary team and consensus on guidelines.