bluuebunny/crossref_metadata_2025 huggingface dataset:
Do Elder Emergency Department Patients and Their Informants Agree about the Elder's Functioning?
Authors: Gerson Lowell W. , Blanda Michelle , Dhingra Pankaj , Davis Janae M. , Diaz Sebastian R.
Published: January 2008

Objective: To compare elder patients' and their informants' ratings of the elder's physical and mental function measured by a standard instrument, the Medical Outcomes Study Short Form 12 (SF‐12). Methods: This was a randomized, cross‐sectional study conducted at a university‐affiliated community teaching hospital emergency department (census 65,000/year). Patients >69 years old, arriving on weekdays between 10 AM and 7 PM, able to engage in English conversation, and consenting to participate were eligible. Patients too ill to participate were excluded. Informants were people who accompanied and knew the patient. Elder patients were randomized 1:1 to receive an interview or questionnaire version of the SF‐12. The questionnaire was read to people unable to read. Two trained medical students administered the instrument. The SF‐12 algorithm was used to calculate physical (PCS) and mental (MCS) component scores. Oral and written versions were compared using analysis of variance. The PCS and MCS scores between patient‐informant pairs were compared with a matched t‐test. Alpha was 0.05. Results: One hundred six patients and 55 informants were enrolled. The patients' average (±SD) age was 77 ± 5 years; 59 (56%; 95% CI = 46% to 65%) were women. There was no significant difference for mode of administration in PCS (p = 0.53) or MCS (p = 0.14) scores. Patients rated themselves higher on physical function than did their proxies. There was a 4.1 (95% CI = 99 to 7.2) point difference between patients' and their proxies' physical component scores (p = 0.01). Scores on the mental component were quite similar. The mean difference between patients and proxies was 0.49 (95% CI = 3.17 to 4.16). The half point higher rating by patients was not statistically significant (p = 0.79). Conclusions: Elders' self‐ratings of physical function were higher than those of proxies who knew them. There was no difference in mental function ratings between patients and their proxies. Switching from informants' to patients' reports in evaluating elders' physical function in longitudinal studies may introduce error.
Preventive Care in the Emergency Department: Should Emergency Departments Institute a Falls Prevention Program for Elder Patients? A Systematic Review
Authors: Weigand John V. , Gerson Lowell W.
Published: January 2008

Objective: To perform a systematic review of the emergency medicine literature to assess the appropriateness of an intervention to identify, counsel, and refer emergency department (ED) patients >64 years old who are at high risk for falls. Methods: The systematic review was facilitated through the use of a structured template, a companion explanatory piece, and a grading and methodological scoring system based on published criteria for critical appraisal. A reference librarian did two PubMed searches using the following: ED visits, patients >64 years old, falls, high risk, and effectiveness of intervention. Emergency Medical Abstracts, Science Citation Index, and the Cochrane Collaboration database were searched. Two team members reviewed the abstracts and selected pertinent articles. References were screened for additional pertinent articles. Results: Twenty‐six articles were reviewed. None were ED‐based primary or secondary falls prevention in older patients. One randomized controlled trial of an intervention to decrease subsequent falls in elder community‐dwelling patients who presented with a fall showed a structured interdisciplinary approach significantly reducing the number of falls. Two ED‐based studies showed it was possible to identify ED patients at risk for falls. Conclusions: Based on one randomized controlled trial demonstrating a significant reduction in the risk of further falls, the burden of suffering caused by falls, and other studies demonstrating the value of interventions to reduce the risk of falling, the authors recommend that EDs conduct research to evaluate the effectiveness of clinical interventions to identify, counsel, and refer ED patients >64 years old who are at high risk for an unintentional fall.
The Intubating Laryngeal Mask Airway: Suggestions for Use in the Emergency Department
Authors: Reardon Robert F. , Martel Marc
Published: January 2008

With the increased use of rapid‐sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.
Violence between Women in an Urban Emergency Department Patient Population
Authors: Mechem C. Crawford , Shofer Frances S. , Reinhard Sharon S. , Hornig Sarah , Datner Elizabeth M.
Published: January 2008

Abstract. Objective: To determine what percentage of women presenting to an urban emergency department (ED) for any reason had been the victims of violence committed by another woman in the previous year. Methods: This was a prospective study of a consecutive sample of female patients of legal age presenting to the ED between 8 AM and 12 midnight over an 11‐week period. Patients were asked a series of questions adapted from the George Washington University Universal Violence Prevention Screening Protocol. Non‐English‐speaking patients, those unable to give informed consent, and those meeting regional criteria for major trauma were excluded. Results: One thousand six hundred seventy‐six women participated; 426 (25%) refused. Of the 1,250 women interviewed, 118 (9.4%; 95% CI = 7.8% to 11.1%) reported being assaulted by another woman in the previous 12 months. Compared with the nonvictims, the victims were more frequently younger and single. The most common forms of assault were slapping, grabbing, and shoving (54.7% of victims). These were followed by being choked, kicked, bitten, or punched (46.2%). Eighteen percent of the assaults involved a weapon or an object. Five percent of the victims described being forced to have sex. Thirty‐seven percent of the victims contacted the police, 13% required medical attention, 17% pursued legal action, and 10% sought follow‐up counseling. Conclusions: Nine percent of the women in the study sample had been assaulted by another woman in the previous year. Further attention to the recognition and management of violence committed by women against other women may be warranted to ensure that patients receive appropriate treatment and referral.
Impact of Ambulance Diversion Policies in Urban, Suburban, and Rural Areas of Central Maryland
Authors: Scheulen James J. , Li Guohua , Kelen Gabor D.
Published: January 2008

Abstract. As a method to control patient flow to overburdened hospitals, effective emergency medical services (EMS) systems provide policies for ambulance diversion. The Maryland state EMS system supports two types of alert for general hospital use: red alert, aimed at limiting the delivery of patients who may require intensive care unit (ICU) admission, and yellow alert, aimed at preventing further overload of already overtaxed emergency departments (EDs). Objective: To examine the effect of those alert policies in different geographical environments, urban, suburban, and rural. Methods: Alert data for 23 hospitals in Central Maryland and ambulance arrival data for approximately 138,000 ambulance calls during calendar year 1996 were combined and analyzed. The impacts of diversion practices in the geographic areas were compared. Results: Red alert reduced volume in all patient acuity levels in all geographic areas by a statistically significant 0.4 patient/hr. Yellow alert diverted low‐acuity patients at the rate of 0.13 patient/hr (p < 0.001) in urban areas and at the rate of 0.16 patient/hr (p < 0.001) in suburban areas, but had minimal impact in the flow of patients in the rural environment. Conclusions: The ED diversion policy has some limited effect in preventing further patient volume in urban and suburban areas, but has virtually no impact in rural areas. However, an ICU diversion policy diverts patients of all acuities uniformly and inordinately diverts patients not likely to require ICU admissions while having only minimal impact on patients who do require ICU resources. The impact of red alert is uniform in all geographic areas. The impact and efficacy of ambulance diversion policies should be evaluated to ensure they are having the intended effect. While perhaps initially effective, the impact of alert policies may change over time.
Ethics Seminars: Beyond Authorship Requirements—Ethical Considerations in Writing Letters of Recommendation
Authors: Larkin Gregory L. , Marco Catherine A.
Published: January 2008

Abstract.Letters of recommendation may serve a number of vital functions related to the evaluation, selection, and promotion of candidates. The lure of academic celebrity or the desire of an individual candidate for a flattering letter must not threaten the veracity of the content. Letters of recommendation should be appropriately authored to meet the needs of the institution or individual requesting the letter, while keeping authenticity paramount. Length and content should be complete but not overly verbose. Relevant elements suggested by standardized formats should typically be included, such as nature of contact with the applicant, commitment to emergency medicine, work ethic, ability to develop a differential and treatment plan, personality, interpersonal interactions, and an overall comparative ranking. The seven cardinal elements of an exemplary letter of recommendation are that it should be: 1)authentic(based on adequate first‐hand knowledge of the candidate's skills); 2)honest(accurate; avoiding exaggeration or hyperbole); 3)explicit(avoidance of veiled omissions); 4)balanced(taking care to incorporate both strengths and weaknesses); 5)confidential(avoiding unnecessary or unanticipated disclosure); 6)of appropriate detail and length(content relevant to the institutional or individual requests); and 7)technically clear(avoidance of unnecessary abbreviations and jargon). The implied duty to future students, colleagues, researchers, and patients who might come in contact with the applicant should motivate authors to write honest, explicit, appropriate, and complete letters.
Electrocardiographic ST‐segment Elevation The Diagnosis of Acute Myocardial Infarction by Morphologic Analysis of the ST Segment
Authors: Brady William J. , Syverud Scott A. , Beagle Charlotte , Perron Andrew D. , Ullman Edward A. , Holstege Christopher , Riviello Ralph J. , Ripley Anne , Ghaemmaghami Chris A.
Published: January 2008

Acute myocardial infarction (AMI) is one of many causes of ST‐segment elevation (STE) in emergency department (ED) chest pain (CP) patients. The morphology of STE may assist in the correct determination of its cause, with concave patterns in non‐AMI syndromes and non‐concave waveforms in AMI. Objectives: To determine the impact of STE morphologic analysis on AMI diagnosis and the ability of this technique to separate AMI from non‐infarction causes of STE. Methods: The electrocardiograms (ECGs) of consecutive ED adult CP patients (with three serial troponin I determinations) were interpreted in two‐step fashion by six attending emergency physicians (EPs): 1) the determination of STE by three EPs followed by 2) STE morphologic analysis (either concave or non‐concave) in those patients with STE. The impact of STE morphology analysis was investigated in the identification of AMI and non‐AMI causes of STE. Acute myocardial infarction was diagnosed by abnormal serum troponin I values (>0.1 mg/dL) followed by a rise and fall of the serum marker; STE diagnoses of non‐AMI causes were determined by medical record review. Interobserver reliability concerning STE morphology was determined. Study inclusion criteria included at least three troponin values performed in serial fashion no more frequently than every three hours, initial ED ECG, ED diagnosis, and final hospital diagnosis. Results: Five hundred ninety‐nine CP patients were entered in the study, with 171 (29%) individuals having STE on their ECGs. Of the 171 patients who had STE, 56 had AMI, 50 had unstable angina pectoris (USAP), and 65 had non‐coronary final diagnoses. Forty‐nine patients had non‐concave STE, 46 with AMI and three with USAP; no patient with a non‐coronary diagnosis had a non‐concave STE morphology. The sensitivity and specificity of the non‐concave STE morphology for AMI diagnoses were 77% and 97%, respectively; the positive and negative predictive values for non‐concave morphology in AMI diagnoses were 94% and 88%, respectively. Interobserver reliability in the STE morphology determination revealed a kappa coefficient of 0.87. Conclusions: A non‐concave STE morphology is frequently encountered in AMI patients. While the sensitivity of this pattern for AMI diagnosis is not particularly helpful, the presence of this finding in adult ED chest pain patients with STE strongly suggests AMI. This technique produces consistent results among these EPs.
Faculty Triage Shortens Emergency Department Length of Stay
Authors: Partovi Sirous N. , Nelson Brian K. , Bryan Earl D. , Walsh Matthew J.
Published: January 2008

Objective: To determine whether faculty triage (FT) activities can shorten emergency department (ED) length of stay (LOS). Methods: This was a comparison study measuring the impact of faculty triage vs no faculty triage on ED LOS. It was set in an urban county teaching hospital. Subjects were patients presenting to the registration desk between 9 AM and 9 PM on 16 consecutive Mondays (August 2 to November 15, 1999). On eight Mondays, an additional faculty member was stationed at the triage desk. He or she was asked to expedite care by rapid evaluation orders for diagnostic studies and basic therapeutic interventions, and by moving serious patients to the patient care areas. He or she was not provided with detailed instructions or protocols. The ED LOS, time of registration (TIMEREG), inpatient admission status (ADMIT), x‐ray utilization (XRAY), total patients registered each day between 9 AM and 9 PM (TOTREG), and patients who left without being seen (LWBS) were determined using an ED information system. The LOS was analyzed in relation to FT, ADMIT, and XRAY by the Mann‐Whitney U test. The LOS was related to TIMEREG and TOTREG by simple linear regression. Stepwise multiple linear regression models to predict LOS were generated using all the variables. Results: Patients without FT (n? 814) had a mean LOS of 445 minutes. Patients with FT (n? 920) had a mean LOS of 363 minutes. Mean difference in LOS was ‐82 minutes (95% CI ? ‐111 to ‐53), a reduction of 18%. The LOS was also related to: ADMIT +203 minutes (95% CI ? 168 to 238), TOTREG ‐2.7 min/additional patient registered (95% CI ? ‐1.15 to ‐4.3), and TIMEREG +0.14 min/min since 9 AM (95% CI ? 0.07 to 0.21). The LWBS was reduced by 46% with FT. In multiple regression analysis, ADMIT, FT, TIMEREG, and XRAY were all related to LOS, but the model explained only a small part of variance (adjusted R2? 0.093). The faculty cost is estimated to be 11.98/patient. Conclusions: Faculty triage offers a moderate increase in efficiency at this ED, albeit with relatively high cost.
Rochester, New York A Decade of Emergency Department Overcrowding
Authors: Schneider Sandra , Zwemer Frank , Doniger Andrew , Dick Robbin , Czapranski Tim , Davis Eric
Published: January 2008

Overcrowding is common in emergency departments (EDs) throughout the United States. The history of ED overcrowding in Rochester, New York, is notable due to its unique health care system that introduced the concepts of managed care as early as the 1950s. An effect of this system was to intentionally restrict resources and allow the issue of access to limit utilization. Overcrowding in EDs was severe in the late 1990s‐2000, and became an accepted local standard of care. Objective: To study the strategies to reduce ED overcrowding in Rochester in the last decade. Methods: A descriptive analysis of individual hospital and community efforts to decrease ED overcrowding. Results: Of the strategies tried, those that had little effect on ED overcrowding were based from the ED, such as ambulance diversion. Those that were successful were those that addressed factors external to the ED such as increased flexibility of inpatient resources; float nurses who responded to acute care needs; a transition team (mid‐level provider along with registered nurse (RN)/licensed practical nurse) who cared for inpatients boarded in the ED; integrated services across affiliated hospitals/systems; an early alert system that notified key personnel before “code red” criteria were met; and a multidisciplinary team to round in the ED and analyze resource needs. Current community‐wide initiatives include precise tracking of code red hours; monitoring patient length of stay (LOS) in the ED and inpatient units; education of physicians and nursing homes regarding ED alternatives; exploration of additional resources for subacute and long‐term care; establishing a regional forum to address the nursing shortage; development of an ED triage system to coordinate diversion activities during code red; and consideration of a county‐wide state of emergency when needed. Conclusions: Emergency department overcrowding is the end result of a variety of factors that must be addressed system‐wide.
Effect of an Emergency Department (ED) Managed Acute Care Unit on ED Overcrowding and Emergency Medical Services Diversion
Authors: Kelen Gabor D. , Scheulen James J. , Hill Peter M.
Published: January 2008

Objective: To determine the impact of an inpatient, emergency department (ED)‐managed acute care unit (ACU) on ED overcrowding and use of ambulance diversion. Methods: Descriptive observational study with prospectively collected data from a 14‐bed ACU recently opened remote from the main ED. Rates of patients who left without being seen (LWBS) and ambulance diversion frequency and duration were adjusted for ED patient volumes and compared with those for the period immediately before the ACU was opened and with those for a matching time period during the previous year. Results: There were 1,589 patients seen in the ACU during the first ten weeks of operation, representing about 14.5% of the ED volume (10,871). About 33% could be classified as post‐ED management, 20% as admission processing, and the rest as primary evaluation. The number of patients who LWBS decreased from 10.1% of the ED census two weeks prior to opening of the ACU, and from 9.4% during the previous year, to 5.0% (range 4.2%‐6.2%) during the ensuing ten weeks post opening. Ambulance diversion was a mean of 6.7 hours per 100 patients before the unit opened and 5.6 hours per 100 patients during the same time in the previous year, and decreased to 2.8 hours per 100 patients after the unit opened (p < 0.05, respectively). A six‐month pre‐ and two‐month post‐examination revealed that the mean monthly hours of ambulance diversion for the ED decreased by 40% (202 hours vs 123 hours) (p < 0.05) in contrast to a mean increase of 44% (186 hours vs 266 hours) (p < 0.05) experienced by four proximate hospitals. Conclusions: An ED‐managed ACU can have significant impact on ED overcrowding and ambulance diversion, and it need not be located proximate to the ED.
Reliability of the Visual Analog Scale for Measurement of Acute Pain
Authors: Bijur Polly E. , Silver Wendy , Gallagher E. John
Published: January 2008

Objective: Reliable and valid measures of pain are needed to advance research initiatives on appropriate and effective use of analgesia in the emergency department (ED). The reliability of visual analog scale (VAS) scores has not been demonstrated in the acute setting where pain fluctuation might be greater than for chronic pain. The objective of the study was to assess the reliability of the VAS for measurement of acute pain.

Methods: This was a prospective convenience sample of adults with acute pain presenting to two EDs. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) and a Bland‐Altman analysis were used to assess reliability of paired VAS measurements obtained 1 minute apart every 30 minutes over two hours.

Results: The summary ICC for all paired VAS scores was 0.97 [95% CI = 0.96 to 0.98]. The Bland‐Altman analysis showed that 50% of the paired measurements were within 2 mm of one another, 90% were within 9 mm, and 95% were within 16 mm. The paired measurements were more reproducible at the extremes of pain intensity than at moderate levels of pain.

Conclusions: Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high. Ninety percent of the pain ratings were reproducible within 9 mm. These data suggest that the VAS is sufficiently reliable to be used to assess acute pain.
Role of Flexion—Extension Radiographs in Blunt Pediatric Cervical Spine Injury
Authors: Ralston Mark E. , Chung Kee , Barnes Patrick D. , Emans John B. , Schutzman Sara A.
Published: January 2008

Abstract. Objective: To determine whether flexion—extension cervical spine radiography (FECSR) is abnormal in children who have sustained blunt cervical spine injury (CSI) when standard cervical spine radiography (SCSR) demonstrates no acute abnormalities. Methods: This was a blinded radiographic review of 129 patients ≤16 years of age evaluated at an academic pediatric trauma center during July 1990—March 1996. All patients had SCSR (anteroposterior/lateral views) and FECSR performed for a trauma‐related event within seven days of injury. Results: Of 46 patients without acute abnormalities on SCSR, one patient (with final clinical diagnosis of “no CSI”) had acute abnormalities on FECSR (95% CI = 0.06% to 11.5%). Of 50 patients with isolated loss of lordosis on SCSR, no patient had acute abnormalities on FECSR (95% CI = 0% to 5.8%). The FECSR review revealed no acute abnormalities in 75 of 83 patients (90.4%) with suspicious findings for CSI viewed on SCSR (95% CI = 81.9% to 95.7%). Complications during FECSR were noted in one patient with transient paresthesias (0.8%) (95% CI = 0.02% to 4.2%). Conclusions: In children who underwent acute radiographic evaluation of blunt cervical spine trauma, FECSR was unlikely to be abnormal when no acute abnormality or isolated loss of lordosis was evident on SCSR. In a subset of patients with suspicious findings for occult CSI on SCSR, FECSR was useful in ruling out ligamentous instability in the acute, posttrauma setting.
Emergency Department Utilization by Noninstitutionalized Elders
Authors: Shah Manish N. , Rathouz Paul J. , Chin Marshall H.
Published: January 2008

Abstract. Objectives: To the best of the authors knowledge, no nationally representative, population‐based study has characterized the proportion of elders using the emergency department (ED) and factors associated with ED use by elders. This article describes the proportion of elder Medicare beneficiaries using the ED and identifies attributes associated with elder ED users as compared with nonusers. Methods: The 1993 Medicare Current Beneficiary Survey was used, a national, population‐based, cross‐sectional survey of Medicare beneficiaries linked with Medicare claims data. The study population was limited to 9,784 noninstitutionalized individuals aged 66 years or older. The Andersen model of health service utilization was used, which explains variation in ED use through a combination of predisposing (demographic and social), enabling (access to care), and need (comorbidity and health status) characteristics. Results: Eighteen percent of the sample used the ED at least once during 1993. Univariate analysis showed ED users were older; were less educated and lived alone; had lower income and higher Charlson Comorbidity Index scores; and were less satisfied with their ability to access care than nonusers (p < 0.01, chi‐square). Logistic regression identified older age, less education, living alone, higher comorbidity scores, worse reported health, and increased difficulties with activities of daily living as factors associated with ED use (p < 0.05). Need characteristics predicted ED use with the greatest accuracy. Conclusions: The proportion of elder ED users is slightly higher than previously reported among Medicare beneficiaries. Need (comorbidity and health status) characteristics predict ED utilization with the greatest accuracy.
Direct Correlation between Diffusion of Loxosceles reclusa Venom and Extent of Dermal Inflammation
Authors: Gomez Hernan F. , Greenfield Diann M. , Miller Mark J. , Warren Jeffrey S.
Published: January 2008

Abstract. Objectives: Envenomation by Loxosceles species (brown recluse) spiders results in large dermal inflammatory lesions. Venom‐induced dermal inflammation occurs indirectly via soluble mediators of inflammation. This study aimed to explore whether the anatomic extent of dermonecrotic arachnidism is due to the cascade of soluble proinflammatory mediators elicited by venom deposited at the bite site, or due to diffusion of the venom per se. Methods: Three New Zealand white rabbits received intradermal L. reclusa venom (3‐μg) injections in the flank. At the time of maximum dermal inflammation (24 hr), paired 4‐mm dermal biopsies were obtained in 2‐cm intervals extending 0 to 12 cm from the inoculation site. Normal dermal tissue was obtained from the opposite flank to serve as a negative control. One biopsy sample from each interval was homogenized and assayed for myeloperoxidase (MPO) activity and for the presence of venom via an enzyme immunoassay (EIA). The other paired dermal biopsy was sectioned, and examined for the presence of polymorphonuclear neutrophils (PMNs) by microscopy. Lesional areas were measured using digital images imported into imaging software. Results: Mean ± SD lesional diameter 24 hours post inoculation measured 9.18 ± 0.64 cm. Venom was detected in biopsies 0 to 10 cm from the injection site. As expected, the highest venom concentrations were measured at the inoculation site (4.28 ± 3.9 ng/4 mm). In addition, PMNs and MPO were detected up to 8 and 10 cm from the inoculation site, respectively. Neither PMNs nor MPO was detected in tissue absent of venom (kappa = 0.88, p < 0.001). Conclusions: Loxosceles venom diffuses from the envenomation site. The extent of dermal inflammation mirrors the extent of Loxosceles venom diffusion. This observation implies that the venom itself defines the extent and magnitude of tissue injury following Loxosceles envenomation.
Electrocardiographic ST‐segment Elevation: Correct Identification of Acute Myocardial Infarction (AMI) and Non‐AMI Syndromes by Emergency Physicians
Authors: Brady William J. , Perron Andrew D. , Chan Theodore
Published: January 2008

Abstract. Objective: To determine the emergency physician's (EP's) ability to identify the cause of ST‐segment elevation (STE) in a hypothetical chest pain patient. Methods: Eleven electrocardiograms (ECGs) with STE were given to EPs; the patient in each instance was a 45‐year‐old male with a medical history of hypertension and diabetes mellitus with the chief complaint of chest pain. The EP was asked to determine the cause of the STE and, if due to acute myocardial infarction (AMI), to decide whether thrombolytic therapy (TT) would be administered (the patient had no contraindication to such treatment). Rates of TT administration were determined; appropriate TT administration was defined as that occurring in an AMI patient, while inappropriate TT administration was defined as that in the non‐AMI patient. Results: Four hundred fifty‐eight EPs completed the questionnaire; levels of medical experience included the following: postgraduate year 2‐3, 193 (42%); and attending, 265 (58%). The overall rate of correct interpretation of the study ECGs was 94.9% (4,782 correct interpretations out of 5,038 instances). Acute myocardial infarction with typical STE, ventricular paced rhythm, and right bundle branch block were never misinterpreted. The remaining conditions were misinterpreted with rates ranging between 9% (left bundle branch block, LBBB) and 72% (left ventricular aneurysm, LVA). The overall rate of appropriate thrombolytic agent administration was 83% (1,525 correct administrations out of 1,832 indicated administrations). The leading diagnosis for which thrombolytic agent was given inappropriately was LVA (28%), followed by benign early repolarization (23%), pericarditis (21%), and LBBB without electrocardiographic AMI (5%). Thrombolytic agent was appropriately given in all cases of AMI except when associated with atypical STE, where it was inappropriately withheld 67% of the time. Conclusions: In this survey, EPs were asked whether they would give TT based on limited information (ECG). Certain syndromes with STE were frequently misdiagnosed. Emergency physician electrocardiographic education must focus on the proper identification of these syndromes so that TT may be appropriately utilized.
Effect of a δ Receptor Agonist on Duration of Survival during Hemorrhagic Shock
Authors: Summers Richard L. , Li Zizhuang , Hildebrandt Drew
Published: January 2008

Objectives:Selective δ receptor agonists have been shown to stabilize membrane physiologic processes, reduce metabolic rates, and provide protection against ischemic insults through Katpchannel opening in a variety of organ beds. However, their potential for affecting outcomes in states of generalized ischemia has not been explored. The authors examined the effect of the nonselective δ receptor agonist, DADLE (D‐Ala2‐Leu5‐enkephalin), on hemodynamic stability and duration of survival in an animal model of severe hemorrhagic shock.Methods:Conscious Sprague Dawley rats with indwelling catheters were hemorrhaged at a rate of 3.25 mL/100 grams over 20 minutes after half of the group received 1% DADLE (1 mg/kg IV). Following the hemorrhage, all rats were continuously monitored for heart rate (HR), mean arterial pressure (MAP), and life signs for up to three hours (death defined as apnea, systolic blood pressure < 30 mm Hg without pulsations, and electroencephalographic silence). Survival rates and hemodynamic trends were compared between the control and DADLE‐treated groups.Results:In the 14 rats studied (8 DADLE; 6 controls), initial hemorrhage resulted in similar hemodynamic shock (average MAP fall: 118 to 59 vs 119 to 55 mm Hg). Analysis of survival at 3.5 hours revealed statistically significant differences between the control and DADLE groups. While 50% of the DADLE group survived past the three hours, no control animals were still alive at the end of the experimental period. The MAP trended downward and the HR increased for the control group, but all hemodynamic parameters stabilized in the rats treated with DADLE.Conclusions:Most current strategies for treating shock focus on the supply side of resuscitation. The coordinated various actions of DADLE have the potential to work in concert in the intact organism to improve overall survival during severe hemorrhagic shock. In an animal model of severe hemorrhagic shock, there was improvement in hemodynamic stability and a prolonged survival with DADLE treatment. Physiologic manipulation with DADLE appears to be a way to improve survival during shock with possible clinical implications.
Evaluation of a Structured Application Assessment Instrument for Assessing Applications to Canadian Postgraduate Training Programs in Emergency Medicine
Authors: Bandiera Glen , Regehr Glenn
Published: January 2008

Objective: To determine the interrater reliability and predictive validity of a structured instrument for assessing applications submitted to a Fellow of the Royal College of Physicians of Canada (FRCP) emergency medicine residency program. Methods: An application assessment instrument was derived based on faculty and resident input, institutional and national documents, and previous protocols. The instrument provided a score based on objective anchors for each of four application components. Three assessors were introduced to the instrument in a detailed tutorial session. Assessors were given five applications to score and results were compared for understanding of the scoring principles. The instrument was used in a developmental pilot to assess the 2001 cohort of applications and revised again. Applications for the 2002 study cohort were submitted through a central application service. Assessors used the instrument to score each application independently. Interrater reliability was determined by calculating a two‐way mixed‐effect Cronbach's alpha. Results: Forty applications were received for the year 2002. Thirty‐eight application packages were complete and data collection was complete for all 38. The single‐rater reliabilities for the curriculum vitae, personal letter, transcript, reference letters, and overall package were 0.73, 0.52, 0.64, 0.61, and 0.72, respectively. The three‐rater reliabilities for the components were 0.89, 0.77, 0.84, and 0.82, respectively. The three‐rater reliability of the overall application score was 0.89. Conclusions: Three‐rater reliabilities for each component and the entire application package were high. Multiple assessors are required to generate acceptable reliabilities. Using strict design and implementation principles can lead to a reliable instrument for assessing complex application packages.
Health Utility Measures and the Standard Gamble
Authors: Alex G. Michael John , Wyrwich Kathleen W.
Published: January 2008

The standard gamble is a method used to measure health utilities of varying health states and allow for comparisons across populations and different clinical settings. These health utility scores are useful as measures of outcome for quality of life and applicable to economic evaluation studies. Nonetheless, the measurement process can be cognitively challenging, and controversies remain regarding raters and rating methods.
An Evaluation of Emergency Medicine Resident Interaction Time with Faculty in Different Teaching Venues
Authors: Chisholm Carey D. , Whenmouth Laura F. , Daly Elizabeth A. , Cordell William H. , Giles Beverly K. , Brizendine Edward J.
Published: January 2008

Objectives: To measure actual emergency medicine (EM) resident interaction time with faculty and to investigate the potential to use direct observation as an assessment tool for the core competencies. By 2006 all EM residencies must implement resident assessment techniques of the six Accreditation Council for Graduate Medical Education core competencies. Emergency medicine educators recommend direct observation as the optimal evaluation tool for patient care, systems‐based practice, interpersonal and communication skills, and professionalism. Continuous faculty presence in the emergency department (ED) is widely believed to facilitate direct observation as an assessment technique. Methods: Observational study of EM resident–faculty interaction time during two‐hour periods. Study venues included two EDs, two trauma services, inpatient medicine, adult and pediatric intensive care units (ICUs), and a pediatric outpatient clinic. Using a priori definitions, the authors categorized faculty–EM resident interaction time as direct observation of patient care, indirect patient care, or non‐patient care activities, and calculated total faculty interaction time. Subjects were blinded to the nature of the study, and data gathering was encrypted. Results: Two hundred seventy observation periods of two hours each were conducted, sampling 32 EMR1, 33 EMR2–3, 41 EM, and 38 non‐EM faculty. The mean total faculty interaction time ranged from a high of 30% (95% CI = 20% to 41%) in the pediatric ICU to a low of 10% (95% CI = 3% to 16%) on internal medicine wards. Overall, EM faculty interaction time was 20% (95% CI = 18% to 22%). Direct observation by faculty ranged from a high of 6% for EMR2–3s in the critical care areas of the ED (95% CI = 3% to 9%) to a low of 1% (95% CI = 0% to 2%) on internal medicine wards. Overall ED direct observation time was 3.6% (95% CI = 2.6% to 4.7%). Emergency department direct observation did not vary within EM resident training level or by ED site. Direct observation varied by treatment area within the EDs, with the critical care areas being substantially higher (6%) than the noncritical care areas (1%). Conclusions: Faculty direct observation time of EM residents was low in all training venues studied. Direct observation was the highest in ED critical care areas and lowest on medicine ward rotations. Emergency medicine faculty involved simultaneously in routine ED teaching, supervision, and patient care rarely performed direct observation, despite their continuous physical presence. This finding suggests that alternative strategies may be required to assess core competencies through direct observation in the ED.
Advanced Statistics: Missing Data in Clinical Research—Part 1: An Introduction and Conceptual Framework
Authors: Haukoos Jason S. , Newgard Craig D.
Published: January 2008

Missing data are commonly encountered in clinical research. Unfortunately, they are often neglected or not properly handled during analytic procedures, and this may substantially bias the results of the study, reduce study power, and lead to invalid conclusions. In this two‐part series, the authors will introduce key concepts regarding missing data in clinical research, provide a conceptual framework for how to approach missing data in this setting, describe typical mechanisms and patterns of censoring of data and their relationships to specific methods of handling incomplete data, and describe in detail several simple and more complex methods of handling such data. In part 1, the authors will describe relatively simple approaches to handling missing data, including complete‐case analysis, available‐case analysis, and several forms of single imputation, including mean imputation, regression imputation, hot and cold deck imputation, last observation carried forward, and worst case analysis. In part 2, the authors will describe in detail multiple imputation, a more sophisticated and valid method for handling missing data.
INTERPROVINCIAL CO‐OPERATION: NEGLECTED ASPECT OF CANADIAN FEDERALISM
Authors: Leach Richard H.
Published: January 2008

This article by an American scholar affords Canadian readers an opportunity for the salutary experience of “seeing ourselves as others see us”. The Editorial Board will gladly consider for publication signed comments of not too great length on this study and on its subject matter.
TOWN AND REGIONAL PLANNING IN TRANSITION
Authors: Milner J. B.
Published: January 2008

This article attempts to show that the most basic problems of local government in transition are involved in currently fashionable community planning. The difficulties of planning and carrying out the plans within the framework of existing or presently acceptable local government machinery effectively demonstrate the urgent need to reconsider many of the traditional concepts.
NOTES ON A CANADIAN MASS MEDIA POLICY
Authors: Knowles A. F.
Published: January 2008

So we may usefully add a new dramatic factor to public education—an uplifting factor which associates knowledge with pride and private effort with a sense of public purpose. We can widen the horizons of the schoolroom and give to every individual, each in his place and work, a living conception of the community which he has the privilege to serve. We can take his imagination beyond the boundaries of his community to discover the destiny of his country. We can light up his life with a sense of active citizenship. We can give him a sense of greater reality in the present and a vision of the future.1
THE ONTARIO LABOUR RELATIONS BOARD AND THE QUEBEC RENTAL COMMISSION
Authors: Veilleux GéArard
Published: January 2008

The truth is that if Parliament were not willing to delegate law‐making power, Parliament would be unable to pass the kind and quantity of legislation which modern public opinion requires.

Great Britain Committee on Ministers' Powers, Report, p. 29.
The structural problem of Canadian federalism
Authors: Smiley D. V.
Published: January 2008

Abstract. A federal system must attempt to deal with diversities which are territorially based. It can do this through two procedures: (i) conferring the power over some of these most pervasive diversities on the states or provinces; (ii) giving the constituent regional units a permanent voice in the central government. It is the argument of this paper that Canadian federalism has come to rely too exclusively on the first method to the neglect of the second. Thus from time to time important geographically‐based attitudes and interests find they have little influence in the federal government and turn to the provinces instead. Thus the price of the survival of Canadian federalism may be the radical restructuring of the central government to make it more effectively representative of these territorially‐based diversities. Several tentative suggestions are made to this end ‐ measures to decrease the dominance of the Prime Minister over Parliament, a federal bureaucracy based deliberately on representative lines, the reorganization of the cabinet and several of the departments of government to make them more representative of geographically‐based interests, reforms in the electoral system. In general, the survival of Canadian federalism requires some method to obstruct the growing power of the provinces and this method may well be that central institutions come to act in terms of Calhoun's rule of concurrent majorities.

Sommaire. Tout systène fédéral doit essayer de s'occuper des situations diverses dont la base est géographique. Cela peut se faire de deux façons: (i) endonnant aux états ou aux provinces le pouvoir de traiter de certaines des particularités les plus courantes; (ii) en donnent aux groupes représentant les régions une voix permanente au sein du gouvernement central. Cette communication soutient que le fédéralisme canadien en est arrivéà utiliser presque exclusivement la premiere méthode au détriment de la seconde. De temps à autre, des attitudes et intérêts d'inspiration géographique se trouvent exercer peu d'influence dans le gouvernement fédéral et tendent à sa manifester au niveau provincial. Ainsi le prix de la survive du fédéralisme canadien pourrait être la restructuration radicale du gouvernement central pour qu'il représente mieux les diversités à base territoriale. On a offert différentes suggestions à cette fin ‐ des mesures pour diminuer l'emprise du premier ministre sur le parlement, une bureaucratie fédérate établie de facon délibérée d'après le principe de la représentation, la réorganisation du cabinet et de plusieurs ministères du gouvernement pour qu'ils représentent mieux les intérêts géographiques, des réformes du système électoral. D'une façon générale, la survie du fédéralisme canadien dépend d'une méthode permettant d'enrayer le pouvoir croissant des provinces et il se pourrait que cette méthode demande que les institutions centrales se conforment à la règie de Calhoun des majorités coexistantes.
Pour une politique de stabilisation régionale
Authors: Raynauld André
Published: January 2008

Abstract. Regional unemployment disparities in Canada are sensitive to changes in aggregate demand. It would be desirable to find ways to stimulate the economy in one region while restraining it in another. Provincial governments having taxing and spending powers should be able to implement anticyclical fiscal policies. For this purpose they should have an indirect access to an ultimate source of liquidity which can be provided only by the Bank of Canada. It is proposed to set up a regional stabilization fund which would acquire short‐term provincial bonds up to a limit determined by the desirability of deficit financing in any one province for stabilization purposes. The fund would issue its own bonds and the Bank of Canada would be asked to purchase these bonds in the same manner as she does with respect to federal securities. In as much as provincial deficit financing is effective, the federal deficit would be proportionately reduced.

The major argument against such a course of action is high regional leakages through imports. Recent evidence shows that leakages are much lower than is generally assumed. The conclusion is that regional stabilization is indeed possible; the proposed fund would increase considerably the effectiveness of stabilization policies in Canada.

Sommaire. Les disparités régionales quant aux emplois varient au Canada en fonction de la demande globale. Il serait souhaitable de trouver des moyens de stimuler l'économie dans une région et en même temps, de la modérer dans une autre. Les gouvernements provinciaux ayant le pouvoir de taxer et de dépenser devraient pouvoir mettre en vigueur des politiques fiscales anticycliques. A cet fin, ils ont besoin d'un acoès indirect à une source ultime de liquidité qui ne peut être fournie que par la Banque du Canada. Nous suggérons la création d'un fonds de stabilisation régionale qui acquerrait des effets provinciaux à court terme jusqu'à concurrence du financement déficitaire souhaitable pour une province donnée, aux fins de stabilisation. Le fonds émettrait ses propres effets et l'on demanderait à la Banque du Canada de les acheter de la même façon qu'elle le fait pour les effets fédéraux. Le déficit fédéral serait réduit dans la mesure où le financement déficitaire provincial donnerait les résultats escomptés.

Le principal argument contre ce genre de mesure, c'est l'effet adverse produit par les importations dans la région, mais on a prouvé récemment que cet effet était beaucoup moins important qu'on ne l'avait pensé précédemment. La conclusion, c'est que la stabilisation régionale est possible et la création de ce fonds augmenterait considérablement l'efficacité des politiques de stabilisation au Canada.