bluuebunny/crossref_metadata_2025 huggingface dataset:
Bringing Together Local Culture and Rural Development: Findings from Ireland, Pennsylvania and Alaska
Authors: Brennan M.A. , Flint Courtney G. , Luloff A.E.
Published: September 2008

The developmental trajectories of communities are routinely explained by reference to economic history, human capital deficits, or the structure of local labour markets. The role of local culture in understanding community development or in interpreting empirical research has received less attention. We believe culture plays an important independent role in shaping community debate and action. Framing community as an interactional field emphasises the opportunities created when people who share interests come together to address local problems. Interaction and local culture are essential parts of community and community development. Appreciating community uniqueness and local culture helps in the interpretation of study data and clarifies development trajectories. Research from Ireland, Pennsylvania and Alaska illustrates the linkages between local culture and community development.
Understanding Consumer Rationalities: Consumer Involvement in European Food Safety Governance of Avian Influenza
Authors: De Krom Michiel P.M.M.
Published: September 2008

Avian influenza is one more of the recent food scares inciting shifts in European food safety governance, away from a predominantly science‐based approach towards one involving scientists, policymakers, actors in the food‐supply chain and consumers. While these shifts are increasingly receiving scholarly attention, sociological insight into the involvement of consumers and other actors across the multiple levels of today's food safety governance requires further development. This article aims at contributing to the understanding of consumer perspectives on food safety governance by expounding the results of an explorative research among Dutch consumers, which focused on food risks related to avian influenza. To give ample room for the construction of contextual knowledge, consumers of poultry meat were questioned at various retailers by applying a qualitative interviewing method. From this research, it is concluded that multiple consumer rationalities about food safety governance exist. As a consequence of the existence of these multiple consumer rationalities, a differentiated governance approach to restore or retain consumer confidence in food safety in view of food‐related risks is more likely to be pertinent than a ‘one‐size‐fits‐all’ approach.
Reasons for the Relatively Lower Entrepreneurial Activity Levels of Rural Women in Spain
Authors: Driga Otilia , Lafuente Esteban , Vaillant Yancy
Published: September 2008

This study examines the impact that selected institutional factors have upon the entrepreneurial activity of women and men in rural areas. To do so, the results of the Adult Population Survey from the Spanish Global Entrepreneurship Monitor for the year 2004 have been used in a rare events logit regression model where rurality and sex have been introduced as interaction terms in order to identify any statistically significant distinctions of the impact of the selected independent variables upon rural women's entrepreneurial activity. The results indicate that compared to rural men, Spanish rural women tend to be less involved in entrepreneurial activities and are less optimistic about their abilities as entrepreneurs, although the fear of failure is not a significant impediment of their involvement in entrepreneurship.
Enlightened: the art of finger reading*
Authors: Breidegard Björn , Eriksson Yvonne , Fellenius Kerstin , Holmqvist Kenneth , Jönsson Bodil , Strömqvist Sven
Published: September 2008

Abstract. For some forty years the eye‐tracking technology has facilitated the study of eye movement patterns for sighted people during reading and other visual activities. Today – a newly developed automatic finger tracking system makes it possible to reconstruct blind people’s tactile reading in real time and to automatically analyze finger movements during Braille text reading and tactile picture recognition. In this case study, the very first automatic finger tracking system is presented together with results indicating how Braille readers can increase awareness of their own reading styles. This opens up for future Braille education to become more evidence‐based and, at the same time, for a new research field: contrastive studies of language in its auditory, visual and tactile manifestations.
Dei ex machina: a note on plural/mass indefinite determiners*
Authors: Zamparelli Roborto
Published: September 2008

Abstract. This article argues that the Italian plural indefinite articledeiand its French counterpart is a partitive structure without an overt numeral. Unlike a similar proposal in (Chierchia 1998a), the present account crucially holds that the definite DP embedded in these ‘defective partitives’ is a kind‐denoting DP. This assumption derives the lack of existence presupposition, the absence of cardinal numerals afterdei, the restrictions to certain types of DPs, the failure ofne‐extraction and various other properties of this construction.
Causes of death amongst French patients with amyotrophic lateral sclerosis: a prospective study
Authors: Gil J. , Funalot B. , Verschueren A. , Danel‐Brunaud V. , Camu W. , Vandenberghe N. , Desnuelle C. , Guy N. , Camdessanche J. P. , Cintas P. , Carluer L. , Pittion S. , Nicolas G. , Corcia P. , Fleury M.‐C. , Maugras C. , Besson G. , Le Masson G. , Couratier P.
Published: September 2008

Background and purpose:  To prospectively investigate causes of death and the circumstances surrounding death in 302 patients with amyotrophic lateral sclerosis (ALS). The functional status of patients immediately before death was also determined.

Methods:  Information was obtained from neurologists at ALS centres, patients’ files, and, when deaths occurred outside a medical facility, attending physicians.

Results:  Most patients (63%) died in a medical facility. The most frequently reported cause of death was respiratory failure (77%), including terminal respiratory insufficiency (58%), pneumonia (14%), asphyxia due to a foreign body (3%) and pulmonary embolism (2%). Ten per cent of patients died from other causes: post‐surgical or traumatic conditions (5%), cardiac causes (3.4%), suicide (1.3%) and sudden death of unknown origin (0.7%). The cause of death could not be determined in 13% of cases (6% inside a medical facility and 25% outside). At the time of death, only 55% of patients were receiving riluzole, 33% were undergoing non‐invasive ventilation, 3% had a tracheotomy and 37% a gastrostomy.

Conclusion:  The information provided by this study helps to improve our understanding of the natural history of the disease and may help optimize the quality of care we can offer patients at the end of life.
Tensions in Higher Education Leadership: Towards a Multi‐Level Model of Leadership Practice
Authors: Bolden Richard , Petrov Georgy , Gosling Jonathan
Published: September 2008

UK higher education is undergoing a period of significant change that generates a series of tensions and difficulties for universities and university leaders. This paper explores these tensions through analysis of findings from a study comprising 152 semi‐structured face‐to‐face interviews in 12 UK universities. Building on from theories of ‘distributed leadership’ in schools, five main constituent elements of leadership practice in higher education are identified (personal, social, structural, contextual and developmental) and explored to show how they shape perceptions and experiences of leadership. The paper concludes with a refined model that teases apart the multilayered nature of higher education leadership at individual, group and organisational levels. In particular, it is argued that ‘social capital’ and ‘social identity’ act as important bridges between individual agency and organisational structure and that although widely distributed, higher education leadership may be best regarded as ‘hybrid’.
CHOOSING NOT TO LOOK: REPRESENTATION, REPATRIATION, AND HOLOCAUST ATROCITY PHOTOGRAPHY1
Authors: CRANE SUSAN A.
Published: September 2008

This essay considers, from ethical and historical‐critical perspectives, alternatives to unconditional public access to Holocaust atrocity photographs. Photographic images have become the common coin of public awareness and historical information about the Holocaust. For the generations immediately following the genocide, atrocity photos and images of Nazi crimes served as vital testimony. For succeeding generations, however, access to certain “recirculated” images (Barbie Zelizer) has created a sense of familiarity with the Holocaust and with the National Socialist era that may prevent, rather than facilitate, engagement with the historical subject, particularly for students. Few of the victims of the Shoah pictured in either the best known or the least circulated images were willing subjects. As such, the bulk of Holocaust and National Socialist photography should perhaps fall under the same category as the results of Nazi medical experiments: they have been rendered inadmissible because they are ethically compromised materials, made without the participants’consent. While I am not advocating the wholesale destruction of Holocaust photographs, I will suggest that removing them from view or “repatriating” them might serve Holocaust memory better than their reduction to atrocious objects of banal attention. Just as the Native American Grave Protection and Repatriation Act of 1990 provided a mechanism for the reclassification of human remains, from ethnographic to spiritually sacred artifacts, we should consider what a similar reclassification of Holocaust photographs could offer. Have Holocaust atrocity photographs reached the limits of their usefulness as testimony?
Small Rho GTPases are key regulators of peripheral nerve biology in health and disease
Authors: Krause Sven , Stendel Claudia , Senderek Jan , Relvas João B. , Suter Ueli
Published: September 2008

Abstract  A thorough knowledge of the cellular and molecular basis of the structure and function of peripheral nerves is of paramount importance not only for a better understanding of the fascinating biology of the peripheral nervous system but also for providing critical insights into the various diseases affecting peripheral nerves as the firm foundation of potential treatments. Genetic approaches in model organisms, in combination with research on hereditary forms of neuropathies, have contributed significantly to our progress in this field. In this review, we will focus on recent advances using these synergistic approaches that led to the identification of small Rho GTPases and their regulators as crucial functional players in proper development and function of myelinated peripheral nerves, with a particular emphasis on the cell biology of Schwann cells in health and disease.
Muscle performance relates to physical function and quality of life in long‐term chronic inflammatory demyelinating polyradiculoneuropathy
Authors: Harbo Thomas , Andersen Henning , Overgaard Kristian , Jakobsen Johannes
Published: September 2008

Abstract  The aim of the present study was to determine the severity and distribution of assessed muscle weakness and to relate muscle performance to measures of function and quality of life in long‐term chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Fourteen patients with 8.7 years (3.3–11.5) of confirmed CIDP consecutively referred to the referral center for CIDP patients at Aarhus University Hospital, Denmark, during the period 1992–2002 were compared with matched healthy controls. The main outcome parameter was muscle performance assessed with isokinetic dynamometry. Overall disability sum score (ODSS), neurological symptom score (NSS), neuropathy impairment score (NIS), health‐related quality‐of‐life survey (SF‐36), nerve conduction studies, physical fitness, hand and walking performance, and quantitative sensory testing were secondary variables. The mean (95% CI) isokinetic strength of all measured muscles was reduced by 19.4% (5.9–32.8%) (p < 0.01). In the legs, distal weakness was predominant, strength at ankle being 37.0% (14.7–59.2%) reduced. Isokinetic strength was closely related to manual muscle strength, ODSS, NIS, walking performance, and physical components of SF‐36. In conclusion, isokinetic strength relates to measures of function, impairments, gait performance, and physical components of health‐related quality of life in long‐term CIDP. Furthermore, a detailed characterization of severity and distribution of weakness has been provided using this technique.
Double‐Counting in Life Cycle Calculations
Authors: Lenzen Manfred
Published: September 2008

Many popular frameworks apply life cycle calculations to examine environmental burdens occurring throughout the life cycle of products and services that are either purchased by final consumers or demanded as inputs by producers. Accounting for the full supply chain of producer items can lead to double‐counting effects when results of separate studies are added up and referenced or compared to totals. If, for instance, energy life cycle inventories were prepared for all consumer and producer items in an economy and added up, the resulting total amount of energy would be greater than national energy consumption. Although this double‐counting is inconsequential if analyses are appraised in isolation without reference to national totals, it leads to serious errors when large interconnected systems are analyzed or when results are placed into wider (e.g., regional, national, or global) contexts. The article lists a number of prominent policy and decision‐making frameworks that make use of life cycle techniques, where this double‐counting error is highly undesirable. It proposes a solution to the double‐counting problem in which supply chains in the product life cycle are split and burdens shared between the supplying and demanding sides of every transaction in the economy.
Uses and Misuses of Multicriteria Decision Analysis (MCDA) in Environmental Decision Making
Authors: Steele Katie , Carmel Yohay , Cross Jean , Wilcox Chris
Published: September 2008

We focus on a class of multicriteria methods that are commonly used in environmental decision making—those that employ the weighted linear average algorithm (and this includes the popular analytic hierarchy process (AHP)). While we do not doubt the potential benefits of using formal decision methods of this type, we draw attention to the consequences of not using them well. In particular, we highlight a property of these methods that should not be overlooked when they are applied in environmental and wider decision‐making contexts: the final decision or ranking of options is dependent on the choice of performance scoring scales for the criteria when the criteria weights are held constant. We compare this “sensitivity” to a well‐known criticism of the AHP, and we go on to describe the more general lesson when it comes to using weighted linear average methods—a lesson concerning the relationship between criteria weights and performance scoring scales.
The Mechanisms of Policy Diffusion
Authors: Shipan Charles R. , Volden Craig
Published: September 2008

Local policy adoptions provide an excellent opportunity to test among potential mechanisms of policy diffusion. By examining three types of antismoking policy choices by the 675 largest U.S. cities between 1975 and 2000, we uncover robust patterns of policy diffusion, yielding three key findings. First, we distinguish among and find evidence for four mechanisms of policy diffusion: learning from earlier adopters, economic competition among proximate cities, imitation of larger cities, and coercion by state governments. Second, we find a temporal component to these effects, with imitation being a more short‐lived diffusion process than the others. Third, we show that these mechanisms are conditional, with larger cities being better able to learn from others, less fearful of economic spillovers, and less likely to rely on imitation.
Policy Responsiveness and Incumbent Reelection in State Legislatures
Authors: Hogan Robert E.
Published: September 2008

Does policy responsiveness on the part of incumbent legislators affect their prospects for reelection? Recent studies of congressional campaigns demonstrate that incumbents who support policies that are more congruent with their constituents' preferences face fewer reelection obstacles. The present analysis considers this question in state legislative elections where voter knowledge of legislator activities is generally quite low. The findings demonstrate that incumbents positioned farther from the average citizen and toward their party's base are only slightly more likely to be challenged than other incumbents. However, more partisan voting incumbents do attract challengers capable of raising and spending larger amounts of money. Interestingly, incumbents positioned closer to their party's base actually receive a greater share of the vote in most contested elections. Only when challengers spend significant amounts of money do we see the positive effects of partisan voting by incumbents diminished. Overall, these findings demonstrate the mechanisms by which policy positions of incumbents in a low‐information environment affect the challengers that emerge and the level of voter support received.
Economic Inequality and Intolerance: Attitudes toward Homosexuality in 35 Democracies
Authors: Andersen Robert , Fetner Tina
Published: September 2008

Using hierarchical linear models fitted to data from the World Values Survey and national statistics for 35 countries, this article builds on the postmaterialist thesis by assessing the impact of economic inequality across and within nations on attitudes toward homosexuality. It provides evidence that tolerance tends to decline as national income inequality rises. For professionals and managers, the results also support the postmaterialist argument that economic development leads to more tolerant attitudes. On the other hand, attitudes of the working class are generally less tolerant, and contrary to expectations of the postmaterialist thesis, are seemingly unaffected by economic development. In other words, economic development influences attitudes only for those who benefit most. These findings have political implications, suggesting that state policies that have the goal of economic growth but fail to consider economic inequality may contribute to intolerant social and political values, an attribute widely considered detrimental for the health of democracy.
Adjusted Exponentially Tilted Likelihood with Applications to Brain Morphology
Authors: Zhu Hongtu , Zhou Haibo , Chen Jiahua , Li Yimei , Lieberman Jeffrey , Styner Martin
Published: September 2008

SummaryIn this article, we develop a nonparametric method, called adjusted exponentially tilted (ET) likelihood, and apply it to the analysis of morphometric measures. The adjusted exponential tilting estimator is shown to have the same first‐order asymptotic properties as that of the original ET likelihood. The adjusted ET likelihood ratio statistic is applied to test linear hypotheses of unknown parameters, such as the associations of brain measures (e.g., cortical and subcortical surfaces) with covariates of interest, such as age, gender, and gene. Simulation studies show that the adjusted exponential tilted likelihood ratio statistic performs as well as the t‐test when the imaging data are symmetrically distributed, while it is superior when the imaging data have skewed distribution. We demonstrate the application of our new statistical methods to the detection of statistically significant differences in the morphology of the hippocampus between two schizophrenia groups and healthy subjects.
Fast FSR Variable Selection with Applications to Clinical Trials
Authors: Boos Dennis D. , Stefanski Leonard A. , Wu Yujun
Published: September 2008

SummaryA new version of the false selection rate variable selection method ofWu, Boos, and Stefanski(2007, Journal of the American Statistical Association 102, 235–243) is developed that requires no simulation. This version allows the tuning parameter in forward selection to be estimated simply by hand calculation from a summary table of output even for situations where the number of explanatory variables is larger than the sample size. Because of the computational simplicity, the method can be used in permutation tests and inside bagging loops for improved prediction. Illustration is provided in clinical trials for linear regression, logistic regression, and Cox proportional hazards regression.
Prospective Evaluation of Topical Antibiotics for Preventing Infections in Uncomplicated Soft‐tissue Wounds Repaired in the ED
Authors: Dire Daniel J. , Coppola Marco , Dwyer David A. , Lorette John J. , Karr Jerry L.
Published: September 2008

Objective: To determine differences in infection rates among uncomplicated, repaired wounds managed with: topical bacitracin zinc (BAC); neomycin sulfate, bacitracin zinc, and polymyxin B sulfate combination (NEO); silver sulfadiazine (SIL); and petrolatum (PTR).

Methods: This was a prospective, randomized, double‐blind, placebo‐controlled study conducted at a military community hospital with an emergency medicine residency program. Patients were enrolled if they: presented to the ED within 12 hours of injury and did not have puncture wounds, allergies to the agents used, or a history of immunocompromise; were not receiving antibiotics, chemotherapy, or steroids at the time of presentation; had not taken antibiotics within the preceding seven days; did not have an underlying fracture; and were not pregnant as determined by history. Local anesthetics without epinephrine and high‐pressure irrigation with normal saline were used for all the patients. Wound scrubbing, debridement, and polyglactin subcutaneous (SQ) suture placement were carried out when necessary. Interrupted simple sutures using a monofilament, nonabsorbable material were used for skin closure. Numbered, randomized vials were given to all patients, with standardized instructions to inspect, clean, and redress their wounds three times a day. The wounds were evaluated for clinical infection at the time of follow‐up.

Results: Among the groups, there was no difference in patient ages; gender; wound location, type, length, or depth; time elapsed from injury to ED treatment; number of wounds scrubbed or necessitating debridement; number of SQ and cutaneous sutures used; and rate of compliance with returning the used vial of dispensed topical agent. The wound infection rates for the treatment groups were: BAC, six of 109 (5.5%); NEO, five of 110 (4.5%); SIL, 12 of 99 (12.1%); and PTR, 19 of 108 (17.6%) (p = 0.0034).

Conclusion: The use of topical antibiotics resulted in significantly lower infection rates than did the use of a petrolatum control. BAC and NEO had the lowest wound infection rates.
Demographics of Cardiac Arrest: Association with Residence in a Low‐income Area
Authors: Feero Stan , Hedges Jerris R. , Stevens Penny
Published: September 2008

Objective: To report cardiac arrest demographics and assess whether arrest rate is associated with differences in intracity regional population densities, incomes, or race distributions.

Methods: One‐year retrospective review of out‐of‐hospital cardiac arrests in a city with a two‐tier emergency medical service (EMS) system. Associations of population density, median income, and race data with age‐ and gender‐adjusted cardiac arrest rates for seven city regions and groupings of high‐ and low‐income census tracts were made.

Results: Median income, but not race or population density, was associated with sex‐ and age‐adjusted intracity regional cardiac arrest rates (p = 0.034). This association of cardiac arrest rate with income status was magnified when the 20 lowest and the 20 highest income census tracts were compared. Cardiac arrest victims in these two income groups did not differ in regard to rate of witnessed arrest, bystander‐administered CPR, or previous cardiac disease. Rates of survival to hospital discharge were not significantly different between the two groups.

Conclusion: The association of lower income with cardiac arrest suggests that cardiac health promotion and EMS intervention measures, including CPR instruction, should be targeted to lower‐income neighborhoods. These findings may help explain previous studies suggesting a racial or population density association with cardiac arrest rates.
Cerumen Occlusion Lowers Infrared Tympanic Membrane Temperature Measurement
Authors: Doezema David , Lunt Margaret , Tandberg Dan
Published: September 2008

Objective: To examine the effect that cerumen occlusion of the ear canal has on infrared tympanic membrane temperature measurement.

Methods: A prospective, randomized, single‐blind human study was carried out in a university hospital observation unit. The subjects were a convenience sample of human volunteers aged 18 years or older who did not have cerumen occlusion or scarred tympanic membranes. A paraffin‐coated human cerumen plug was placed in one randomly chosen ear, and after 20 minutes of equilibration the temperature in each ear was measured with an infrared thermometer. Analysis of the difference in mean temperature between the occluded and nonoccluded ears was by Student's paired t‐test.

Results: Infrared tympanic membrane temperatures were measured in 43 subjects aged 21 to 58 years. The mean temperature of the occluded ear canal was 0.3°C lower than that of the opposite ear canal (p = 0.0001, 95% CI 0.16–0.45°C).

Conclusion: Cerumen occlusion of the ear canal causes underestimation of body temperature measured by infrared tympanic membrane thermometry.
Characteristics of Emergency Medicine Resident Orientation Programs
Authors: Brillman Judith C. , Sklar David P. , Viccellio Peter
Published: September 2008

Objective: To determine the prevalence, duration, composition, and goals of emergency medicine resident orientation programs.

Methods: Eleven‐item, descriptive mail surveys were sent by the education committee of SAEM to the program directors of all emergency medicine residency programs approved by the RRC as of January 1992.

Results: Sixty‐nine of 86 survey instruments (80%) were returned. Orientation programs were offered in 64 residencies, 41 PGY1–3 programs, five PGY1–4 programs, and 18 PGY2–4 programs. Results are tabulated below.
Infiltration Pain and Local Anesthetic Effects of Buffered vs Plain 1% Diphenhydramine
Authors: Singer Adam J. , Hollander Judd E.
Published: September 2008

Objective:To compare the levels of infiltration pain and local anesthetic effects of plain and buffered 1% diphenhydramine.

Methods:A prospective, randomized. double‐blind, paired study was performed using 30 adult volunteers. Intradermal injections (0.5 mL) of plain and buffered 1% diphenhydramine were made in the subjects' forearms. one in the left and the other in the right. The pain of infiltration was recorded on a previously validated 10‐cm visual analog scale (VAS). The volunteers also were asked which injection was less painful. Sequential measurements of the diameter of anesthesia to pinprick were made at 1, 2, 5, 10, 15, 20, 25, and 30 minutes. The VAS scores and anesthetic diameters were compared for plain and buffered diphenhydramine using a paired Wilcoxon rank sum test.

Results:There was no statistically significant difference between buffered diphenhydramine and plain diphenhydramine for pain of injection (23.5 ± 19.2 mm vs 28.2 ± 18.7 mm. p = 0.24). Repeated‐measures analysis of variance for anesthetic diameters demonstrated no significant difference between buffered diphenhydramine and plain diphenhydramine (p = 0.87). At no single measurement period were the anesthetic diameters different.

Conclusions:In a study with a sample size large enough to detect an 11‐mm difference in VAS scores (power = 80%,), no difference was found in pain of infiltration and anesthetic effects when plain 1% diphenhydramine was compared with buffered 1% diphenhydramine. Buffering of diphenhydramine does not appear to result in a clinically significant reduction in the pain of infiltration.
Right Lung Ventilation in a Porcine Open‐chest Shock Model
Authors: Ilkhanipour Kaveh , Seaberg David C. , Stengel Churles L. , Kapsner Christopher E. , Menegazzi James J.
Published: September 2008

Objective: To determine the effect of selective right lung ventilation on gas exchange and hemodynarnics when compared with bilateral lung ventilation in a porcine open‐chest shock model.

Methods: 4 randomized, controlled laboratory investigation was performed using a static hemorrhagic shock model in 12 adult swine undergoing thoracotomy. The animals were subjected to a fixed 40% circulating blood volume hemorrhage over 20 minutes. Each animal was then assigned to either a tracheal (control) or a right mainstem (experimental) intubation group. Minute ventilation was held constant in both groups and tidal volumes were decreased by 33% in the right mainstem intubation group. Following intubation and left lateral thoracotomy. another 20% fixed‐volume hemorrhage was instituted simultaneously with IV crystalloid and whole blood resuscitation for both groups over 30 minutes. Heart rate. blood pressure. and arterial blood gases were measured at 5‐minute intervals.

Results: There was no significant difference between the control and experimental groups for any of the measured variables. including mean arterial pressure, pH, partial arterial pressure of CO2 (Paco2), and Pao2. over time. All animals survived the study protocol.

Conclusion: Selective right lung ventilation has no detrimental effect on gas exchange or hemodynarnics when compared with standard bilateral lung ventilation in a porcine open‐chest shock model.
Randomized, Prospective Trial of Fenoldopam vs Sodium Nitroprusside in the Treatment of Acute Severe Hypertension
Authors: Patmcek Edward A. , Bednarczyk Edward M. , Dunbar Lala M. , Foulke Garrett E. , Holeslaw Terry L. ,   for the Fenoldopam Study Group
Published: September 2008

Objective:To compare the safeties and efficacies of IV fenoldopam (FNP) vs sodium nitroprusside (NTP) in severe acute hypertension.

Methods:A prospective. randomized, open‐label, multimember international trial, at 24 academic medical centers, was conducted. The participants were adult patients (21–80 years of age) who had supine diastolic blood pressures (DBPs) ≥ 120 mm Hg, were capable of written informed consent, and did not have selected exclusion criteria. The subjects were randomized to either FNP or NTP therapy; DBP was titrated to 95–110 mm Hg. or a maximum reduction of 40 mm Hg for very high pressures. Infusions were maintained for at least six hours, then the patients were weaned off the IV therapy and oral medication was started. Measurements included BP, heart rate, and duration of study drug infusion and frequency of side effects or complications.

Results:A total of IS3 patients (90 FNP, 93 NTP) were enrolled. Fifteen patients from each arm were excluded from efficacy analysis due to protocol violation. There was no significant difference in baseline characteristics. The two antihypertensive agents were equivalent in controlling and maintaining DBP. Systolic blood pressure (SBP) was reduced to a slightly greater degree for the NTP‐treated patients during the initial (0.5–1‐hr) study period, and both SBP and DBP were reduced more for the FNP‐treated patients in the subset receiving infusions during the 12–24‐hour period. The adverse effect profiles of the drugs were similar, as were the times to achieve target pressure, with no clinically relevant difference.

Conclusions:For patients who had acute severe hypertension, FNP and NTP were equivalent in terms of efficacy and acute adverse events. Because of a unique mechanism of action, FNP may have advantages in selected subsets of patients. Further studies may be indicated in patient populations with pure “hypertensive emergencies.”
Use of Radiography in Acute Knee Injuries: Need for Clinical Decision Rules
Authors: Stiell Ian G. , Wells George A. , McDowell Ian , Greenberg Gary H. , McKnight R. Douglas , Cwinn A. Adam , Quinn James V. , Yeats Ashley
Published: September 2008

Objectives: To study: 1) the efficiency of the current use of radiography in acute knee injuries, 2) the judgments and attitudes of experienced clinicians in their use of knee radiography, and 3) the potential for decision rules to improve efficiency.

Methods: This two‐stage study of adults with acute knee injuries involved: 1) a retrospective review of all 1,967 patients seen over a 12‐month period in the EDs of one community and two teaching hospitals, and 2) a prospective survey of another 1,040 patients seen by attending emergency physicians. The prospective survey assessed each clinician's estimate of the probability of a knee or patella fracture; 120 patients were independently assessed by two physicians.

Results: Of the 1,967 patients seen in the first stage, 74.1% underwent radiography but only 5.2% were found to have fractures. Of the 1,727 knee and patella radiographic series ordered. 92.4% were negative for fracture. In the second stage. experienced physicians predicted the probability of fracture to be 0 or 0.1 for 75.6% of the patients. The kappa value for this response was 0.51 (95% CI 0.34 to 0.68). The physicians also indicated that they would have been Comfortable or very comfortable in not ordering radiography for 55.5% of the patients. The area under the receiver operating characteristic curve for the physicians' prediction of fracture was 0.87 (95% CI 0.82 to 0.91). reflecting good discrimination between fracture and nonfracture cases. Likelihood ratios for the physicians' prediction ranged from 0.09 at the 0 level to 42.9 at the 0.9–1.0 level.

Conclusions: Emergency physicians order radiography for most patients with acute knee injuries, even though they can accurately discriminate between fracture and nonfracture cases and expect most of the radiographs to be normal. These findings suggest great potential for more efficient use of knee radiography, possibly through the use of a clinical decision rule.
Bedside Fluoroscopy for the Detection of Foreign Bodies
Authors: Wyn Tod , Jones Jeffrey , McNinch Dale , Heacox Robert
Published: September 2008

Objective: To determine the sensitivity and specificity of portable fluoroscopy for foreign‐body detection using an exvivo experimental model.

Methods: A prospective, randomized masked investigation was performed to characterize foreign‐body detection in cubes of beef. Three emergency physicians (EPs) independently used a portable fluoroscope to determine the presence or absence of various foreign bodies in ten cubes of beef (approximately 6 cm on each side). Six different groups of foreign bodies were examined: glass, wood, graphite (pencil lead), metal (needle), plastic, and gravel. An independent observer placed the six objects randomly into each set of ten beef cubes. One hundred observations were made by each physician using sets of ten beef cubes at a time.

Results: Fluoroscopy detected 117 of 180 foreign bodies (sensitivity 65%; 95% CI 58–72%), including all cubes of beef embedded with gravel, metal, and glass. Graphite was detected 27 of 30 times (sensitivity 90%; 95% C1 74–9896). None of the plastic or wooden foreign bodies was identified despite magnification techniques and real‐time imaging (sensitivity 0%; 95% C10–17%. each). Of the 120 cubes of meat with no foreign body. two false‐positives were recorded (specificity 98%; 9.5% C1 94–100%). The overall positive predictive value and negative predictive value of fluoroscopy were 98% and 6570, with 95% CIs of 94–10070 and 58–7270, respectively. Interobserver agreement between the three EPs was considered excellent (kappa = 0.75).

Conclusion: Bedside fluoroscopy lacks sufficient sensitivity to rule out many foreign bodies in the ED. Its use should be limited to suspected gravel, glass, pencil lead, and metallic objects, which are known to be radiopaque.
Poor Correlation of Short‐ and Long‐term Cosmetic Appearance of Repaired Lacerations
Authors: Hollander Judd E. , Blasko Barbara , Singer Adam J. , Valentine Sharon , Thode Henry C. , Henry Mark C.
Published: September 2008

Objective: To describe the consistency of a cosmetic scale for repaired lacerations and to determine whether the appearance of lacerations at the time of suture removal correlates with the appearance six to nine months later.

Methods: A convenience sample of patients who had lacerations repaired in a university teaching hospital were evaluated at the time of suture removal and sin to nine months following repair. All lacerations were assigned 0 or 1 point each for the presence or absence of a step‐off of borders, contour irregularities, margin separation, edge inversion, excessive distortion. and overall appearance. A total cosmetic score (0–6) was calculated by adding the scores for the categories above. The consistency of the cosmetic scale was assessed by comparison of scores given by two different practitioners evaluating each patient at suture removal and long‐term follow‐up. The 38 evaluating practitioners were assigned based on availability and did not necessarily perform serial evaluations of the same patient.

Results: The 41 participating patients had a median age of 19 years (range. 2–82 years). Wounds were located predominantly on the head (73%) and upper extremity (22%). Long‐term follow‐up was performed at a median of 219 days (range, 155–280 days) after suture removal. Interpractitioner concordance regarding optimal appearance (score of 6 vs ≤5) was moderate (kappa = 0.52) at the time of suture removal and substantial at the time of long‐term follow‐up (kappa = 0.68). However, the correlation of actual scores at the time of suture removal vs at long‐term follow‐up was poor (r = 0.17. p = 0.29).

Conclusion: For our clinicians, the six‐item categorical scale appears consistent as a tool for the assessment of the cosmetic appearance of wounds. However. correlation between laceration appearance at the time of suture removal and six to nine months later is poor.
Relating Patient Satisfaction to Waiting Time Perceptions and Expectations: The Disconfirmation Paradigm
Authors: Thompson David A. , Yarnold Paul R.
Published: September 2008

Objective: To determine the association of patient satisfaction with waiting time perceptions and expectations.

Methods: A random sample of patients seen at one community hospital ED during a one‐year period was surveyed by telephone within two to four weeks of evaluation to determine perceived satisfaction and waiting time perceptions and expectations.

Results: In response to 3, 641 attempted phone surveys, 1, 574 patients had usable interviews. Consistent with a hypothesis derived using the disconfirmation paradigm (i.e., that satisfaction is a function of the magnitude and direction of the difference between perceived service and expected service), the patients were least satisfied when waiting times were longer than expected, were relatively satisfied when waiting times were perceived as equal to expectations, and were highly satisfied when waiting times were shorter than expected (p < 0.0001). Overall. the measure of effect strength (values from 0 to 1) of perceived waiting time vs expectation on the patient satisfaction score was 0.32. indicating moderate association.

Conclusions: The current study supports the validity of the disconfirmation paradigm in relating patient satisfaction to waiting time perceptions and expectations. Furthermore, it emphasizes that achieving satisfaction in a service encounter necessitates that perceived performance meet or exceed patient expectations.
Ectopic Pregnancy—Part II: Diagnostic Procedures and Imaging
Authors: Brennan Daniel F.
Published: September 2008

Ectopic pregnancy is an increasingly common and potentially catastrophic condition in which the patient often presents to the ED with abdominal pain or vaginal bleeding. Recent developments in the laboratory (sensitive PhCG assays, progesterone assays), in ultrasonogra‐phy (transvaginal probes, Doppler ultrasonography), and in the combination of modalities (discriminatory zone of PhCG for ultrasono‐graphic evidence of IUP) have allowed the earlier diagnosis of ectopic pregnancy, with the potential for a reduction in maternal mortality and morbidity.

Understanding the strengths and limitations of the variety of diagnostic modalities available will allow the clinician to formulate a rational strategy for the early diagnosis of ectopic pregnancy. Numerous algorithms have been developed. All begin wiht high clinical suspicion for women of reproductive age with abdominal/ pelvic pain or vaginal bleeding. Pregnancy testing with a sensitive PhCG qualitative test is next. For stable patients found to be pregnant, zoography generally follows (often first Tran abdominally then transvaginally). Unstable patients require immediate resuscitation and gynecology consultation; invasive diagnostic methods may supplant laboratory studies and sonography. Unclear cases may necessitate the use of quantitative PhCG (discriminatory zone), other pregnancy hormones (progesterone), invasive procedures (laparoscopy, culdocentesis, D&C), or observation (serial ßhCGs). A suggested algorithm incorporating these elements is shown (Fig. 1).
The Quantity of Cause‐of‐injury Information Documented on the Medical Record: An Appeal for Injury Prevention
Authors: Schwartz Robert J. , Boisoneau David , Jacobs Lenworth M.
Published: September 2008

Objective: To determine how much information about the cause of injury (available at the time of ED treatment) is documented on the medical record. This information is used by medical records coders to assign e‐codes.

Methods: Quantitative “stages of information” were defined: stage 1 = the maximum amount of information available from the patient, as collected by a trained research assistant; stage 2 = the amount of information obtained by the care provider during the patient interview; and stage 3 = the amount of information the care provider documented in the medical record. Comparisons were made between the three stages; subgroup analyses compared amounts of information loss between the stages for levels of care provider and cause‐of‐injury information categories.

Results: Information was obtained from 109 patients. Only 46% of the cause‐of‐injury information available during the ED visit was recorded on the medical record. Incomplete history taking (obtaining 68% of the available information) and failure to document (writing 67% of the information obtained during the patient interview) contributed equally to the loss of information. The most information was obtained about who had received the injury (72%) and the least amount of information was in the category of where the injury had occurred (14%). Attending physicians collected the most information (74%) but documented significantly less (65%) than did physician assistants (70%) or medical students (81%). Medical students collected the least (65%) but documented the most, resulting in the students' medical records' being the most complete (52%) for cause‐of‐injury information.

Conclusions: Emergency providers obtain significantly less cause‐of‐injury information than is available from the patient. Also, these providers' handwritten medical records contain significantly less cause‐of‐injury information than was obtained during the patient interview.
Weapon Carriage among Major Trauma Victims in the Emergency Department
Authors: Ordog Gary J. , Wasserberger Jonathan , Ordog Cindy , Ackroyd Greg , Atluri Syama
Published: September 2008

Objective: To determine the occurrence of weapon carriage by major trauma patients at a university/county hospital ED.

Methods: Retrospective observational study of major trauma patients seen in the ED of a major urban trauma center in Los Angeles from 1979 to 1993. All major trauma patients were searched routinely for weapons by the security police. Cases of violence in the ED caused by these weapons were reviewed.

Results: Over the 14‐year period, 26.7% of the victims of major trauma presenting to ED were armed with lethal weapons. The occurrence of automatic weapon seizure increased significantly from an annual rate of only 0.2 in the first five years to an average of 17 over the last five years (p < 0.001). A total of 115 “incidents” of violence involving weapons in the ED were recorded during this period; 1.7% of the weapons brought to the ED led to violence and injury. There were four fatalities of armed and dangerous patients, but only six minor injuries to the staff. No other (unarmed) patient in the ED at the time of these incidents was injured.

Conclusions: ED major trauma patients at one urban trauma center in Los Angeles frequently carry weapons, including automatic military weapons. In addition to violence prevention measures such as weapon confiscation, plans must be made and practiced for the management of violence within the “sacrosanct” hospital doors to protect both patients and ED personnel.
Resident Service Hours in Emergency Medicine
Authors: Wols Matthew , Kramer David , Strange Gary R. ,   for the SAEM Education Committee
Published: September 2008

Objective: The number of hours worked by residents in all specialties has become a controversial issue. Residents often are expected to competently conduct patient care activities and to take educational advantage of clinical experiences in spite of frequent fatigue and sleep deprivation. This survey of residency directors was designed to assess the scheduled clinical time for emergency medicine (EM) residents.

Methods: A 13‐question survey dealing with time commitments of EM residents was sent to the residency directors of all accredited EM residency programs in the United States in the fall of 1991. Residency directors were asked to indicate the number of shifts, hours, and days off per week; and the number of night shifts and weekend days off per month for each postgraduate year of residency training (PGY1‐PGY4). Directors also were asked whether shifts were scheduled randomly or predictably with progression from days to nights with time off after nights.

Results: Seventy of 71 (98.6% response rate) residency directors responded. Residents were scheduled for an average of 49.1 hours per week. Scheduled hours decreased from an average of 51.9 at the PGY1 level to an average of 44.5 at the PGY4 level. A similar progression with year of training was noted for scheduled night shifts/ month, days off/week, and weekend days off/month. A PGY1 trainee averaged 7.0 night shifts/month, 1.9 days off/week, and 3.0 weekend days off/month; while a PGY4 trainee averaged 5.3, 2.4, and 3.2, respectively. Only 40% of the directors reported predictable scheduling progressing from days to nights.

Conclusion: Emergency medicine resident schedules, as reported by residency directors, fall well within current specialty‐specific requirements and compare favorably with the reported numbers for other specialties. However, because large ranges in scheduling parameters were reported, the data may be of value to residency directors, residents, and prospective residents. Most programs did not report a predictable schedule progression of shifts.
Abdominal Wall Hematoma in an Elderly Man
Authors: Lindbeck George H.
Published: September 2008

This report describes an abdominal wall hematoma that occurred in an unusual location and resulted in significant hemorrhage in a generally healthy individual. Angiography‐directed therapeutic embolization was halted due to an embolic complication. Evidence of continued hemorrhage led to surgical intervention. After a right flank incision was made, fresh blood as well as approximately 1 L of clotted blood were evacuated from the abdominal wall. After resection of a portion of the twelfth rib, the twelfth intercostal artery was noted to be actively bleeding and was ligated. This operative procedure controlled the patient's blood loss. The etiologies, presenting findings, diagnostic studies, and modes of therapy reported for abdominal wall hematomas are reviewed.