bluuebunny/crossref_metadata_2025 huggingface dataset:
Appropriateness of Medication Selection for Older Persons in an Urban Academic Emergency Department
Authors: Chin Marshall H. , Wang Linda C. , Jin Lei , Mulliken Robert , Walter James , Hayley Deon Cox , Karrison Theodore G. , Nerney Michael P. , Miller Annette , Friedmann Peter D.
Published: January 2008

Objectives: To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes. Methods: The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy‐nine percent of the patients were African‐American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug‐disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health‐related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study. Results: Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug‐disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug‐disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death. Conclusions: Suboptimal medication selection was fairly common and was associated with worse patient‐reported health‐related quality of life.
Effects of a Pneumonia Clinical Pathway on Time to Antibiotic Treatment, Length of Stay, and Mortality
Authors: Benenson Ronald , Magalski Anthony , Cavanaugh Sally , Williams Eric
Published: January 2008

Objectives: A clinical pathway standardizing management for patients with an admission diagnosis of pneumonia was initiated after a previous study found delayed time to initial antibiotic administration, a longer length of stay, and higher mortality rate for the authors patients as compared with those in a “benchmark” hospital. The current study was undertaken to determine whether implementation of the clinical pathway resulted in statistically significant decreases for these measures, both in the initial year following pathway implementation and two years later. Methods: A retrospective chart review was completed for three cohorts of pneumonia patients admitted via the ED: 1) three months immediately prior to pathway implementation, 2) 10‐12 months after implementation of the pathway, and 3) 34‐36 months after implementation of the pathway. Four standard antibiotic regimens were used following pathway implementation: community‐acquired, community‐acquired penicillin‐allergic, nursing home‐acquired, and nursing home‐acquired penicillin‐allergic. Demographics, medical history, presentation signs and symptoms, process of care, and outcome data were abstracted from each patient's medical record. Results: The mean time to antibiotic administration decreased from 315 minutes prepathway to approximately 175 minutes during the first postpathway period and 171 minutes at three years (ANOVA, p < 0.0001). The percentage of patients who received antibiotics in the ED increased from 58% prepathway to 94% during the first postpathway period and 97% at three years (chi square, p < 0.0001). Length of stay decreased from 9.7 prepathway to 8.9 days during the first postpathway period and 6.4 days at three years (ANOVA, p < 0.0001). There was no significant change of in‐hospital mortality (9.6% prepathway to 5.2% and 4.9%) in the two respective periods. Conclusions: This study demonstrates that implementation of a pneumonia clinical pathway for the management of hospitalized patients admitted via the ED decreases the time to initial antibiotic treatment and increases the proportion of patients initially treated with antibiotics in the ED. These effects were evident in the first year following pathway implementation and sustained at the three‐year study interval.
Implementing the Food and Drug Administration's Final Rule for Waiver of Informed Consent in Certain Emergency Research Circumstances
Authors: Biros Michelle H. , Fish Susan S. , Lewis Roger J.
Published: January 2008

In 1996, the Food and Drug Administration released its Final Rule for Waiver of Informed Consent in Certain Emergency Research Circumstances (the Final Rule). The Department of Health and Human Services (DHHS) also released an update of its regulations related to waiver of informed consent in emergency research. These new regulations allow resuscitation research to proceed with a waiver of informed consent under very narrow and specific clinical research circumstances. Waiving informed consent for research participation has profound ethical and scientific implications. However, in unpredictable life‐threatening clinical situations for which current therapy is unproven or unsatisfactory, patients usually are unable to consent on their own behalf to participate in clinical trials of potentially beneficial but experimental interventions. Because of the time‐dependent nature of most resuscitation interventions, it is usually not feasible to identify and contact the legally authorized representative who can speak on behalf of the patient within the presumed therapeutic window of the intervention under investigation. For such clinical trials to proceed, a waiver of informed consent is usually necessary. Patients who are critically ill or injured and unable to provide meaningful prospective informed consent because of their current life‐threatening condition are vulnerable and require additional protections beyond those for research subjects who can speak on their own behalf. The Final Rule and the DHHS‐updated regulations incorporate a number of additional patient safeguards that must occur if a clinical trial is to proceed with waiver of informed consent. Specific means of adequately meeting these requirements are not described in the regulations. Although this was intentional on the part of the federal regulators so that individual protocols and research environments would direct the development of these patient safeguards, the lack of specific guidance has led to confusion on the appropriate implementation of the new regulations. This article reviews some of the key concepts of the Final Rule, with suggestions on their purpose and meaning. It also reviews the studies that have been approved to date to proceed with waiver of informed consent, and offers suggestions for the process of implementing the requirements of the Final Rule for research involving patients who are unable to give prospective informed consent.
A Proposed Consent Process in Studies that Use an Exception to Informed Consent
Authors: Sloan Edward P. , Nagy Kimberly , Barrett John
Published: January 2008

Federal regulations allow an exception to informed consent when it is not feasible to obtain informed consent in certain emergency research circumstances. A multicenter, randomized, single‐blinded, normal saline procedure‐controlled efficacy trial of diaspirin cross‐linked hemoglobin (DCLHb) in acute traumatic hemorrhagic shock was conducted. The study intended to include 850 of the most severely injured trauma patients with hemorrhage and persistent hypoperfusion as demonstrated by vital signs suggestive of vascular collapse or a base deficit that signified prolonged hypoperfusion. It was anticipated that some patients would be unable to provide informed consent, and that identification and availability of some patients legally authorized representatives (LARs) would be unlikely within the therapeutic window of the intervention. Each participating institution therefore developed a process to implement exception to informed consent. Each hospital's proposed process was reviewed by the institutional review board, the sponsor, the FDA, and the study's data monitoring committee chair. The goal was the development of local implementation processes by which the best interests of patients and their families could be fulfilled using prospective informed consent, the exception to informed consent, and consent to continue in emergency research, as appropriate for each individual patient. This paper describes the proposed implementation method developed for Cook County Hospital. It includes several important features, 1) prospective informed consent by the patient, when feasible; 2) the ability of the patient to decline participation, even when deemed incompetent to provide prospective informed consent; 3) prospective consent by the family/LAR, when feasible; 4) the use of a scripted abbreviated consent by the patient family/LAR in life‐threatening situations when it is possible only to briefly discuss the research being conducted; 5) independent approval for the use of the consent exception by a second physician immediately prior to patient enrollment; 6) the repeated use of consent to continue (both for the family/LAR and by the patient) when an exception to consent has been utilized; and 7) ongoing review of the informed consent process on a case‐by‐case basis by the institution's scientific review committee. The authors believe this proposed informed consent process maximizes the communication between investigators, patients and their proxies, and the institution's scientific review committee. Multiple mechanisms exist that allow for consent to be provided or declined, both prior to and after enrollment in the research protocol. The ongoing immediate review of the process allows for process enhancements to be made as needed.
Concert Medicine: Spectrum of Medical Problems Encountered at 405 Major Concerts
Authors: Grange Jeff T. , Green Steven M. , Downs Warren
Published: January 2008

Objectives: To identify factors predictive of patient load at major commercial concert first‐aid stations, and to characterize the spectrum of presenting injuries and illnesses at such events. Methods: This study was a retrospective case series of patients presenting to on‐site first‐aid stations at five major concert venues in southern California over a five‐year period. The authors compared the number of patients per ten thousand attendees (PPTT) with four potential predictors (music type, overall attendance, temperature, and indoor vs outdoor location) using univariate techniques and negative binomial regression. The spectrum of chief complaints observed is described. Results: There were 1,492 total patients out of 4,638,099 total attendees at 405 separate concerts. The median patient load per concert was 2.1 PPTT, ranging from 0 PPTT at 53 concerts to 71 PPTT at a punk rock festival that turned into a riot. Patient load varied significantly by music category (p = 0.0001) but not with overall attendance, temperature, or indoor vs outdoor location. Median PPTT by music category ranged from 1.3 PPTT for rhythm and blues to 12.6 PPTT for gospel/Christian, with negative binomial regression indicating that rock concerts had 2.5 times (95% CI = 2.0 to 3.0) the overall patient load of non‐rock concerts. Music type, however, was able to account for only 4% of the variability observed in the regression model. Trauma‐related complaints predominated overall, with similar rates at rock and non‐rock concerts. Four cardiac arrests occurred at classical concerts. Conclusion: Rock concert first‐aid stations evaluated 2.5 times the patient load of non‐rock concerts overall, although there was substantial concert‐to‐concert variability. Trauma‐related complaints predominate at both rock and non‐rock events. These data may assist individuals and organizations planning support for such events.
Blood Lead Levels in Emergency Department Patients with Retained Lead Bullets and Shrapnel
Authors: Farrell Susan E. , Vandevander Patricia , Schoffstall John M. , Lee David C.
Published: January 2008

Objective: To determine whether patients with retained lead shrapnel who present to the ED have elevated whole blood lead levels (BLLs) compared with matched control patients. Methods: Test subjects were patients with x‐ray evidence of retained lead shrapnel who presented to any of three urban EDs, and consented to inclusion in the study. BLLs were obtained from 15 ED patients, and data regarding time since injury and symptoms of plumbism were collected. Control subjects consisted of 15 ED patients, without similar lead exposure, matched for age, sex, race, and place of dwelling as determined by zip code, who also presented to any of the same three EDs. Results: The mean (±SD) BLL in the test subjects was 17 ± 9.78 μg/dL (range 7‐50 μg/dL). Time since impalement ranged from 1 to 45 years. The mean BLL in the control subjects was 7 ± 3.77 μg/dL (0‐16 μg/dL). This difference was statistically significant (two‐tailed t‐test p = 0.002). Conclusions: In this preliminary study, the patients with retained lead shrapnel who presented to the ED had significantly elevated BLLs, compared with the matched control subjects. Chronic plumbism may be considered in patients with retained lead shrapnel, and a history should be taken to assess the presence of symptoms referable to plumbism. These patients may require long‐term follow‐up to assess the development of elevated blood lead level and lead toxicity.
The Impact of Environmental Factors on Emergency Medicine Resident Career Choice
Authors: Stern Susan A. , Kim Hyungjin Myra , Neacy Kathleen , Dronen Steven C. , Mertz Michelle
Published: January 2008

Abstract. Objective: To evaluate the impact of environmental factors on emergency medicine (EM) resident career choice. Methods: Program directors of all U.S. EM residencies were surveyed in November 1997. A 22‐item questionnaire assessed resources allocated to research, fellowship availability, academic productivity of faculty and residents, and career choices of residency graduates. Results: The response rate was 83%. The program director (mean ± SD) estimates of resident career choice were as follows: 27.8 ± 19.1% pursued academic positions with emphasis on teaching, 5.4 ± 9.8% pursued academic positions with emphasis on research, and 66.8 ± 23.1%, pursued private practice positions. In addition, 5.70 ± 6.13% of the residency graduates were estimated to seek felloship training. Univariate analyses demonstrated that increasing departmental funding for research, having substantial resource availability (defined as having at least two of the following: dedicated laboratory space; support for a laboratory research technician/assistant, a clinical research nurse or study coordinator, a statistician, or an assistant with a PhD degree), a greater number of peer‐reviewed publications by residents (r = 0.22; p = 0.08), and a greater number of peer‐reviewed publications by faculty (r = 0.26; p = 0.04) positively correlated with the percentage of graduates who pursue academic research careers. Using multiple regression, however, increasing intramural funding and the presence of substantial resource availability were the only variables predictive of resident pursuit of an academic research career. Conclusion: Modification of the EM training environment may influence the career choices of graduates. Specifically, greater commitment of departmental funds and support of resources for research may enhance the likelihood of a trainee's choosing an academic research career.
Alterations in Hepatic Gluconeogenesis, Prostanoid, and Intracellular Calcium during Sepsis
Authors: Maitra Subir R. , Homan Clark S. , Beuhler Michael C. , Thode Henry C. , Henry Mark
Published: January 2008

Abstract. Objective: The metabolic alterations observed during sepsis may be associated with changes in local concentrations of intracellular calcium (Ca2+) and prostanoid synthesis in the liver. The authors studied hepatocyte intracellular Ca2+ and the release of glucose and prostanoid in an in‐vivo murine liver perfusion model. Methods: Sepsis was induced in anesthetized, fasted rats by cecal ligation and puncture (CLP, n = 42). Hepatic glucose release was studied in control (n = 10) and CLP (n = 10) groups using a non‐recirculating liver perfusion model with and without lactate as gluconeogenic substrate. Hepatocyte intracellular Ca2+ (n = 11) was measured using the selective indicator Fura‐2 under basal and epinephrine (10‐5 M) stimulated conditions. 6‐Keto‐prostaglandin F1α (6‐Keto) and thromboxane B2 (TxB2) were determined from liver perfusate by radioimmunassay (n = 11). Data were analyzed using t‐tests and repeated‐measures ANOVA. Results: Plasma glucose was significantly lower in CLP groups compared with controls (74.9 ± 6.6 vs 115.7 ± 4.6 mg/dL, p < 0.05). Plasma lactate was significantly higher in CLP vs controls (3.7 ± 0.4 vs 1.4 ± 0.1 mM, p < 0.05). Glucose release in isolated perfused livers was significantly lower in CLP vs controls (8.5 vs 16 ± 1.2 μM/g/hr, p < 0.001). With the addition of lactate + pyruvate to the perfusate, glucose output in CLP livers was significantly lower following 5 (9.9 ± 0.7 vs 17.7 ± 1.1 μM/g/hr, p < 0.05) and 10 (11.9 ± 1.2 vs 20.6 ± 1.3 μM/g/hr, p < 0.001) minutes of perfusion. The basal level of intracellular calcium ([Ca2+]i) in CLP rats (460.1 ± 91.6 nM) was significantly higher than in control rats (196.3 ± 35.5 nM) (p < 0.05). A significant increase (p < 0.05) in [Ca2+]i occurred after the addition of epinephrine in hepatocytes in control (196.3 ± 35.5 vs 331.8 ± 41.4 nM) but not CLP (460.1 ± 91.6 vs 489.4 ± 105 nM) rats. 6‐Keto was significantly lower in CLP compared with controls at 30 minutes (25.7 ± 3.9 vs 33.4 ± 5.5 pg/mL, p < 0.05), whereas TxB2 was not significantly altered (52.1 ± 34.7 vs 87.5 ± 43.2 pg/mL). Conclusion: These results demonstrate that CLP sepsis is associated with an increase in hepatocyte intracellular free Ca2+ concentration along with attenuation of hormone‐mediated Ca2+ mobilization and hepatic gluconeogenesis.
The Predictive Value of Endometrial Stripe Thickness in Patients with Suspected Ectopic Pregnancy Who Have an Empty Uterus at Ultrasonography
Authors: Dart Robert G. , Dart Linda , Mitchell Patricia , Berty Clara
Published: January 2008

Abstract. Prior research suggests that, in patients with empty uteri at ultrasonography, endometrial stripe thickness may be predictive of ectopic pregnancy or the likelihood of obtaining chorionic villi after a dilatation and evacuation procedure (D+E). However, it is unclear whether the predictive value of endometrial stripe thickness is confined to patients with low beta‐human chorionic gonadotropin (β‐hCG) values. Objective: To determine whether endometrial stripe thickness is predictive of the risk of ectopic pregnancy or the likelihood of obtaining chorionic villi after D+E in patients with β‐hCG values >1,000 mIU/mL or ≤1,000 mIU/mL. Methods: In an urban academic ED, the authors conducted a retrospective chart review of consecutive ED patients from August 1991 to August 1997 with abdominal pain or vaginal bleeding, a positive β‐hCG value, and an empty uterus by transvaginal ultrasound examination. Patients were divided into four groups—group 1: endometrium thin, β‐hCG value ≤1,000 mIU/mL; group 2: endometrium thick, β‐hCG value ≤1,000 mIU/mL; group 3: endometrium thin, β‐hCG value >1,000 mIU/mL; and group 4: endometrium thick, β‐hCG value >1,000 mIU/mL. The secondary analysis was limited to patients who had a D+E performed within 48 hours of the ED visit. The risks of ectopic pregnancy and the likelihoods of obtaining chorionic villi after D+E were compared using chi‐square or Fishers' exact test where appropriate, with a p‐value of 0.05 being significant. Results: 224 patients were enrolled in the initial analysis. Intergroup differences in the frequency of ectopic pregnancy were of borderline significance (p = 0.08). However, when the comparison was limited to the groups with β‐hCG values ≤1,000 mIU/mL, the predictive value of endometrial stripe thickness reached statistical significance (group 1: 27/99 [27%], group 2: 2/28 [7%], p = 0.05). 79 patients had a D+E performed. Intergroup differences in the rate of obtaining chorionic villi were significant (p = 0.002). Group 1 had the lowest frequency of having chorionic villi identified (4/26 [15%]) and was the only group in which villi were obtained in fewer than 50% of cases. Conclusion: Endometrial stripe thickness may be predictive of the risk of ectopic pregnancy and the likelihood of obtaining chorionic villi at D+E. However, its predictive value appears to be confined to patients with β‐hCG values ≤1,000 mIU/mL.
Prevalence, Therapeutic Response, and Outcome of Ventricular Tachycardia in the Out‐of‐hospital Setting: A Comparison of Monomorphic Ventricular Tachycardia, Polymorphic Ventricular Tachycardia, and Torsades de Pointes
Authors: Brady William J. , DeBehnke Daniel J. , Laundrie Dennis
Published: January 2008

Abstract. Objective: To investigate out‐of‐hospital ventricular tachycardia (VT) cardiac arrest patients, comparing the prevalences and outcomes of the following VT subtypes among this population: monomorphic VT (MVT), polymorphic VT (PVT), and torsades de pointes (TdP, PVT with a prolonged QT interval). Methods: This was a retrospective review from a fire department‐based paramedic system of nontraumatic VT cardiac arrest patients (January 1991 to December 1994) with a supraventricular perfusing rhythm (SVPR) at some time during out‐of‐hospital care, with a measurable QT interval. QT interval was measured from an SVPR, and corrected QT interval (QTc) was calculated and considered prolonged if > 0.45 sec. VT was classified as polymorphic or monomorphic. TdP was defined as PVT with a prolonged QT interval. Results: 196 patients were identified; six were excluded due to incomplete medical records, leaving 190 who met inclusion criteria and were used for data analysis. 117 (62%) patients had MVT, while 73 (38%) patients had PVT; of the 73 patients with PVT, 37 (51%) had normal QTc (non‐TdP PVT) and 36 (49%) had prolonged QTc (TdP PVT). 97 (51%) patients had prolonged QTc (PQTc). Regardless of VT type (i.e., MVT vs PVT), 97 (51%) patients had prolonged QTc, with a mean QTc of 0.476 ± 0.15 seconds prearrest and 0.464 ± 12 seconds postarrest. Patients with PQTc were not more likely to have PVT (70 [37%] vs 76 [40%]; p = 0.705). No significant difference with respect to paramedic‐witnessed arrests in each VT morphology group and each QT group was found. The overall hospital discharge rate was 28.4%. Regardless of VT type, patients had similar rates of out‐of‐hospital return of spontaneous circulation (ROSC) and hospital discharge; patients with PQTc were less likely to be discharged from the hospital (19.6% vs 37.6%; p = 0.01). 27.8% of TdP and 26.8% of non‐TdP patients were discharged (p = 0.912). Conclusions: In this population of out‐of‐hospital VT arrest patients, MVT is the most common form of VT encountered; PVT and the subtype TdP are also seen in this population with approximately equal frequencies. All three rhythm types demonstrate similar responses to standard Advanced Cardiac Life Support therapy with equal rates of out‐of‐hospital ROSC and hospital discharge. PQTc may be a marker of poor clinical outcome in patients with out‐of‐hospital VT arrest.
Glottal Patency during Experimental Cortical Seizures in Piglets
Authors: Leaming James M. , Terndrup Thomas E. , Ognibene Steven
Published: January 2008

Abstract. Objective: Systemically‐induced seizures produce glottal airflow obstruction in anesthetized pigs, resulting in hypercapnia and respiratory acidosis. Cortically‐induced seizures may be more representative of human seizure disorders. The purpose of this study was to describe glottal area patency (GAP) in piglets during cortically‐induced seizures. Methods: Nineteen spontaneously breathing, lightly anesthetized (alphaxalone—alphadolone IV) piglets (aged 10 ± 2 days) were instrumented for recording nasal airflow, subglottic pressure, and electrocorticogram. Glottal visualization was achieved supraglottically using a 1.2‐mm fiberoptic scope inserted through the thyrohyoid membrane. Following baseline‐control, hypoxic‐rebreathing, and new baseline recordings, seizures were induced using subcortical injections of crystalline penicillin G (100,000 units/injection). Five consecutive‐breath representative epochs were digitized from baseline‐control, hypoxic‐rebreathing, and seizure conditions. For each breath, GAP was measured at the onset of inspiratory pressure, peak of inspiratory effort (Ip), and onset of expiration. Results: The piglets were physiologic at baseline‐control and new baseline conditions, and showed expected increases in ventilation and GAP during rebreathing experiments. GAP was maximum at Ip under baseline and rebreathing conditions, but was significantly decreased and airway resistances were increased during seizure conditions (p < 0.05, ANOVA). Conclusions: Generalized seizure activity results in reduced GAP at the peak of inspiratory effort. Increased work of breathing during seizures is created by direct mechanical obstruction at the level of the larynx.
A Test of the Feasibility of Pneumococcal Vaccination in the Emergency Department
Authors: Slobodkin David , Kitlas Jennifer L. , Zielske Paul G.
Published: January 2008

Abstract. Objective: To test the feasibility of pneumococcal immunization in an ED. Methods: Cook County Hospital has an annual ED census of 120,000. Patients are 75% black and 15% Hispanic. Eighty‐two percent of patients are uninsured. Seventy‐three percent report no primary physician. Between May 27, 1997, and July 26, 1997, nurses had standing orders that patients meeting CDC‐recommended criteria were to be offered pneumococcal immunization. Immunization was recorded in the system‐wide registration computer. Results: During the study period, 1,833 patient screenings encounters (13% of all patients) identified 1,493 high‐risk patients. Only 10% of screened high‐risk patients reported previous pneumococcal immunization. 1,173 were immunized against pneumococcus. Median number of immunizations per nurse per shift was 1.62. Patient throughput was not altered. Conclusion: Pneumococcal immunization is both necessary and feasible in a busy ED serving patients with little access to other immunization services.
Minor Head Trauma in Anticoagulated Patients
Authors: Garra Gregory , Nashed Ashraf H. , Capobianco Leo
Published: January 2008

Objective: To determine the incidence of clinically significant intracranial injury in the anticoagulated patient suffering minor head trauma without loss of consciousness (LOC) or acute neurologic abnormality. Methods: A retrospective chart review was performed based on a computerized search of electronic patient records from six community hospital EDs, one of which is a trauma center. Patients taking warfarin who sustained minor head trauma without LOC having no acute neurologic abnormalities treated from January 1994 to January 1996 were identified using a search of electronic ED records. Charts were reviewed for mechanism of injury, physical examination findings of head injury, and concomitant injury. Prothrombin time and head CT results were recorded if obtained. For those patients not receiving a head CT on ED evaluation, telephone follow‐up was performed to determine outcome. Results: There were 65 patients meeting inclusion criteria. Thirty‐eight patients had prothrombin times obtained, with ranges from 12.0 sec to 30.7 sec. There was no intracranial injury found in any of the 39 patients having a head CT. Additionally, follow‐up on the 26 patients who did not undergo CT scanning revealed no evidence of complications related to their head injuries. Conclusions: The incidence of clinically significant intracranial injury is extremely low in the anticoagulated patient suffering minor blunt head trauma without LOC or acute neurologic abnormality. CT scanning may not be necessary in these patients. Larger prospective studies are needed to confirm these findings.
Proposed Fellowship Training Program in International Emergency Medicine
Authors: VanRooyen Michael J. , Clem Kathleen J. , Holliman C. James , Wolfson Allan B. , Green Gary , Kirsch Thomas D.
Published: January 2008

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.
Tuberculosis Exposure Risk in Emergency Medicine Residents
Authors: Asimos Andrew W. , Kaufman Jay S. , Lee Carol H. , Williams Cleopas M. , Carter Wallace A. , Chiang William K.
Published: January 2008

Abstract. Objectives: To assess purified protein derivative (PPD) test surveillance and respiratory protection practices of emergency medicine (EM) residents, along with the prevalence of PPD test conversion and the development of active tuberculosis (TB) in EM residents. Methods: The study instrument was an anonymous, self‐reporting, multiple‐choice survey administered to U.S. and Canadian EM residents. It was distributed for voluntary completion in conjunction with the American Board of Emergency Medicine's annual in‐service examination, which was administered February 25, 1998. Results: A total of 89.3% (n = 2,985) of residents eligible to complete the survey completed at least part of it. The majority of residents are PPD‐tested once a year. The prevalence of PPD test conversions in EM residents was between 1.4% (36/2,575) and 2.0% (52/2,575). Of the residents who PPD test‐converted, the ED was most often the perceived area of TB source exposure (n = 15). Two residents (0.08%) reported having developed active TB, including chest radiographic findings or clinical infection, which equals a 0.14% (95% CI = 0.005 to 0.31) risk of developing active TB over a three‐year residency. Half of all the residents do not routinely wear National Institute for Occupational Safety and Health (NIOSH)‐approved particulate filtration respirator (PFR) masks in patient encounters at risk for TB exposure. While more than a third of EM residents have not undergone fit testing for a NIOSH‐approved PFR mask, the lack of routine easy availability of such masks is the most common reason they are not routinely worn by EM residents during at‐risk encounters for TB transmission. Conclusions: Most surveillance PPD testing of EM residents is performed at intervals recommended by the CDC. TB control programs at institutions sponsoring EM residencies need to improve both compliance with PFR mask fit testing by EM residents and availability of approved PFR masks in appropriate areas of the ED. Despite poor compliance with personal respiratory protection in ED patient encounters at risk for TB transmission, the risk of an EM resident's developing active TB over a three‐year residency is low.
The Occupational Risk of Motor Vehicle Collisions for Emergency Medicine Residents
Authors: Steele Mark T. , Ma O. John , Watson William A. , Thomas Harold A. , Muelleman Robert L.
Published: January 2008

Abstract. Objective: To determine the prevalence and risk factors associated with motor vehicle collisions (MVCs) and near‐crashes as reported by emergency medicine (EM) residents following various ED shifts. Methods: A survey was sent to all allopathic EM‐2‐EM‐4 residents in May 1996 asking whether they had ever been involved in an MVC or near‐crash while driving home after an ED shift. The residents night shift schedules, self‐reported tolerance of night work, ability to overcome drowsiness, sleep flexibility, and morningness/eveningness tendencies also were collected. Results: Seventy‐eight programs participated and 62% of 1,554 eligible residents returned usable surveys. Seventy‐six (8%, 95% CI = 6% to 10%) residents reported having 96 crashes and 553 (58%, 95% CI = 55% to 61%) residents reported being involved in 1,446 near‐crashes. Nearly three fourths of the MVCs and 80% of the near‐crashes followed the night shift. Stepwise logistic regression of all variables demonstrated a cumulative association (R = 0.19, p = 0.0004) that accounted for 4% of the observed variability in MVCs and near‐crashes. Univariate analysis showed that MVCs and near‐crashes were inversely related to residents shiftwork tolerance (p = 0.019) and positively related to the number of night shifts worked per month (p = 0.035). Conclusions: Residents reported being involved in a higher number of MVCs and near‐crashes while driving home after a night shift compared with other shifts. Driving home after a night shift appears to be a significant occupational risk for EM residents.
The Perceived Effectiveness of Total Quality Management as a Tool for Quality Improvement in Emergency Medicine
Authors: VanRooyen Michael J. , Grabowski Jurek G. , Ghidorzi Anthony J. , Dey Chayan , Strange Gary R.
Published: January 2008

Abstract. Objectives: To describe the perceived effectiveness of using the Total Quality Management (TQM) approach to quality improvement in both academic and nonacademic EDs, and to discuss some important barriers to effectiveness of TQM programs. Method: A mail survey of 100 EDs was conducted with telephone follow‐up. Hospitals were randomly selected from three subgroups: university teaching hospitals, nonuniversity teaching hospitals, and private nonteaching hospitals. ED physician directors or nonphysician administrators with knowledge of departmental quality improvement initiatives were surveyed. Results: The overall response rate was 60%. Of the respondents, 54 (90.0%) used TQM techniques as part of their quality improvement initiatives. TQM techniques were used more frequently and for a longer duration in academic programs. ED staff participation in TQM projects was relatively low; less than 25% in the majority (79.6%) of all EDs. TQM initiatives were ranked least effective in university settings, of which 11 of 13 (84.6%) rated their TQM programs as ineffective or having no effect. More mature programs (>5 years old) had a significantly higher ranking for effectiveness than those programs less than 2 years old. Conclusions: Total Quality Management is being utilized in a large number of EDs. TQM initiative is perceived as having little or no positive effect. This is particularly the case in academic EDs.
Recent Trends and Controversies in Industry‐sponsored Clinical Trials
Authors: Reed Caitlin R. , Camargo Carlos A.
Published: January 2008

Abstract. In recent years, industry has become an important source of funding for biomedical research. Industry‐sponsored clinical trials are a particular source of controversy. In light of recent developments, the authors reevaluate the 1995 SAEM guidelines for investigator involvement in industry‐sponsored clinical trials. The authors divide industry‐funded clinical trials into two categories: investigator‐initiated and industry‐initiated, and discuss the differences between them. They examine several areas of ethical debate, including exclusivity contracts between a principal investigator and a corporate sponsor, the size of per‐patient reimbursements for recruiting patients into clinical trials, and authorship criteria. Finally, the authors oppose the assumption that industry‐sponsored research is automatically biased, and suggest that multiple levels of review will help to uncover bias, whatever the source. Once mutual respect for ethical guidelines and practices are established, collaboration between emergency medicine researchers and industry should be encouraged.
Prevalence of Cardiac Valve Abnormalities in Afebrile Injection Drug Users
Authors: Levitt M. Andrew , Snoey Eric R. , Tamkin Gary W. , Gee Garwood
Published: January 2008

Abstract. Objectives: To determine the prevalence of occult valvular pathology in afebrile injection drug users (IDUs) compared with an afebrile, non‐IDU population. To characterize the type of valvular pathology present in light of current recommendations regarding periprocedural antibiotic prophylaxis against endocarditis. Methods: This was a comparative, cross‐sectional study involving a convenience sample of 98 patients with a history of injection drug use, and 99 non‐IDU patients presenting to a large urban ED. Patients were excluded if they had one or more of the following: a history of cardiac valve abnormality, a history of endocarditis, fever on presentation, or a cardiac murmur. Data were collected that included demographics, medical history, and details of injection drug use. Transthoracic echocardiography (echo) was performed on each subject in the ED, and read in a blinded fashion by a single board‐certified cardiologist. Results: Among 98 IDUs and 99 non‐IDUs, 12% of the IDUs had aortic valve thickening, compared with 5.1% of the non‐IDUs (99% CI for difference of 7.8%= ‐3.0% to 18.6%). Forty‐four percent of the IDUs had mitral valve thickening, compared with 25% of the non‐IDUs (99% CI for difference of 18.3%= 0.9% to 35.7%). Eleven percent of the IDUs vs 1% of the non‐IDUs had tricuspid valve thickening (99% CI for difference of 10.4%= 1.6% to 19.2%). No patient had pulmonic valve thickening. Six percent of the IDUs vs 0% of the non‐IDUs had mitral annulus thickening (99% CI for difference of 6.3%= ‐0.1% to 12.8%). Twelve percent of the IDUs vs 3% of the non‐IDUs had mitral chordae thickening (99% CI for difference of 9.5%= ‐0.4% to 19.4%). Tricuspid chordae thickening was recorded in 2% of the IDUs vs 0% of the non‐IDUs (99% CI for difference of 2.1%= ‐1.7% to 6.0%). Most important, the prevalence of valvular regurgitation was small, and evenly distributed in the two groups. No valvular vegetations were seen. Conclusion: Both non‐IDUs and IDUs have occult valvular pathology. There is an increased prevalence in IDUs of tricuspid and mitral valve thickening. The prevalence of valvular regurgitation, a reported indication for periprocedural antibiotic prophylaxis, was small and the affected valves were not statistically different between the two groups. These findings question the selected routine use of antibiotic prophylaxis in IDU patients undergoing invasive procedures.
Out‐of‐hospital and Emergency Department Management of Epidemic Scombroid Poisoning
Authors: Eckstein Marc , Serna Monica , DelaCruz Prosy , Mallon William K.
Published: January 2008

Abstract. Objective: To report two epidemic outbreaks of scombroid food poisoning and their emergency medical services (EMS) response and emergency department (ED) treatment, analyzing the impact of early physician involvement and on‐line medical control. Methods: Retrospective case series of two multiple‐casualty incidents (MCIs) involving scombroid food poisoning. Results: A total 57 patients were treated from two separate incidents, with 30 patients transported to area hospitals. One patient required treatment with a cardiac medication in the field and another patient eventually required hospital admission. On‐scene medical control (incident 1) and early identification of the index case (incident 2) were instrumental to out‐of‐hospital care interventions and conservation of resources. Patient triage, field treatment, and hospital transport were expedited, with some patients treated and released from the scene. Conclusions: Immediate diagnosis of a food‐borne illness in the out‐of‐hospital setting allows rapid treatment at the scene and allows for the efficient transport of multiple patients to a single receiving facility. EMS medical directors should be able to immediately respond to such incidents to make presumptive diagnoses and accurately direct patient care. When this is not possible, early identification of the index case facilitates early diagnosis and treatment.
Defining, Identifying, and Measuring Error in Emergency Medicine
Authors: Handler Jonathan A. , Gillam Michael , Sanders Arthur B. , Klasco Richard
Published: January 2008

Abstract. The findings of a consensus committee created to address the definition, measurement, and identification of error in emergency medicine (EM) are presented. The literature of error measurement in medicine is also reviewed and analyzed. The consensus committee recommended adopting a standard set of terms found in the medical error literature. Issues surrounding error identification are discussed. The pros and cons of mandatory reporting, voluntary reporting, and surveillance systems are addressed, as is error reporting at the clinician, hospital, and oversight group levels. Committee recommendations are made regarding the initial steps EM should take to address error. The establishment of patient safety boards at each institution is also recommended.
System Contributions to Error
Authors: Adams James G. , Bohan J. Stephen
Published: January 2008

Abstract. An unacceptably high rate of medical error occurs in the emergency department (ED). Professional accountability requires that EDs be managed to systematically eliminate error. This requires advocacy and leadership at every level of the specialty and at each institution in order to be effective and sustainable. At the same time, the significant operational challenges that face the ED, such as excessive patient care requirements, should be recognized if error reduction efforts are to remain credible. Proper staffing levels, for example, are an important prerequisite if medical error is to be minimized. Even at times of low volume, however, medical error is probably common. Engineering human factors and operational procedures, promoting team coordination, and standardizing care processes can decrease error and are strongly promoted. Such efforts should be coupled to systematic analysis of errors that occur. Reliable reporting is likely only if the system is based within the specialty to help ensure proper analysis and decrease threat. Ultimate success will require dedicated effort, continued advocacy, and promotion of research.
Errors in Emergency Medicine Research Strategies
Authors: Kyriacou Demetrios N. , Coben Jeffrey H.
Published: January 2008

Abstract.Medical errors in emergency departments (EDs) may be an important “public health risk.” Therefore, scientific public health approaches should be used to 1) assess the magnitude of emergency medical errors with surveillance methods, 2) identify causal factors of these medical errors with clinical epidemiologic methods, and 3) evaluate the effectiveness of interventions aimed at reducing or eliminating emergency medicine errors with health service research techniques. Since errors result from complex human—system interaction, research efforts should focus on actions taken by the patient, factors concerning the ED environment, and actions taken by health care workers. Other medical and nonmedical fields have already made great advancements in studying and reducing human error. Many of these advancements could readily be adapted to study emergency medical errors.
Emergency Department Workplace Interruptions Are Emergency Physicians “Interrupt‐driven” and “Multitasking”?
Authors: Chisholm Carey D. , Collison Edgar K. , Nelson David R. , Cordell William H.
Published: January 2008

Abstract. Objective: Although interruptions have been shown in aviation and other work settings to result in error with serious and sometimes fatal consequences, little is known about interruptions in the emergency department (ED). The authors conducted an observational, time—motion task‐analysis study to determine the number and types of interruptions in the ED. Methods: Emergency physicians were observed in three EDs located in an urban teaching hospital, a suburban private teaching hospital, and a rural community hospital. A single investigator followed emergency staff physicians for 180‐minute periods and recorded tasks, interruptions, and breaks‐intask. An “interruption” was defined as any event that briefly required the attention of the subject but did not result in switching to a new task. A “break‐intask” was defined as an event that required the attention of the physician for more than 10 seconds and subsequently resulted in changing tasks. Results: The mean (±SD) total number of patients seen at all three sites during the 180‐minute study period was 12.1 ± 3.7 patients (range 5‐20). Physicians performed a mean of 67.6 ± 15.7 tasks per study period. The mean number of interruptions per 180‐minute study period was 30.9 ± 9.7 and the mean number of breaks‐in‐task was 20.7 ± 6.3. Both the number of interruptions (r = 0.63; p < 0.001) and the number of breaks‐in‐task (r = 0.56; p < 0.001) per observation period were positively correlated with the average number of patients simultaneously managed. Conclusions: Emergency physicians are “interruptdriven.” Emergency physicians are frequently interrupted and many interruptions result in breaks‐in‐task.
Errors in Emergency Physician Interpretation of ST‐segment Elevation in Emergency Department Chest Pain Patients
Authors: Brady William J. , Perron Andrew , Ullman Edward
Published: January 2008

Abstract. Objective: To determine the rate of error in emergency physician (EP) interpretation of the cause of electrocardiographic (ECG) ST‐segment elevation (STE) in adult chest pain patients. Methods: The authors conducted a retrospective ECG review of adult chest pain patients in a university hospital emergency department (ED) over a three‐month period (January 1 to March 31, 1996). ST‐segment elevation was determined to be present if the ST segment was elevated ≥1 mm in the limb leads and ≥2 mm in the precordial leads in at least two anatomically contiguous leads. Initial eEP ECG interpretation was compared with the final interpretation by a cardiologist supported by the results of various clinical investigations. The rate of incorrect ECG diagnosis was calculated. Results: Two hundred two patients had STEs. The rate of ECG STE misinterpretation was 12 of 202 (5.9%). The most frequently misdiagnosed form of STE was left ventricular aneurysm, for which two of five cases were believed to represent acute myocardial infarction (AMI). The benign early repolarization (BER) pattern was the second most frequently misinterpreted STE entity—in a total of three cases, two were initially noted to represent pericarditis and one AMI. ST‐segment elevation resulting from actual AMI was initially incorrectly noted to be noninfarction in etiology in two cases, one patient with BER and the other with left ventricular hypertrophy. Conclusions: Emergency physicians show a low rate of ECG misinterpretation in the patient with chest pain and STE. The clinical consequences of this misinterpretation are minimal.