bluuebunny/crossref_metadata_2025 huggingface dataset:
The antimicrobial nalidixic acid as a probe for molecular recognition of α- and β-cyclodextrins
Authors: Shehatta I S , Ibrahim M S , Sultan M R
Published: November 2002

The inclusion of the antibacterial drug nalidixic acid (NAL) in α- and β-cyclodextrin (CD) cavities was studied using UVvis absorption and voltammetric methods. It was corroborated that the UV absorption bands of NAL are intensified in the presence of α- and β-CDs. A pronounced decrease in the peak currents of NAL was also noticed upon the addition of α- and β-CDs. From the changes in the peak currents, it was concluded that NAL forms 1:1 inclusion complexes with the various hosts, which is also revealed in the phase solubility profile of the NALβ-CD system, as a representative example. From voltammetric data, the logarithm of the binding constants were calculated to be 2.60 and 3.20 for α- and β-CDs, respectively. The magnitude of the formation constants, as well as the Gibbs free energies for NAL with α- and β-CDs, shows that NAL is bound more strongly to β-CD, with a more apolar cavity, than to α-CD. These observations suggest that hydrophobic interaction is the most important recognition element in the binding process. All orientations of entering NAL into the cavity have been considered herein, with the purpose of characterizing the inclusion complex of NAL with CD. Combining the experimental results and molecular modeling and energy calculations on the inclusion complexes yielded a more detailed picture of the solution structure of the complex formed between NAL and either α-CD or β-CD. It was inferred that the inclusion process can occur through the 2-methylpyridine side. An additional hydrogen bond was also found to be formed between the carboxyl group of NAL, which remains outside the β-CD cavity, and the secondary hydroxyl group of β-CD. This hydrogen bond should, therefore, be operating as an important second recognition element in the NALβ-CD system. Key words: cyclodextrins, hostguest association, inclusion complexes, nalidixic acid, solubility, voltammetry.
Studies of a benzoporphyrin derivative with Pluronics
Authors: Hioka N , Chowdhary R K , Chansarkar N , Delmarre D , Sternberg E , Dolphin D
Published: November 2002

The synthetic route for the benzoporphyrin derivatives produces two regioisomers in equimolar quantities (ring A and B isomers). A derivative of the A-ring product, BPD-MA (benzoporphyrin-derivative monoacid ring A, verteporfin), has recently been approved in North America and Europe for the treatment of age-related macular degeneration. The B-ring isomers, contrary to the A-ring isomers, exhibit high aggregation in many formulations, which results in inadequate drug delivery for clinical uses. To avoid aggregation, a non-ionic surfactant polymer such as a Pluronic  poly(ethylene oxide)-poly(propylene oxide)-poly(ethylene oxide)  may be used as a formulation excipient. The triblock polymer investigated here is designated P123 (or poloxamer 403). When used to formulate a monoacid benzoporphyrin B-ring derivative (2), a critical micelle concentration of P123 in water occurred at approximately 0.015 to 0.03%. The apparent pKaof compound 2 was dependent on its concentration in P123, and decreased as the molar ratio (P123:2) increased. High concentrations of P123 and neutral pH were found to be the best conditions to maintain the drug in its monomeric form. Kinetic studies suggest that the aggregate of 2 contains several molecules, and is formed by a catalyzed self-assembly process. Samples with 1 mg mL1of drug, at pH = 7.4, and 4.8% of Pluronic showed satisfactory capacity to load and keep monomers stable. This formulation has potential PDT applications.Key words: Pluronic, poloxamers, block copolymers, photosensitizing drug, photodynamic therapy (PDT), formulation, micelles.
Crystal chemistry of tetraradial species. Part 10. Tilting at windmills: conformations of the tetraphenyl species ZPh40, ±1 (Z = B, C, N)
Authors: Knop Osvald , Rankin Kathryn N , Cameron T Stanley , Boyd Russell J
Published: November 2002

The equilibrium geometries of the isoelectronic ZPh40, ±1 (Z = B, C, N) molecules have been optimized, in S4 and D2d symmetries, at the HF/6-31G(d,p) and B3LYP/6-31G(d,p) levels, with the phenyl rings constrained to be planar. The ground-state conformations of all three species are shown to be of S4 symmetry, but the difference of the energies of the S4 and the D2d conformations is estimated to amount to only ~1 kcal mol1, with a barrier to concerted rotational reorientation of the phenyl rings of ~5.0 kcal mol1 for BPh4, ~6.4 kcal mol1 for CPh4, and ~7.9 kcal mol1 for NPh+4. A redetermination of the crystal structure of CPh4 from 60°C X-ray data agrees with the results of previous determinations at ambient temperature; the CPh4 molecule in the crystal is slightly compressed along the S4 axis relative to the free molecule, otherwise the geometries of the two are essentially the same. Correlations between the optimized geometric parameters of the ZPh40, ±1 molecules have been examined and analyzed in detail, as have the substitution-induced changes in the geometry of the phenyl ring. The results confirm and strengthen the conclusions from the statistical studies by Domenicano et al. on the geometry of benzene rings monosubstituted by atoms of elements from the first row of the Periodic system.Key words: tetraphenylborate, tetraphenylmethane, tetraphenylammonium, ab initio molecular geometries.
Feedback Inhibition of Catecholamine Release by Two Different α
2
-Adrenoceptor Subtypes Prevents Progression of Heart Failure
Authors: Brede Marc , Wiesmann Frank , Jahns Roland , Hadamek Kerstin , Arnolt Carsten , Neubauer Stefan , Lohse Martin J. , Hein Lutz
Published: November 2002

Background—

Elevated plasma norepinephrine levels are associated with increased mortality in patients and in animal models with chronic heart failure. To test which α
2
-adrenoceptor subtypes operate as presynaptic inhibitory receptors to control norepinephrine release in heart failure, we investigated the response of gene-targeted mice lacking α
2
-adrenoceptor subtypes (α
2
-KO) to chronic left ventricular pressure overload. In addition, we determined the functional consequences of genetic variants of α
2
-adrenoceptors in human patients with chronic heart failure.

Methods and Results—

Cardiac pressure overload was induced by transverse aortic constriction. Three months after aortic banding, survival was dramatically reduced in α
2A
-KO (52%) and α
2C
-KO (47%) mice compared with wild-type and α
2B
-deficient (86%) animals. Excess mortality in α
2A
- and α
2C
-KO strains was attributable to heart failure with enhanced left ventricular hypertrophy and fibrosis and elevated circulating catecholamines. The clinical importance of this finding is emphasized by the fact that heart failure patients with a dysfunctional variant of the α
2C
-adrenoceptor had a worse clinical status and decreased cardiac function as determined by invasive catheterization and by echocardiography.

Conclusions—

Our results indicate an essential function of α
2A
- and α
2C
-adrenoceptors in the prevention of heart failure progression in mice and human patients. Identification of heart failure patients with genetic α
2
-adrenoceptor variants as well as new α
2
-receptor subtype–selective drugs may represent novel therapeutic strategies in chronic heart failure and other diseases with enhanced sympathetic activation.
Distinctive Electrophysiological Properties of Pulmonary Veins in Patients With Atrial Fibrillation
Authors: Jaïs Pierre , Hocini Mélèze , Macle Laurent , Choi Kee-Joon , Deisenhofer Isabel , Weerasooriya Rukshen , Shah Dipen C. , Garrigue Stéphane , Raybaud Florence , Scavee Christophe , Le Metayer Philippe , Clémenty Jacques , Haïssaguerre Michel
Published: November 2002

Background—

Atrial fibrillation (AF) is frequently initiated from pulmonary veins (PVs), but little is known of the electrophysiological properties of PVs.

Methods and Results—

Two groups were studied: 28 patients (49±13 years old) with paroxysmal AF and 20 control patients (49±14 years old) without AF. Effective and functional refractory period and conduction time from PV to left atrium (LA) were compared in the 2 groups by use of programmed stimulation with a single extrastimulus in the PVs and LA. In the AF group, the venous effective refractory periods (ERPs) were shorter than that of the LA: 185±71 versus 253±21 ms,
P
<0.001, whereas in the control group, they were longer (282±45 versus 253±41 ms,
P
=0.009). The venous ERPs and functional refractory periods in patients with AF were also shorter than that observed in control subjects (185±71 versus 282±45 ms and 210±77 versus 315±43 ms, respectively,
P
<0.001), whereas LA ERPs were not significantly different. Decremental conduction in PVs was more frequent (93% versus 56%,
P
=0.01) and had a greater increment (102±65 versus 42±40 ms,
P
<0.001) in patients with AF. Finally, AF was more frequently induced when pacing was performed in PVs (22 of 90) versus LA (1 of 81) in patients with AF (
P
<0.001).

Conclusions—

The PVs of patients with AF exhibited distinctive electrophysiological properties, which were strikingly different from those of patients devoid of AF, potentially explaining their arrhythmogenicity.
Inactivation of the Lysyl Oxidase Gene
Lox
Leads to Aortic Aneurysms, Cardiovascular Dysfunction, and Perinatal Death in Mice
Authors: Mäki Joni M. , Räsänen Juha , Tikkanen Hilkka , Sormunen Raija , Mäkikallio Kaarin , Kivirikko Kari I. , Soininen Raija
Published: November 2002

Background—

The lysyl oxidases are extracellular copper enzymes that initiate the crosslinking of collagens and elastin, 5 human isoenzymes having been characterized so far. The crosslinks formed provide the tensile strength and elastic properties for various extracellular matrices, including vascular walls. We studied the role of the first described isoenzyme Lox by inactivating its gene in mice.

Methods and Results—

Murine
Lox
gene was disrupted by routine methods.
Lox
−/−
mice died at the end of gestation or as neonates, necropsy of the live-born pups revealing large aortic aneurysms. In light microscopy, hazy and unruffled elastic lamellae in the
Lox
−/−
aortas were observed, and electron microscopy of the aortic walls of the
Lox
−/−
fetuses showed highly fragmented elastic fibers and discontinuity in the smooth muscle cell layers in
Lox
−/−
fetuses. The wall of the aorta in the
Lox
−/−
fetuses was significantly thicker, and the diameter of the aortic lumen was significantly smaller than that in the
Lox
+/+
aortas. In
Lox
−/−
fetuses, Doppler ultrasonography revealed increased impedance in the umbilical artery, descending aorta, and intracranial artery blood velocity waveforms, decreased mean velocities across cardiac inflow and outflow regions, and increased pulsatility in ductus venosus blood velocity waveforms.

Conclusions—

Lox has an essential role in the development and function of the cardiovascular system. Inactivation of the
Lox
gene causes structural alterations in the arterial walls, leading to abnormalities in the cardiovascular functions. Alterations in LOX activity may also play a critical role in certain human cardiovascular diseases.
Calcium Antagonist Lacidipine Slows Down Progression of Asymptomatic Carotid Atherosclerosis
Authors: Zanchetti Alberto , Bond M. Gene , Hennig Michael , Neiss Albrecht , Mancia Giuseppe , Dal Palù Cesare , Hansson Lennart , Magnani Bruno , Rahn Karl-Heinz , Reid John L. , Rodicio Josè , Safar Michel , Eckes Lothar , Rizzini Paolo
Published: November 2002

Background—

Most cardiovascular events associated with hypertension are complications of atherosclerosis. Some antihypertensive agents influence experimental models of atherosclerosis through mechanisms independent of blood pressure lowering.

Methods and Results—

The European Lacidipine Study on Atherosclerosis (ELSA) was a randomized, double-blind trial in 2334 patients with hypertension that compared the effects of a 4-year treatment based on either lacidipine or atenolol on an index of carotid atherosclerosis, the mean of the maximum intima-media thicknesses (IMT) in far walls of common carotids and bifurcations (CBM
max
). This index has been shown by epidemiological studies to be predictive of cardiovascular events. A significant (
P
<0.0001) effect of lacidipine was found compared with atenolol, with a treatment difference in 4-year CBM
max
progression of −0.0227 mm (intention-to-treat population) and −0.0281 mm (completers). The yearly IMT progression rate was 0.0145 mm/y in atenolol-treated and 0.0087 mm/y in lacidipine-treated patients (completers, 40% reduction;
P
=0.0073). Patients with plaque progression were significantly less common, and patients with plaque regression were significantly more common in the lacidipine group. Clinic blood pressure reductions were identical with both treatments, but 24-hour ambulatory systolic/diastolic blood pressure changes were greater with atenolol (−10/−9 mm Hg) than with lacidipine (−7/−5 mm Hg). No significant difference between treatments was found in any cardiovascular events, although the relative risk for stroke, major cardiovascular events, and mortality showed a trend favoring lacidipine.

Conclusion—

The greater efficacy of lacidipine on carotid IMT progression and number of plaques per patient, despite a smaller ambulatory blood pressure reduction, indicates an antiatherosclerotic action of lacidipine independent of its antihypertensive action.
Renderings of Digital Art
Authors: Paul Christiane
Published: November 2002

This essay identifies the current qualifier of choice, “new media,” by explaining how this term is used to describe digital art in various forms. Establishing a historical context, the author highlights the pioneer exhibitions and artists who began working with new technology and digital art as early as the late 1960s and early 1970s. The article proceeds to articulate the shapes and forms of digital art, recognizing its broad range of artistic practice: music, interactive installation, installation with network components, software art, and purely Internet-based art. The author examines the themes and narratives specific to her selection of artwork, specifically interactive digital installations and net art. By addressing these forms, the author illustrates the hybrid nature of this medium and the future of this art practice.
Ten Myths of Internet Art
Authors: Ippolito Jon
Published: November 2002

This article identifies ten myths about Internet Art, and explains the difficulties museums and others have understanding what it means to make art for the Internet. In identifying these common misconceptions, the author offers insight on successful online works, provides inspiration to Internet artists, and explains that geographical location does not measure success when making art for the Internet. The article also mentions that the World Wide Web is only one of the many parts that make up the Internet. Other online protocols include e-mail, peer-to-peer instant messaging, video-conferencing software, MP3 audio files, and text-only environments like MUDs and MOOs. The author concludes his list of myths with the idea that surfing the Internet is not a solitary experience. Online communities and listservers, along with interactive Internet artworks that trace viewers and integrate their actions into respective interfaces, prove that the Internet is a social mechanism.
Past, Present, and Future Tense
Authors: Muir Gregor
Published: November 2002

Given the task at hand, “to select new media works that have changed or are impacting the course of new media art and music,” the author, along with his colleagues, set out to identify the fullness of the digital spectrum. The article explains his selections of artwork by consciously establishing a past, present, and future media collection. He begins with a 1965 piece from Nam June Paik and ends with JODI.org, acknowledging the large jump made from past to present media. Concluding the article with a look at the history of digital art, the author raises comparisons and dilemmas that allow readers to question and reflect on the status of new media art.
Ten Dreams of Technology
Authors: Dietz Steve
Published: November 2002

This article presents the ten dreams of technology that frame the author/ c urator's selection of ten new media artworks. The “dreams” or themes presented by the author have been developed and/or questioned by artists throughout the history of the intersection of art and technology. This history emerges through artworks that the author describes as containing a “compelling vitality that we must admire.” The collection of dreams includes: Symbiosis, Emergence, Immersion, World Peace, Transparency, Flows, Open Work, Other, New Art, and Hacking. The author notes that these dreams of technology have a future, even if it is not yet determined.
Art in Digital Times: From Technology to Instrument
Authors: Weil Benjamin
Published: November 2002

The author's approach to selecting digital art encompasses four major themes. The first relates to reprocessing information and the use of sampling as a means of representing the culturescape we inhabit. The second involves the emergence of interactive environments and installations. New forms of storytelling frame the third view and the final theme relates to bridging the categorical gaps, as demonstrated in computer generated multimedia work.
Music and Life
Authors: Chadabe Joel
Published: November 2002

Music is increasingly reflecting the world around us, combining the rhythms, activities, and experiences of everyday life through electronic technology. A new integration of music and life has emerged utilizing sonic materials such as sounds and words, that establish dynamic interactive processes with the public. This essay examines relevant histories in order to identify when and how this union originated. From Pierre Schaeffer to Paul Miller (a.k.a. DJ Spooky), the author writes a history, chronologically mapping the numerous musical projects that help support and define this music and life concept.
The Emerging Imperative for Health Care Quality Improvement
Authors: Kizer Kenneth W.
Published: November 2002

There are widespread and growing concerns about the variable and too often inadequate quality of health care in the United States. As a result, health care quality is being questioned and subjected to scrutiny as never before. Awareness of the quality deficits, combined with rising health care expenditures and changing attitudes of payers and consumers, has given rise to a nascent but growing quality improvement movement. Multiple barriers must be surmounted by this movement, but substantive work is under way on all fronts. Emergency medicine will definitely be affected by the quality improvement movement and should quickly move forward to define and establish performance measures for high‐quality emergency care in an era when chronic disease dominates the agenda. Emergency medicine should also aggressively work to operationalize a culture of quality to minimize medical errors, to practice evidence‐based medicine, to translate research results into clinical practice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excellence.
Quality in Clinical Practice
Authors: Cone David C. , Nedza Susan M. , Augustine James J. , Davidson Steven J.
Published: November 2002

This paper reports the proceedings of the discussion panel assigned to look at clinical aspects of quality in emergency medicine. One of the seven stated objectives of the Academic Emergency Medicine consensus conference on quality in emergency medicine was to educate emergency physicians regarding quality measures and quality improvement as essential aspects of the practice of emergency medicine. Another topic of interest was a discussion of the value of information technology in facilitating quality care in the clinical practice of emergency medicine. It is important to note that this is not intended to be a comprehensive review of this extensive topic, but instead is designed to report the discussion that occurred at this session of the consensus conference.
Measuring and Improving Quality in Emergency Medicine
Authors: Graff Louis , Stevens Carl , Spaite Daniel , Foody JoAnne
Published: November 2002

The findings are presented of a consensus committee created to address the measuring and improving of quality in emergency medicine. The objective of the committee was to critically evaluate how quality in emergency medicine can be measured and how quality improvement projects can positively affect the care of emergency patients. Medical quality is defined as “the care health professionals would want to receive if they got sick.” The literature of quality improvement in emergency medicine is reviewed and analyzed. A summary list of measures of quality is included with four categories: condition‐specific diseases, diagnostic syndromes, tasks/procedures, and department efficiency/efficacy. Methods and tools for quantifying these measures are examined as well as their accuracy in assessing quality and adjusting for differences in environment, and patient populations. Successful strategies for changing physician behavior are detailed as well as barriers to change. Examples are given of successful quality improvement efforts. Also examined is how to address the emergency care needs of vulnerable populations such as older persons, women, those without health insurance, and ethnic minorities.
Quality and Education
Authors: Croskerry Pat , Chisholm Carey , Vinen John , Perina Debra
Published: November 2002

Juxtaposing quality with education in emergency medicine (EM) generates two distinct issues: 1) the quality of education in EM, and 2) educating about quality in EM. There is considerable overlap between the two, and neither should be considered without the other. This paper focuses on education about quality in EM, with some discussion of the quality of EM education. Despite its apparent importance, there is a relative paucity of research on this topic.
Researching Quality in Emergency Medicine
Authors: Bizovi Kenneth E. , Wears Robert , Lowe Robert A.
Published: November 2002

Research aimed at promoting quality of medical care must be quality research. This paper addresses issues of study design that can affect the validity of such research. The authors draw on previous research about medical errors—recognizing that issues of study design pertaining to medical errors apply to other research on quality of care and, indeed, to clinical research in general. The November 2000 Special Issue of Academic Emergency Medicine addressed medical errors in emergency medicine. In that issue, Kyriacou and Coben described three categories of research on medical errors: 1) research aimed at describing the magnitude of the problem; 2) research identifying causal factors for medical errors; and 3) research evaluating interventions aimed at improving quality of care. These three categories correspond to research methodologies that are, respectively, 1) descriptive; 2) qualitative; and 3) analytic. This article discusses challenges to the validity of each type of research and suggests some possible solutions to these problems. In addition, the article reviews projects that illustrate important issues in research quality. Three research projects are discussed: 1) a published project evaluating an intervention aimed at improving quality; 2) a quality improvement project that is transformed into a research project; and 3) a quality monitoring research project that exemplifies how a statistical technique borrowed from industry can offer a unique solution to quality challenges in medicine. Each of these projects demonstrates some of the challenges in researching quality and their solutions.
The Development of Indicators to Measure the Quality of Clinical Care in Emergency Departments Following a Modified‐Delphi Approach
Authors: Lindsay Patrice , Schull Michael , Bronskill Susan , Anderson Geoffrey
Published: November 2002

Objective: To develop and apply a systematic approach to identify and define valid, relevant, and feasible measures of emergency department (ED) clinical performance. Methods: An extensive literature review was conducted to identify clinical conditions frequently treated in most EDs, and clinically relevant outcomes to evaluate these conditions. Based on this review, a set of condition—outcome pairs was defined. An expert panel was convened and a Modified‐Delphi process was used to identify specific condition—outcome pairs where the panel felt there was a link between quality of care for the condition and a specific outcome. Next, for highly rated condition—outcome pairs, specific measurable indicators were identified in the literature. The panelists rated these indicators on their relevance to ED performance and need for risk adjustment. The feasibility of calculating these indicators was determined by applying them to a routinely collected data set. Results: Thirteen clinical conditions and eight quality‐of‐care outcomes (mortality, morbidity, admissions, recurrent visits, follow‐up with primary care, length of stay, diagnostics, and resource use) were identified from the literature (104 pairs). The panel selected 21 condition—outcome pairs, representing eight of 13 clinical conditions. Then, the panel selected 29 specific clinical indicators, representing the condition—outcome pairs, to measure ED performance. It was possible to calculate eight of these indicators, covering five clinical conditions, using a routinely collected data set. Conclusions: Using a Modified‐Delphi process, it was possible to identify a series of condition—outcome pairs that panelists felt were potentially related to ED quality of care, then define specific indicators for many of these condition—outcome pairs. Some indicators could be measured using an existing data set. The development of sound clinical performance indicators for the ED is possible, but the feasibility of measuring them will be dependent on the availability and accessibility of high‐quality data.
The Emergency Department as Usual Source of Medical Care: Estimates from the 1998 National Health Interview Survey
Authors: Walls Craig A. , Rhodes Karin V. , Kennedy Jae J.
Published: November 2002

In emergency medicine, there is an ongoing debate regarding patients who use the emergency department (ED) as their usual source of medical care—an arguably costly and inefficient pattern of utilization. However, there are few accurate national data on the prevalence of such usage. This analysis uses the 1998 National Health Interview Survey to estimate the number of Americans who name the ED as their usual source of care, and compares their characteristics with those who have a usual source of care other than the ED. Poverty, lack of insurance, younger age, male gender, and minority race or ethnicity predicted identifying the ED as the usual source of care.
Improving the Care of Patients with Non‐ST‐elevation Acute Coronary Syndromes in the Emergency Department: The CRUSADE Initiative
Authors: Hoekstra James W. , Pollack Charles V. , Roe Matthew T. , Peterson Eric D. , Brindis Ralph , Harrington Robert A. , Christenson Robert H. , Smith Sidney C. , Ohman E. Magnus , Gibler W. Brian
Published: November 2002

Although acute coronary syndromes (ACS) represent a well‐recognized source of morbidity and mortality for patients with cardiovascular disease, evidence‐based therapies shown to improve outcomes for ACS are frequently underused in appropriate patients, especially in the emergency department (ED). Despite dissemination of expert recommendations from the American College of Cardiology/American Heart Association (ACC/AHA) and ED‐focused recapitulation of them in the emergency medicine literature, significant barriers continue to limit the adoption of guidelines in clinical practice and appear to hinder the use of beneficial therapies and interventions in the ED. Unique and creative approaches are therefore needed to stimulate better adherence to practice guidelines and improve the quality of care for patients with non‐ST‐elevation myocardial infarction (NSTE) ACS. The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines) quality improvement and educational initiative provides an innovative and multifaceted approach to the education of emergency physicians and cardiologists in the care of patients with NSTE ACS. The CRUSADE initiative is a multidisciplinary cooperative effort involving over 400 EDs and medical centers. It includes an ACS registry designed to characterize demographic patterns and risk stratification results in patients who meet diagnostic criteria for high‐risk NSTE ACS. It also measures the use of ED treatment modalities including aspirin, heparin, beta‐blockers, and platelet inhibitors as recommended in the ACC/AHA guidelines. The results of a given institution's treatment patterns will be reported back to the practitioners, with comparisons with national norms. These reports can be used as quality improvement tools to improve care at participating institutions. Beyond a static registry, these reports are coupled with educational efforts by the CRUSADE steering committee, scientific publications of risk stratification practice and success, as well as ED patterns of care, and tailored educational interventions, to reinforce compliance with the ACC/AHA guidelines. This initiative represents a truly innovative approach to improving care for ACS patients in the ED as well as on the cardiology service. This article describes the CRUSADE initiative and its implications for the practicing emergency physician. It is the intent of CRUSADE to improve patient care in the ED by tracking and encouraging compliance with evidence‐based guidelines for the evaluation and management of NSTE ACS.
Medical Errors—What and When: What Do Patients Want to Know?
Authors: Hobgood Cherri , Peck Clifford R. , Gilbert Benjamin , Chappell Kathryn , Zou Bin
Published: November 2002

Objectives: 1) To determine how and when emergency department (ED) patients and their families wish to learn of health care errors. 2) To assess the error threshold this population believes should trigger reporting to government agencies, state medical boards, and hospital patient safety committees. 3) To evaluate the role patients and families believe medical educators should play in this process. Methods: A 12‐item survey was administered to a convenience sample of ED patients and families during evaluation in a tertiary care academic ED. Results were tabulated and data were reported as percentages. Statistical significance was analyzed using the chi‐square test. Results: 258 surveys were returned (80%). A majority of respondents wished to be informed immediately of any medical error (76%) and to have full disclosure of the error's extent (88%). An overwhelming majority of respondents endorse reporting of errors to government agencies (92%), state medical boards (97%), and hospital committees (99%). Most respondents believe medical educators should focus on teaching students to be honest and compassionate (38%) or on how to tell patients about mistakes (25%). The frequency of hospital admission or physician visits per year had no impact on any response pattern (ns with χ2 test). Conclusions: Regardless of health care utilization, a majority of respondents want full disclosure of medical error and wish to be informed of error immediately upon its detection. Respondents support reporting of errors to government agencies, the state medical board, and hospital committees focused on patient safety. Teaching physicians error disclosure techniques, honesty, and compassion were endorsed as a priority for educators who teach error management.
Drug Interactions in At‐risk Emergency Department Patients
Authors: Gaddis Gary M. , Holt Todd R. , Woods Mark
Published: November 2002

Objectives: Many emergency department (ED) patients are at risk for drug interactions (DIs) because they are elders, and/or they have chronic illnesses requiring treatment with multiple medications. In the ED, medications may be added to complex treatment regimens without the benefit of screening for DIs. Emergency physicians may therefore cause DIs, or miss the opportunity to intervene against a pre‐existing DI. Prior studies are contradictory regarding whether DIs are more likely to be due to medications administered or prescribed in the ED or medications prescribed elsewhere. Screening for DIs using computer software, such as that done by retail pharmacies, is now a standard of practice, and is done more frequently than when these other DI studies were reported during the previous decade. The authors monitored DIs among a focused, at‐risk outpatient ED population, to test the hypothesis that ED‐induced DIs have become the most common DIs in this population‐at‐risk. Methods: A retrospective convenience sample of 200 at‐risk patients seen at a tertiary teaching hospital on selected dates of service was analyzed. Eligible patients were ED outpatients aged 60 years or more taking three or more medications, or any age taking five or more medications. Micromedex Drug‐Reax software identified DIs. DIs had to represent “major” or “minor” severity, and have “excellent” or “good” literature documentation, to be scored as positive. Pre‐existing versus ED‐induced DIs were compared by chi‐square. DIs were stratified by patient age and by number and type of medications taken. Results: The 200 outpatients (125 female, 75 male) had a mean age (±SD) of 64.5 (±17.6) years and were taking an average of 7.2 medications. Seventy‐nine pre‐existing DIs were noted, occurring in 50 of the 200 patients studied. One hundred forty patients received a new medication during their ED visit. Seven new DIs (one in each of seven patients) occurred among these 140 patients. DIs were less frequently caused by medications added during the ED visit (χ2= 22.2, p < 0.001). Digoxin and warfarin were the sources of the greatest number of DIs. Conclusions: ED outpatients in the at‐risk group frequently present with pre‐existing DIs. Medications initiated in the ED are a less frequent cause of DI in this group. Medication screening during an ED visit could complement the role of outpatient pharmacies and potentially improve ED patient safety. DIs are most frequently due to digoxin and warfarin in these patients.
The Effect of Computer‐assisted Prescription Writing on Emergency Department Prescription Errors
Authors: Bizovi Kenneth E. , Beckley Brandon E. , McDade Michelle C. , Adams Annette L. , Lowe Robert A. , Zechnich Andrew D. , Hedges Jerris R.
Published: November 2002

Objective: To determine whether computer‐assisted prescription writing reduces the frequency of prescription errors in the emergency department (ED). Methods: A pre—post retrospective analysis was used to compare errors between handwritten (HW) and computer‐assisted (CA) ED prescriptions. Prescriptions were reviewed for pharmacist clarifications. A clarification was defined as an error if missing information, incorrect information, incorrect dose, non‐formulary medication, or illegibility was the reason for clarification. The HW and CA error rates were compared using odds ratios (ORs) with 95% confidence intervals (95% CIs). Results: During the pre‐intervention period, there were 7,036 patient visits with 2,326 HW ED prescriptions filled for 1,459 patients. There were 91 clarifications, with a rate of 3.9%. There were 54 HW errors, for an error rate of 2.3%. During the post‐intervention period, there were 7,845 patient visits with 1,594 CA prescriptions filled for 1,056 patients. There were 13 clarifications, with a clarification rate of 0.8%, and 11 errors, for a CA error rate of 0.7%. The CA prescriptions were substantially less likely to contain an error [OR 0.31 (95% CI = 0.10 to 0.36)] or to require pharmacist clarification [OR 0.19 (95% CI = 0.10 to 0.36)] than were the HW prescriptions. Conclusions: Computer‐assisted prescriptions were more than three times less likely to contain errors and five times less likely to require pharmacist clarification than handwritten prescriptions.
Measuring the Quality of Hospital‐based Domestic Violence Programs
Authors: Coben Jeffrey H.
Published: November 2002

Objective: To obtain consensus among a panel of experts on performance measures useful for evaluating the quality of hospital‐based domestic violence (DV) programs. Methods: The Delphi process of consensus development was used with a panel of 18 experts including DV researchers, program planners, and advocates. Three rounds were conducted over a period of six months, with each round involving the completion of a written questionnaire. Panelists were instructed to concentrate on structure and process measures of DV program performance. Health outcome measures were not considered. During each round, panelists rated (scale of 1‐5) their level of agreement with each measure, in terms of the measure's usefulness for evaluating hospital‐based DV programs. Data were entered into SPSS on a personal computer and frequency distributions, measures of central tendency, and variance were computed for each measure. Consensus development was defined as a reduction in the item‐specific variance from one round to the next. Results: A total of 37 performance measures were agreed upon. These measures fell within nine different domains of DV program activities, including: Policies and Procedures, Hospital Physical Environment, Hospital Cultural Environment, Training of Providers, Screening and Safety Assessment, Documentation, Intervention Services, Evaluation Activities, and Collaboration. Conclusions: A number of measures have been identified as useful for evaluating hospital‐based DV programs. Use of these measures should assist researchers, program planners, and administrators in assessing the quality of hospital‐based DV programs.
Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias
Authors: Croskerry Pat
Published: November 2002

Clinical decision making is a cornerstone of high‐quality care in emergency medicine. The density of decision making is unusually high in this unique milieu, and a combination of strategies has necessarily evolved to manage the load. In addition to the traditional hypothetico‐deductive method, emergency physicians use several other approaches, principal among which are heuristics. These cognitive short‐cutting strategies are especially adaptive under the time and resource limitations that prevail in many emergency departments (EDs), but occasionally they fail. When they do, we refer to them as cognitive errors. They are costly but highly preventable. It is important that emergency physicians be aware of the nature and extent of these heuristics and biases, or cognitive dispositions to respond (CDRs). Thirty are catalogued in this article, together with descriptions of their properties as well as the impact they have on clinical decision making in the ED. Strategies are delineated in each case, to minimize their occurrence. Detection and recognition of these cognitive phenomena are a first step in achieving cognitive de‐biasing to improve clinical decision making in the ED.
Patient Care Competency in Emergency Medicine Graduate Medical Education: Results of a Consensus Group on Patient Care
Authors: King Randall W. , Schiavone Frederick , Counselman Francis L. , Panacek Edward A.
Published: November 2002

“Patient Care” is the first listed core competency of the six new core competencies recently formulated by the Accreditation Council for Graduate Medical Education (ACGME) and, arguably, the most important. To assist emergency medicine (EM) program directors in incorporating and assessing this competency, the Council of Emergency Medicine Residency Directors (CORD‐EM) held a consensus conference in March 2002. Definitions of this competency were generated that are specific for the training of practitioners in EM. These built upon the ACGME base definition, but include elements unique to or critically important in EM. In addition, all of the ACGME assessment tools were examined and prioritized for use in assessing the competency of EM residents in the area of patient care. Suggestions for an implementation process are also described.
Application of the Medical Knowledge General Competency to Emergency Medicine
Authors: Wagner Mary Jo , Thomas Harold A.
Published: November 2002

In February 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified six general competencies as the basic educational goals required by all training programs for their residents. This places emphasis on educational outcome assessment in residency programs and in the accreditation process. A concomitant goal is to have increasingly valid, reliable assessments of the ability of a resident physician to provide safe, evidenced‐based, humanistic medical care to their patients. To better define these competencies for the specialty of emergency medicine (EM), the Council of Emergency Medicine Residency Directors (CORD‐EM) held a consensus conference in March 2002. This article reports the results of the Consensus Group for the core competency area of medical knowledge. This competency is already being well addressed in residency programs, but there has been inadequate documentation of a resident's knowledge base. The Consensus Group focused on many assessment methods to determine those having the best potential for use in EM programs. Assessment methods felt to be most appropriate for assessment of the medical knowledge base of a resident are presented, as are practical suggestions for incorporating these into EM programs.
Definitions and Competencies for Practice‐based Learning and Improvement
Authors: Hayden Stephen R. , Dufel Susan , Shih Richard
Published: November 2002

The Outcome Project is a long‐term initiative by which the Accreditation Council for Graduate Medical Education (ACGME) is increasing emphasis on educational outcomes in the evaluation of residency programs. The ACGME initiated the Outcome Project to “ensure and improve the quality of graduate medical education.” In order to assist program directors in emergency medicine (EM) to begin complying with components of the ACGME Outcome Project, the Council of Residency Directors in Emergency Medicine (CORD‐EM) convened a consensus conference in March 2002 in conjunction with several other EM organizations. The working group for the competency of Practice‐based Learning and Improvement (PBL) defined the components of PBL as: 1) analyze and assess practice experience and perform practice‐based improvement; 2) locate, appraise, and utilize scientific evidence related to the patient's health problems and the larger population from which they are drawn; 3) apply knowledge of study design and statistical methods to critically appraise the medical literature; 4) utilize information technology to enhance personal education and improve patient care; and 5) facilitate the learning of students, colleagues, and other health care professionals in EM principles and practice. Establishing resident portfolios is a preferred method to chronicle resident competence in PBL. Traditional global evaluation of resident performance is de‐emphasized. Checklist evaluation is appropriate for assessing any competency that can be broken down into specific behaviors or actions. 360‐degree evaluation may be used to assess teamwork, communication skills, management skills, and clinical decision making. Chart‐stimulated recall and record review are additional evaluation methods that can be used to assess resident competency in PBL. Simulations and models, such as computer‐based scenarios, may be ideal for low‐frequency but critical procedures.
Assessment of Communication and Interpersonal Skills Competencies
Authors: Hobgood Cherri D. , Riviello Ralph J. , Jouriles Nicholas , Hamilton Glen
Published: November 2002

Excellent communication and interpersonal (C‐IP) skills are a universal requirement for a well‐rounded emergency physician. This requirement for C‐IP skill excellence is a direct outgrowth of the expectations of our patients and a prerequisite to working in the increasingly complex emergency department environment. Directed education and assessment of C‐IP skills are critical components of all emergency medicine (EM) training programs and now are a requirement of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. In keeping with its mission to improve the quality of EM education and in response to the ACGME Outcome Project, the Council of Emergency Medicine Residency Directors (CORD‐EM) hosted a consensus conference focusing on the application of the six core competencies to EM. The objective of this article is to report the results of this consensus conference as it relates to the C‐IP competency. There were four primary goals: 1) define the C‐IP skills competency for EM, 2) define the assessment methods currently used in other specialties, 3) identify the methods suggested by the ACGME for use in C‐IP skills, and 4) analyze the applicability of these assessment techniques to EM. Ten specific communication competencies are defined for EM. Assessment techniques for evaluation of these C‐IP competencies and a timeline for implementation are also defined. Standardized patients and direct observation were identified as the criterion standard assessment methods of C‐IP skills; however, other methods for assessment are also discussed.
Systems‐Based Practice: The Sixth Core Competency
Authors: Dyne Pamela L. , Strauss Robert W. , Rinnert Stephan
Published: November 2002

Systems‐Based Practice (SBP) is the sixth competency defined by the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. Specifically, SBP requires “Residents [to] demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.” This competency can be divided into four subcompetencies, all of which are integral to training emergency medicine (EM) physicians: resources, providers, and systems; cost‐appropriate care; delivery systems; and patient advocacy. In March 2002, the Council of Emergency Medicine Residency Directors (CORD‐EM) convened a consensus conference to assist residency directors in modifying the SBP competency specific for EM. The Consensus Group modified the broad ACGME definition for SBP into EM‐specific goals and objectives for residency training in SBP. The primary assessment methods from the Toolbox of Assessment Methods were also identified for SBP. They are direct observation, global ratings, 360‐degree evaluations, portfolio assessment, and testing by both oral and written exams. The physician tasks from the Model of the Clinical Practice of Emergency Medicine that are most relevant to SBP are out‐of‐hospital care, modifying factors, legal/professional issues, diagnostic studies, consultation and disposition, prevention and education, multitasking, and team management. Suggested EM residency curriculum components for SBP are already in place in most residency programs, so no additional resources would be required for their implementation. These include: emergency medical services and administrative rotations, directed reading, various interdisciplinary and hospital committee participation, continuous quality improvement project participation, evidence‐based medicine instruction, and various didactic experiences, including follow‐up, interdisciplinary, and case conferences. With appropriate integration and evaluation of this competency into training programs, it is likely that future generations of physicians and patients will reap the benefits of an educational system that is based on well‐defined outcomes and a more systemic view of health care.