bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of Gorlin syndrome (nevoid basal cell carcinoma syndrome) with methylaminolevulinate photodynamic therapy in seven patients, including two children: interest of tumescent anesthesia for pain control in children
Authors: Girard C. , Debu A. , Bessis D. , Blatière V. , Dereure O. , Guillot B.
Published: April 2012

Objective  To report our experience of methylaminolevulinate photodynamic therapy (MAL‐PDT) in the treatment of multiple basal cell carcinoma (BCC) in adults and children with Gorlin syndrome (GS).

Design  Report of cases.

Setting  University of Montpellier, Department of Dermatology.

Patients  Seven Gorlin patients (41 superficial or nodular carcinomas), including two children.

Interventions  Prior superficial curettage for superficial BBCs or debulking for nodular BCCs was systematically performed. Methylaminolevulinic acid was applied topically to lesions 3 h before illumination with 635 nm red light for 10 min (37 J/cm2). To prevent treatment discomfort, analgesics and/or cooling by sprayed water were most often provided, and occasionally 1% lidocaine local anesthesia. A ropivacaine‐lidocaine tumescent anesthesia was performed on the youngest patient.

Main outcome measures  The initial response rate; tolerance, particularly in children; cosmetic outcome.

Results  Overall clearance in patients was 60% after one session of MAL‐PDT and 78% after three sessions. Resolution of the lesions was accompanied by an excellent cosmetic outcome in all patients. Treatments were well tolerated in adults with moderate pain sensation during illumination. In a child, tumescent anesthesia assured excellent tolerance in all treatment stages.

Conclusion  We add our experience to previous articles that consider PDT as an interesting option in the treatment of GS. To our knowledge, this study is the first report of MAL‐PDT in GS children using tumescent anesthesia. Specific guidelines for adult and pediatric patients remain to be established.
Developmental and evolutionary significance of the mandibular arch and prechordal/premandibular cranium in vertebrates: revising the heterotopy scenario of gnathostome jaw evolution
Authors: Kuratani Shigeru , Adachi Noritaka , Wada Naoyuki , Oisi Yasuhiro , Sugahara Fumiaki
Published: April 2012

The cephalic neural crest produces streams of migrating cells that populate pharyngeal arches and a more rostral, premandibular domain, to give rise to an extensive ectomesenchyme in the embryonic vertebrate head. The crest cells forming the trigeminal stream are the major source of the craniofacial skeleton; however, there is no clear distinction between the mandibular arch and the premandibular domain in this ectomesenchyme. The question regarding the evolution of the gnathostome jaw is, in part, a question about the differentiation of the mandibular arch, the rostralmost component of the pharynx, and in part a question about the developmental fate of the premandibular domain. We address the developmental definition of the mandibular arch in connection with the developmental origin of the trabeculae, paired cartilaginous elements generally believed to develop in the premandibular domain, and also of enigmatic cartilaginous elements called polar cartilages. Based on comparative embryology, we propose that the mandibular arch ectomesenchyme in gnathostomes can be defined as aDlx1‐positive domain, and that the polar cartilages, which develop from theDlx1‐negative premandibular ectomesenchyme, would represent merely posterior parts of the trabeculae. We also show, in the lamprey embryo, early migration of mandibular arch mesenchyme into the premandibular domain, and propose an updated version of the heterotopy theory on the origin of the jaw.
Zebrafish Parla‐ and Parlb‐deficiency affects dopaminergic neuron patterning and embryonic survival
Authors: Noble Sandra , Ismail Abid , Godoy Rafael , Xi Yanwei , Ekker Marc
Published: April 2012

J. Neurochem. (2012) 122, 196–207.

Many genes associated with familial Parkinson’s disease contribute to mitochondrial morphology and function. Some of these genes, for example, Pink1 and Parkin, are part of a common pathway. The presenilin‐associated rhomboid‐like (PARL) gene was recently linked to familial Parkinson’s disease. The PARL gene product is found in the inner mitochondrial membrane and cleaves the optic atrophy 1 protein, involved in mitochondrial morphology and apoptosis. In Drosophila, the PARL‐related rhomboid‐7 gene acts upstream of pink1 and parkin. However, such a genetic relationship is still unknown in vertebrates. Here, we show that the zebrafish genome comprises two parl paralogs: parla and parlb. Morpholino‐mediated loss of parla and/or parlb function resulted in mild neurodegeneration, as evidenced by a lower density of dopaminergic neurons. Patterning of dopaminergic neurons was also perturbed in the ventral diencephalon. Morphants exhibited extensive cell death throughout the entire body as well as increased larval mortality. The morphant phenotype could be rescued by injection of human PARL mRNA, but not catalytically inactive PARL, suggesting functional conservation between the human and zebrafish proteins. More importantly, the zebrafish pink1 mRNA as well as the human PINK1 mRNA, but not kinase‐dead nor Parkinson’s disease‐linked mutant PINK1 mRNA, also rescued the morphant phenotype, providing evidence that Parl genes may function upstream of Pink1, as part of a conserved pathway in vertebrates.
Contribution of serine racemase/d‐serine pathway to neuronal apoptosis
Authors: Esposito Simona , Pristerà Andrea , Maresca Giovanna , Cavallaro Sebastiano , Felsani Armando , Florenzano Fulvio , Manni Luigi , Ciotti Maria T. , Pollegioni Loredano , Borsello Tiziana , Canu Nadia
Published: April 2012

Recent data indicate that age‐related N‐methyl‐d‐aspartate receptor (NMDAR) transmission impairment is correlated with the reduction in serine racemase (SR) expression and d‐serine content. As apoptosis is associated with several diseases and conditions that generally occur with age, we investigated the modulation of SR/d‐serine pathway during neuronal apoptosis and its impact on survival. We found that in cerebellar granule neurons (CGNs), undergoing apoptosis SR/d‐serine pathway is crucially regulated. In the early phase of apoptosis, the expression of SR is reduced, both at the protein and RNA level through pathways, upstream of caspase activation, involving ubiquitin proteasome system (UPS) and c‐Jun N‐terminal kinases (JNKs). Forced expression of SR, together with treatment with NMDA and d‐serine, blocks neuronal death, whereas pharmacological inhibition and Sh‐RNA‐mediated suppression of endogenous SR exacerbate neuronal death. In the late phase of apoptosis, the increased expression of SR contribute to the last, NMDAR‐mediated, wave of cell death. These findings are relevant to our understanding of neuronal apoptosis and NMDAR activity regulation, raising further questions as to the role of SR/d‐serine in those neuro‐pathophysiological processes, such as aging and neurodegenerative diseases characterized by a convergence of apoptotic mechanisms and NMDAR dysfunction.
Effects of aging and reproduction on protein quality control in soma and gametes of Drosophila melanogaster
Authors: Fredriksson Åsa , Johansson Krogh Elin , Hernebring Malin , Pettersson Ellinor , Javadi Ala , Almstedt Alvar , Nyström Thomas
Published: April 2012

In organisms with a soma–germ demarcation, the germline must be ‘preserved’ such that harmful damage is not transmitted to the offspring. Keeping the progeny free of damage may be achieved by gametes enjoying elevated, and/or more functional, homeostatic maintenance systems. This possibility was approached here by testing whether the soma and maturating oocytes (eggs) dissected from female Drosophila melanogaster in reproductive ages display differential capacities for protein quality control and whether these capacities change during aging and mating. Eggs exhibited a high capacity to prevent protein aggregation, strong capacity for 26S proteasome‐dependent degradation and reduced levels of oxidatively damaged (carbonylated) proteins compared to the soma. The capacity to prevent protein aggregation was not affected in either soma or eggs by age and/or mating, while the 26S proteasome capacity declined in the soma but was maintained in the eggs of aged females. However, the levels of carbonylated proteins increased with age in both soma and eggs, and this increase was more pronounced in females allowed to mate continuously. Furthermore, the levels of carbonylated proteins in the eggs of mated flies correlated negatively with the propensity of the eggs to develop into an adult fly. In young flies, mating caused a decrease in 26S proteasome capacity and an increase in protein carbonylation in the soma, but not in the eggs. These results are in line with trade‐off theories of aging where aging is considered a consequence of investment in reproduction over somatic maintenance.
Signal‐morphology impedance cardiography during incremental cardiopulmonary exercise testing in pulmonary arterial hypertension
Authors: Ferreira Eloara M. , Arakaki Jaquelina S. Ota‐ , B. Barbosa Priscila , Siqueira Ana Cristina B. , Bravo Daniela M. , Kapins Carlos Eduardo B. , Silva Célia Maria C. , Nery Luiz Eduardo , Alberto Neder J.
Published: April 2012

Background

Haemodynamic responses to exercise are related to physical impairment and worse prognosis in patients with pulmonary arterial hypertension (PAH). It is clinically relevant, therefore, to investigate the practical usefulness of non‐invasive methods of monitoring exercise haemodynamics in this patient population.

Methods

Using a novel impedance cardiography (ICG) approach that does not require basal impedance estimations and relies on a morphological analysis of the impedance signal (Signal‐Morphology‐ICG™), stroke volume (SV) and cardiac index (CI) were evaluated in 50 patients and 21 age‐matched controls during a ramp‐incremental cardiopulmonary exercise testing.

Results

Technically unacceptable readings were found in 12 of 50 (24%) patients. In the remaining subjects, early decrease (N = 9) or a ‘plateau’ in SV (N = 8) and Δ (peak‐unloaded exercise) SV <10 ml were markers of more advanced PAH (P<0.05). ΔCI ≤ 1.5‐fold and early estimated lactate threshold were the only independent predictors of a severely reduced peak oxygen uptake (O2) in patients (R2 = 0.71, P<0.001). The finding of ΔCI ≤ 1.5‐fold plus peak O2 < 50% predicted was associated with a number of clinical and functional markers of disease severity (P<0.001). In addition, abnormal SV responses and ΔCI ≤ 1.5‐fold were significantly related to 1‐year frequency of PAH‐related adverse events (death and balloon atrial septostomy, N = 8; P<0.05).

Conclusions

‘Qualitative’ and ‘semi‐quantitative’ signal‐morphology impedance cardiography™ (PhysioFlow™) during incremental exercise provided clinically useful information to estimate disease severity and short‐term prognosis in patients with PAH in whom acceptable impedance signals could be obtained.
Biphasic clearance of incompatible red blood cells through a novel mechanism requiring neither complement nor Fcγ receptors in a murine model
Authors: Liepkalns Justine S. , Hod Eldad A. , Stowell Sean R. , Cadwell Chantel M. , Spitalnik Steven L. , Zimring James C.
Published: April 2012

BACKGROUND: Antibody binding to red blood cells (RBCs) can induce potentially fatal outcomes, including hemolytic transfusion reactions (HTRs), hemolytic disease of the fetus and newborn, and autoimmune hemolytic anemia. The mechanism(s) of RBC destruction following antibody binding is typically thought to require complement activation and/or the involvement of Fcγ receptors (FcγRs). In the current report, we analyzed mechanisms of HTRs during incompatible transfusions of murine RBCs expressing human glycophorin A (hGPA) into mice with anti‐hGPA.

STUDY DESIGN AND METHODS: C3 and Fcγ receptor knockout, splenectomized, Fcγ receptor blocking antibody–treated, and clodronate‐treated mice were passively immunized with anti‐hGPA (10F7 or 6A7) and transfused with RBCs expressing the hGPA antigen. Posttransfusion blood and serum were collected and analyzed via flow cytometry and confocal microscopy.

RESULTS: This HTR model results in both rapid clearance and cytokine storm. Neither complement nor FcγRs were required for RBC clearance; in contrast, FcγRs were required for cytokine storm. Circulating aggregates of hGPA RBCs were visible during the HTR. Splenectomy and phagocyte depletion by clodronate had no effect on acute RBC clearance; however, incompatible RBCs reentered over 24 hours in clodronate‐treated mice.

CONCLUSION: These data demonstrate a biphasic HTR, the first phase involving sequestration of incompatible hGPA RBCs and the second phase involving phagocytosis of sequestered RBCs. However, the mechanism(s) of phagocytosis in the second phase required neither C3 nor FcγRs. These findings demonstrate novel mechanistic biology of HTRs.
A review on decision support for massive transfusion: understanding human factors to support the implementation of complex interventions in trauma
Authors: Enticott Joanne C. , Jeffcott Shelly , Ibrahim Joseph E. , Wood Erica M. , Cole‐Sinclair Merrole , Fitzgerald Mark , Cameron Peter A. , Phillips Louise E.
Published: April 2012

BACKGROUND: Critically bleeding trauma patients require coordinated and efficient decision‐making processes to ensure optimal management of their massive transfusion (MT) requirements. Human factors (HFs) is a discipline that investigates factors influencing work processes from the organizational, group, and individual levels. Given the complexity of trauma resuscitation, implementing any intervention for decision support in MT is challenging and may benefit from a HFs‐assisted approach.

STUDY DESIGN AND METHODS: A systematic review was performed to identify reports of the introduction of any type of decision support for the provision of MT in critically bleeding adult trauma patients. Crucial contributions reported to influence design and uptake of the intervention were categorized into four HFs categories (environment, human, machine, and task). Extracted information was supplemented by surveying the contact authors. Evidence of clinical practice changes resulting from the intervention was also considered.

RESULTS: We identified nine studies that had reported an intervention implementing new practice guidelines or a MT protocol. All were before‐and‐after comparative cohort studies and used historical controls as the preintervention cohort.

CONCLUSION: Based on the identified reports, this review provides a HFs‐assisted approach to aid clinicians and policy makers with the implementation of decision support for MT in the trauma care setting.
Impact of storage temperature and processing delays on cord blood quality: discrepancy between functional in vitro and in vivo assays
Authors: Louis Isabelle , Wagner Eric , Dieng Mame M. , Morin Hugo , Champagne Martin A. , Haddad Elie
Published: April 2012

BACKGROUND: Optimal conditions of cord blood (CB) storage, processing, cryopreservation, and thawing are critical for banking and transplantation. Nevertheless, standardized procedures are still awaited.

STUDY DESIGN AND METHODS: We evaluated the impact of preprocessing storage and temperature on recovery, viability, and functional differentiation capacities of hematopoietic progenitor cells. We compared units stored at room temperature (RT) or at 4°C for 72 hours before cryopreservation to units processed shortly after collection (<12 hr).

RESULTS: Postthaw results showed similar in vitro characteristics between immediate processing and 4°C storage for cell recovery and viability, both significantly higher than RT storage. Surprisingly, we demonstrated that storage of CB units at RT before processing and cryopreservation profoundly altered in vivo hematopoietic reconstitution in mice, although in vitro hematopoietic colony‐forming unit potential was unaltered.

CONCLUSION: Our findings challenge current CB storage practices and suggest standard in vitro quality assessments may not always be indicative of CB engraftment potential.
The Dynamics of Evolving Beliefs, Concerns Emotions, and Behavioral Avoidance Following 9/11: A Longitudinal Analysis of Representative Archival Samples
Authors: McArdle Shelly C. , Rosoff Heather , John Richard S.
Published: April 2012

September 11 created a natural experiment that enables us to track the psychological effects of a large‐scale terror event over time. The archival data came from 8,070 participants of 10 ABC and CBS News polls collected from September 2001 until September 2006. Six questions investigated emotional, behavioral, and cognitive responses to the events of September 11 over a five‐year period. We found that heightened responses after September 11 dissipated and reached a plateau at various points in time over a five‐year period. We also found that emotional, cognitive, and behavioral reactions were moderated by age, sex, political affiliation, and proximity to the attack. Both emotional and behavioral responses returned to a normal state after one year, whereas cognitively‐based perceptions of risk were still diminishing as late as September 2006. These results provide insight into how individuals will perceive and respond to future similar attacks.
Atrioventricular Conduction After Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement
Authors: ROTEN LAURENT , STORTECKY STEFAN , SCARCIA FLAVIO , KADNER ALEXANDER , TANNER HILDEGARD , DELACRÉTAZ ETIENNE , MEIER BERNHARD , WINDECKER STEPHAN , CARREL THIERRY , WENAWESER PETER
Published: April 2012

AV Conduction After TAVI and SAVR. Introduction: Atrioventricular conduction abnormalities (AVCA) may complicate transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). The aim of this study was to prospectively evaluate AVCA after TAVI and SAVR.

Methods and Results: Among 50 patients undergoing TAVI and 25 patients undergoing SAVR a continuous 7‐day Holter electrocardiogram (ECG) was recorded after the procedure. ECGs during TAVI and 12‐lead ECGs before and 1 and 7 days after TAVI and SAVR were analyzed. At baseline, TAVI patients were older (mean 82.1 vs 75.4, P < 0.001), had a longer PR interval (median 200 milliseconds vs 175 milliseconds, P = 0.004) and broader QRS width (median 100 milliseconds vs 80 milliseconds, P = 0.007) than SAVR patients. New AVCA were observed among 29 TAVI patients (58%), mostly new left bundle branch block (76%). Predilatation induced new AVCA in 14 TAVI patients (28%). New AVCA resolved within 24 hours in 15 TAVI patients (30%), and persisted in 14 TAVI (28%) and 3 SAVR patients (12%, P = 0.12). Among patients with persistent QRS width <120 milliseconds during the first 24 hours after TAVI, QRS width remained stable during the remainder of the observation period. During Holter monitoring complete AV block was observed in 4 TAVI patients (8%) and 3 SAVR patients (12%; P = 0.68).

Conclusions: Almost half of AVCA during TAVI are induced by predilatation, but half of them resolve within 24 hours. Persistent AVCA are more frequently observed after TAVI than SAVR. If QRS width is below 120 milliseconds the first day after TAVI, the risk of late AVCA seems low. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1115‐1122, October 2012)
Low Rate of Atrial Fibrillation Recurrence Verified by Implantable Loop Recorder Monitoring Following a Convergent Epicardial and Endocardial Ablation of Atrial Fibrillation
Authors: GERSAK BORUT , PERNAT ANDREJ , ROBIC BORIS , SINKOVEC MATJAZ
Published: April 2012

Implantable Loop Recorder Monitoring Outcomes for the Convergent AF Procedure. Objective: Evaluate long‐term outcomes in patients undergoing the Convergent procedure (CP) for the treatment of atrial fibrillation (AF).

Background: The CP provides a multidisciplinary approach, combining endoscopic creation of epicardial linear lesions followed by endocardial mapping and ablation and targets persistent and longstanding persistent AF patients who are at increased risk of heart failure, stroke, and mortality.

Methods: Outcomes from a prospective nonrandomized study were recorded for consecutive patients by interrogation of implanted Reveal® monitors. Rhythm status and AF burden were quantified 6–24 months postprocedure, and compared relative to AF type, gender, age, body mass index, left atrial size, left ventricular ejection fraction, and congestive heart failure, hypertension, age >75 years, age between 65 and 74 years, stroke/TIA/TE, vascular disease (previous MI, peripheral arterial disease or aortic plaque), diabetes mellitus, female (CHA2DS2VASc).

Results: A total of 50 patients were enrolled with 94% having persistent or longstanding persistent AF. There were 2 atrioesophageal fistulas reported. In one patient, the fistula resulted in death at 33 days postprocedure; in the second, the fistula was surgically repaired but patient died 8 months postprocedure from a CVI. After CP, 95% of patients were in sinus rhythm at 6‐month follow‐up; 88% at 12 months; and 87% at 24 months. The median AF burden recorded with Reveal XT monitors was 0.0%, 0.1%, and 0.1% at 6, 12, and 24 months with 81%, 81%, and 87% of patients reporting a burden less than 3%, respectively.

Conclusion: Using 24 × 7 continuous loop recording, the CP demonstrated success in treating persistent and longstanding persistent AF patients. Endocardial mapping and catheter ablation with diagnostic confirmation of procedural success complemented the endoscopic creation of epicardial linear lesions in restoring sinus rhythm. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1059‐1066, October 2012)
A Hybrid EM and Monte Carlo EM Algorithm and Its Application to Analysis of Transmission of Infectious Diseases
Authors: Yang Yang , Longini Jr. Ira M. , Halloran M. Elizabeth , Obenchain Valerie
Published: April 2012

SummaryIn epidemics of infectious diseases such as influenza, an individual may have one of four possible final states: prior immune, escaped from infection, infected with symptoms, and infected asymptomatically. The exact state is often not observed. In addition, the unobserved transmission times of asymptomatic infections further complicate analysis. Under the assumption of missing at random, data‐augmentation techniques can be used to integrate out such uncertainties. We adapt an importance‐sampling‐based Monte Carlo Expectation‐Maximization (MCEM) algorithm to the setting of an infectious disease transmitted in close contact groups. Assuming the independence between close contact groups, we propose a hybrid EM‐MCEM algorithm that applies the MCEM or the traditional EM algorithms to each close contact group depending on the dimension of missing data in that group, and discuss the variance estimation for this practice. In addition, we propose a bootstrap approach to assess the total Monte Carlo error and factor that error into the variance estimation. The proposed methods are evaluated using simulation studies. We use the hybrid EM‐MCEM algorithm to analyze two influenza epidemics in the late 1970s to assess the effects of age and preseason antibody levels on the transmissibility and pathogenicity of the viruses.
Mechanical Properties and Electronic Structure of Mullite Phases Using First‐Principles Modeling
Authors: Aryal Sitaram , Rulis Paul , Ching Wai‐Yim
Published: April 2012

The alumino‐silicate series (Al4+2xSi2−2xO10‐x, x = 0–1), is an important class of structural ceramics with many applications. Except for the end member (x = 0), which is the crystalline phase sillimanite, the reported crystal structures of the other phases, called mullites, all have partially occupied sites which makes any theoretical calculation a formidable task. In this article, we describe a systematic and detailed theoretical investigation of the structures and properties of the phases in this series. We constructed stoichiometric supercell models for the four well‐known mullite phases 3Al2O3·2SiO2, 2Al2O3·SiO2, 4Al2O3·SiO2, 9Al2O3·SiO2, corresponding to x = 0.25, 0.40, 0.67, and 0.842. The construction of the models began with experimentally reported crystal structures followed by systematic removal of selected atoms at the partially occupied sites to maintain charge neutrality. A large number of models were built for each phase and fully relaxed to high accuracy using the Vienna ab initio simulation package program. The model with the lowest total energy for a given x was chosen as the representative structure for that phase. Together with sillimanite (x = 0) and the silica free ι‐Al2O3 (x = 1), this series' electronic structure and mechanical properties were studied via first‐principles calculations. Their elastic coefficients and mechanical properties (bulk modulus, shear modulus, Young's modulus, and Poisson's ratio) were evaluated. The electronic structure, effective charges, bonding, and optical properties of these mullite phases were calculated using the orthogonalized linear combination of atomic orbitals method. These first‐principles results provide the basis for an explanation of the experimentally observed structure and properties of mullite phases and their trends with x at the fundamental level.
2  Matters of Belief: Middle‐Range Theory, Religion, and the “State”
Authors: Kus Susan
Published: April 2012

In early large‐scale polities religion played a critical role in giving conceptual form to new rules that trump social and economic principles of kinship and egalitarian reciprocity in order to justify the existence of privileged elites. How does one both do theoretical justice to the insidiousness of a religion used in service to the state and do justice to conviction in local knowledge and the efficaciousness of belief therein? These are important matters for middle‐range theory in the archaeology of religion. This contribution focuses on the latter half of the conundrum understood from contemporary ethnographic work by the author in the central highlands of Madagascar. It then examines the crafting of state religion during the unification and expansion of the Merina state under the reign of Andrianampoinimerina (1787–1810).
4  Technology and Morality—Rituals in Iron Working among the Fipa and Pangwa Peoples in Southwestern Tanzania
Authors: Barndon Randi
Published: April 2012

Based on ethnographic fieldwork in the 1990s among the Pangwa and Fipa peoples in southwestern Tanzania, this discussion focuses on the locally constructed collective and individual perceptions of technological processes in iron smelting and how these are connected to imagination. Of particular interest is the largely neglected aspect of morality involved in the rituals surrounding iron working. It is argued that aspects of morality, as well as magic and witchcraft, explain the concerns of the people engaged in the complex technology of making iron far better than does fertility symbolism.
9  Meanings and Functions of Enclosed Places in the European Neolithic: A Contextual Approach to Cult, Ritual, and Religion
Authors: Biehl Peter F.
Published: April 2012

This chapter reevaluates theories and methodologies applied to the archaeology of religion stressing the symbolic meaningfulness of material culture, place, and landscape. In a case study—the Neolithic circular enclosure of Goseck in Germany—a contextual approach is used to highlight that ritual practices function both at a community and at an individual level, and as social and communicative acts. The chapter also demonstrates that ritual practice ought to be contextualized with the material culture and the place associated with it in order to better understand and theorize its complex meaning in prehistoric religious life.
Are Patients With Longer Emergency Department Wait Times Less Likely to Consent to Research?
Authors: Limkakeng Alexander T. , Glickman Seth W. , Shofer Frances , Mani Giselle , Drake Weiying , Freeman Debbie , Ascher Simon , Pietrobon Ricardo , Cairns Charles B.
Published: April 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19: 396–401 © 2012 by the Society for Academic Emergency Medicine

Objectives:  There are unique challenges to enrolling patients in emergency department (ED) clinical research studies, including the time‐sensitive nature of emergency conditions, the acute care environment, and the lack of an established relationship with patients. Prolonged ED wait times have been associated with a variety of adverse effects on patient care. The objective of this study was to assess the effect of ED wait times on patient participation in ED clinical research. The hypothesis was that increased ED wait times would be associated with reduced ED clinical research consent rates.

Methods:  This was a retrospective cohort study of all patients eligible for two diagnostic clinical research studies from January 1, 2008, through December 31, 2008, in an urban academic ED. Sex, age, race, study eligibility, and research consent decisions were recorded by trained study personnel. The wait times to registration and to be seen by a physician were obtained from administrative databases and compared between consenters and nonconsenters. An analysis of association between patient wait times for the outcome of consent to participate was performed using a multivariate logistic regression model.

Results:  A total of 903 patients were eligible for enrollment and were asked for consent. Overall, 589 eligible patients (65%) gave consent to research participation. The consent rates did not change when patients were stratified by the highest and lowest quartile wait times for both time from arrival to registration (68% vs. 65%, p = 0.35) and time to be seen by a physician (65% vs. 66%, p = 0.58). After adjusting for patient demographics (age, race, and sex) and study, there was still no relationship between wait times and consent (p > 0.4 for both wait times). Furthermore, median time from arrival to registration did not differ between those who consented to participate (15 minutes; interquartile range [IQR] = 9 to 36 minutes) versus those who did not (15.5 minutes; IQR = 10 to 39 minutes; p = 0.80; odds ratio [OR] = 1.00, 95% confidence interval [CI] = 0.99 to 1.01). Similarly, there was no difference in the median time to be seen by a physician between those who consented (25 minutes; IQR = 15 to 55 minutes) versus those who did not (25 minutes; IQR = 15 to 56 minutes; p = 0.70; OR = 1.00, 95% CI = 0.99 to 1.01).

Conclusions:  Regardless of wait times, nearly two‐thirds of eligible patients were willing to consent to diagnostic research studies in the ED. These findings suggest that effective enrollment in clinical research is possible in the ED, despite challenges with prolonged wait times.
Epidemiology of 6.6 Million Knee Injuries Presenting to United States Emergency Departments From 1999 Through 2008
Authors: Gage Brett E. , McIlvain Natalie M. , Collins Christy L. , Fields Sarah K. , Dawn Comstock R.
Published: April 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19:378–385 © 2012 by the Society for Academic Emergency Medicine

Background:  While knee injuries are treated by a wide range of clinicians, patients with knee injuries frequently present to emergency departments (EDs). The knee is the most commonly injured joint by adolescent athletes with an estimated 2.5 million sports‐related injuries presenting to EDs annually.

Objectives:  The objective was to examine the epidemiology of knee injuries presenting to EDs in the United States from 1999 through 2008.

Methods:  The Consumer Product Safety Commission National Electronic Injury Surveillance System database (NEISS) was used to examine causes of knee injuries treated in U.S. EDs from 1999 through 2008.

Results:  An estimated 6,664,324 knee injuries presented to U.S. EDs from 1999 through 2008, for a rate of 2.29 knee injuries per 1,000 population. Those 15 to 24 years of age had the highest injury rate (3.83), while children younger than 5 years had the lowest rate (0.55). The most common diagnoses were strains and sprains (42.1%), contusions and abrasions (27.1%), and lacerations and punctures (10.5%). The most common general product categories causing injury were sports and recreation (49.3%), home structures (30.2%), and home furnishings (13.6%). Several sex and age group differences were identified. For example, males sustained a higher proportion of basketball‐related injuries (11.1%) than females (3.6%; injury proportion ratio [IPR] = 3.11, 95% confidence interval [CI] = 2.79 to 3.46, p < 0.001). Additionally, individuals 65 years and older sustained a higher proportion of injury due to stairs, ramps, landings, and floors (42.0%), compared to all other ages (20.1%; IPR = 2.09, 95% CI = 1.95 to 2.23, p < 0.001).

Conclusions:  Rates and patterns of knee injuries vary by sex and age. Although knee injuries will likely continue to occur most frequently among youth and young adult athletes, anticipating and responding to trends such as an increase in the incidence of knee injuries among adult and senior patients will enable clinicians to better anticipate caseloads, allocate resources, and determine best practices for diagnosis and treatment of knee injuries in different age groups.
Factors That Influence Medical Student Selection of an Emergency Medicine Residency Program: Implications for Training Programs
Authors: Love Jeffrey N. , Howell John M. , Hegarty Cullen B. , McLaughlin Steven A. , Coates Wendy C. , Hopson Laura R. , Hern Gene H. , Rosen Carlo L. , Fisher Jonathan , Santen Sally A.
Published: April 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19: 455–460 © 2012 by the Society for Academic Emergency Medicine

Objectives:  An understanding of student decision‐making when selecting an emergency medicine (EM) training program is essential for program directors as they enter interview season. To build upon preexisting knowledge, a survey was created to identify and prioritize the factors influencing candidate decision‐making of U.S. medical graduates.

Methods:  This was a cross‐sectional, multi‐institutional study that anonymously surveyed U.S. allopathic applicants to EM training programs. It took place in the 3‐week period between the 2011 National Residency Matching Program (NRMP) rank list submission deadline and the announcement of match results.

Results:  Of 1,525 invitations to participate, 870 candidates (57%) completed the survey. Overall, 96% of respondents stated that both geographic location and individual program characteristics were important to decision‐making, with approximately equal numbers favoring location when compared to those who favored program characteristics. The most important factors in this regard were preference for a particular geographic location (74.9%, 95% confidence interval [CI] = 72% to 78%) and to be close to spouse, significant other, or family (59.7%, 95% CI = 56% to 63%). Factors pertaining to geographic location tend to be out of the control of the program leadership. The most important program factors include the interview experience (48.9%, 95% CI = 46% to 52%), personal experience with the residents (48.5%, 95% CI = 45% to 52%), and academic reputation (44.9%, 95% CI = 42% to 48%). Unlike location, individual program factors are often either directly or somewhat under the control of the program leadership. Several other factors were ranked as the most important factor a disproportionate number of times, including a rotation in that emergency department (ED), orientation (academic vs. community), and duration of training (3‐year vs. 4‐year programs). For a subset of applicants, these factors had particular importance in overall decision‐making.

Conclusions:  The vast majority of applicants to EM residency programs employed a balance of geographic location factors with individual program factors in selecting a residency program. Specific program characteristics represent the greatest opportunity to maximize the success of the immediate interview experience/season, while others provide potential for strategic planning over time. A working knowledge of these results empowers program directors to make informed decisions while providing an appreciation for the limitations in attracting applicants.
Evaluating the Use of Existing Data Sources, Probabilistic Linkage, and Multiple Imputation to Build Population‐based Injury Databases Across Phases of Trauma Care
Authors: Newgard Craig , Malveau Susan , Staudenmayer Kristan , Wang N. Ewen , Hsia Renee Y. , Mann N. Clay , Holmes James F. , Kuppermann Nathan , Haukoos Jason S. , Bulger Eileen M. , Dai Mengtao , Cook Lawrence J. ,   the WESTRN investigators
Published: April 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19: 469–480 © 2012 by the Society for Academic Emergency Medicine

Objectives:  The objective was to evaluate the process of using existing data sources, probabilistic linkage, and multiple imputation to create large population‐based injury databases matched to outcomes.

Methods:  This was a retrospective cohort study of injured children and adults transported by 94 emergency medical systems (EMS) agencies to 122 hospitals in seven regions of the western United States over a 36‐month period (2006 to 2008). All injured patients evaluated by EMS personnel within specific geographic catchment areas were included, regardless of field disposition or outcome. The authors performed probabilistic linkage of EMS records to four hospital and postdischarge data sources (emergency department [ED] data, patient discharge data, trauma registries, and vital statistics files) and then handled missing values using multiple imputation. The authors compare and evaluate matched records, match rates (proportion of matches among eligible patients), and injury outcomes within and across sites.

Results:  There were 381,719 injured patients evaluated by EMS personnel in the seven regions. Among transported patients, match rates ranged from 14.9% to 87.5% and were directly affected by the availability of hospital data sources and proportion of missing values for key linkage variables. For vital statistics records (1‐year mortality), estimated match rates ranged from 88.0% to 98.7%. Use of multiple imputation (compared to complete case analysis) reduced bias for injury outcomes, although sample size, percentage missing, type of variable, and combined‐site versus single‐site imputation models all affected the resulting estimates and variance.

Conclusions:  This project demonstrates the feasibility and describes the process of constructing population‐based injury databases across multiple phases of care using existing data sources and commonly available analytic methods. Attention to key linkage variables and decisions for handling missing values can be used to increase match rates between data sources, minimize bias, and preserve sampling design.
Patients Who Leave Without Being Seen in Emergency Departments: An Analysis of Predictive Factors and Outcomes
Authors: Tropea Joanne , Sundararajan Vijaya , Gorelik Alexandra , Kennedy Marcus , Cameron Peter , Brand Caroline A
Published: April 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19: 439–447 © 2012 by the Society for Academic Emergency Medicine

Objectives:  The objective was to identify predictive factors and outcomes associated with patients who leave emergency departments (EDs) without being seen in Victoria, Australia.

Methods:  This was a retrospective observational study of Victorian ED patient visits between July 1, 2000, and June 30, 2005, using linked hospital, ED, and death registration data. Index ED visits were identified for patients who left without being seen (LWBS) and for those who completed ED treatment and were discharged home. Statistical analyses included a general description and univariate analysis of patient, ED visit, temporal, and hospital‐level factors. Logistic regression models were developed to assess risk factors associated with LWBS status compared to patients who completed treatment, to assess 48 hour re‐presentations to ED; 48‐hour hospital admissions; and 2‐,7‐, and 30‐day mortality among those who LWBS compared to those who completed treatment. Adjusted odds ratios (ORs) and 99% confidence intervals (CIs) are presented.

Results:  There were 239,305 LWBS episodes, for 205,500 patients over the 5‐year period. Independent factors associated with LWBS patients in comparison to those who completed treatment include patients who are younger (15 to 24 years, OR = 2.46, 99% CI = 2.37 to 2.56), male (OR = 1.07, 99% CI = 1.05 to 1.08), of Australian indigenous background (OR = 1.63, 99% CI = 1.53 to 1.73), of non–English‐speaking background (OR = 1.08, 99% CI = 1.06 to 1.10), noncompensable status (OR = 1.73, 99% CI = 1.68 to 1.79), self‐referring (OR = 1.46, 99% CI = 1.43 to 1.49), nonassisted arrival mode (OR = 1.35, 99% CI = 1.30 to 1.40), and those with a hospital admission in the 12 months before the ED presentation (OR = 1.53, 99% CI = 1.51 to 1.55). Patients who LWBS had triage categories of lower urgency (nonurgent, OR = 8.21, 99% CI = 8.00 to 8.43), attended during the evening (OR = 1.10, 99% CI = 1.08 to 1.12), on either Sunday (OR = 1.20, 99% CI = 1.18 to 1.23) or Monday (OR = 1.20, 99% CI = 1.17 to 1.23), in winter (OR = 1.14, 99% CI = 1.12 to 1.16), with higher rates occurring in higher volume EDs (OR = 2.20, 99% CI = 2.15 to 2.26). There was no greater risk of mortality for LWBS patients compared to patients who completed treatment. The risk of hospital admission within 48 hours of discharge was lower for LWBS patients (OR = 0.60, 99% CI = 0.58 to 0.62); however, ED re‐presentation risk was higher (OR = 1.63, 99% CI = 1.60 to 1.67).

Conclusions:  Patients who leave EDs in Victoria, Australia, without being seen are at lower risk of hospital admission and at no greater risk of mortality, but are at higher risk of re‐presenting to an ED compared to patients who complete treatment and are discharged home.
Feasibility of Percutaneous Vagus Nerve Stimulation for the Treatment of Acute Asthma Exacerbations
Authors: Miner James R. , Lewis Lawrence M. , Mosnaim Giselle S. , Varon Joseph , Theodoro Daniel , Hoffmann Thomas J.
Published: April 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19: 421–429 © 2012 by the Society for Academic Emergency Medicine

Objectives:  This study assessed the feasibility of an investigational vagus nerve stimulation (VNS) device for treating acute asthma exacerbations in patients not responding to at least 1 hour of initial standard care therapy.

Methods:  This was a prospective, nonrandomized study of patients treated in the ED for moderate to severe acute asthma (forced expiratory volume in 1 second [FEV1] 25% to 70% of predicted). Treatment entailed percutaneous placement of an electrode near the right carotid sheath and 60 minutes of VNS and continued standard care. VNS voltage was adjusted to perceived improvement, muscle twitching, or adverse events (AEs). All AEs, vital signs, FEV1, perceived work of breathing (WOB), and final disposition were recorded.

Results:  Twenty‐five subjects were enrolled. There were no serious AEs and no significant changes in vital signs. No subject required terminating VNS. One patient had minor bleeding from the procedure, and one had a hematoma and withdrew prior to VNS. AEs related to VNS were temporary and included cough (1 of 24), swallowing difficulty (2 of 24), voice change (2 of 24), and muscle twitching (14 of 24). These resolved when VNS ended. The FEV1 improved at 15 minutes (median = 15.8%, 95% confidence interval [CI] = 9.3% to 22.4%), 30 minutes (median = 21.3%, 95% CI = 8.1% to 36.5%), and 60 minutes (median = 27.5%, 95% CI = 11.3% to 43.5%). WOB improved at 15 minutes (median = 53.9%, 95% CI = 33.7% to 73.9%), 30 minutes (median = 69.1%, 95% CI = 56.4% to 81.8%), and 60 minutes (median = 81.0%, 95% CI = 68.5% to 93.5%).

Conclusions:  Percutaneous VNS did not result in serious AEs and was associated with improvements in FEV1 and perceived dyspnea. Percutaneous VNS appears to be feasible for use in the treatment of moderate to severe acute asthma in patients unresponsive to initial standard care treatment.
The Emergency Department Action in Smoking Cessation (EDASC) Trial: Impact on Delivery of Smoking Cessation Counseling
Authors: Katz David A. , Vander Weg Mark W. , Holman John , Nugent Andrew , Baker Laurence , Johnson Skyler , Hillis Stephen L. , Titler Marita
Published: April 2012

ACADEMIC EMERGENCY MEDICINE 2012; 19: 409–420 © 2012 by the Society for Academic Emergency Medicine

Objectives:  The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse–initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask–advise–assess–assist–arrange) and 2) assess ED nurses’ and physicians’ perceptions of smoking cessation counseling.

Methods:  The authors conducted a pre–post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face‐to‐face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses’ and physicians’ self‐efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.

Results:  Of 650 smokers who completed the post‐ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow‐up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses’ self‐efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in “pros” and “cons” attitudes toward smoking cessation in either ED nurses or physicians.

Conclusions:  Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time‐efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.