bluuebunny/crossref_metadata_2025 huggingface dataset:
Effectiveness of an Organized Follow‐up System for Elder Patients Released from the Emergency Department
Authors: Jones Jeffrey S. , Young Michael S. , LaFleur Robert A. , Brown Michael D.
Published: September 2008

Objectives: To determine whether an effective telephone callback system can be successfully implemented in a busy ED and to quantify the benefits that can be obtained related to the follow‐up care of elder patients.

Methods: This was a prospective, cohort study conducted at a community teaching hospital during a 6‐month period. Consecutive patients ≥60 years old and released from the ED were selected for telephone follow‐up. Calls were made by a research nurse within 72 hours after the patient's ED visit. Follow‐up information included current medical status, problems encountered during the ED visit, compliance, and impact of the illness on self‐care capabilities.

Results: Seventy‐nine percent (831/1,048) of the patients selected for telephone follow‐up were successfully contacted. The calls lasted an average of 4 ± 2.5 minutes. Although 94% (778/831) of these patients had a regular physician, 14% failed to make their recommended follow‐up arrangements. Compliance was significantly improved when a follow‐up physician was contacted during the patient's ED visit. Approximately 96% of the patients were either satisfied or very satisfied with their ED care. However, 13% (109/831) had moderate deterioration in their ability to care for themselves. Of the patients contacted, 333 (40%) required further clarification of their home care instructions, 31 were advised to return to the ED for reevaluation, and 26 were referred to a medical social worker for psychosocial concerns.

Conclusion: A telephone callback system is a feasible and effective method to improve follow‐up care of elder patients released from the ED.
Implementation of a Hypertext‐based Curriculum for Emergency Medicine on the World Wide Web
Authors: Savitt Daniel L. , Steele Dale W.
Published: September 2008

This project reports the publication of a variety of existing curricular resources for emergency medicine on the global Internet in a format that allows hypertext links between related material, timely updates, and end‐user feedback. Curricular elements were converted to Hypertext Markup Language with extensive links between related content. The completed document contains instructions for curriculum development, specific curricula for subspecialty areas within a residency, reading lists for subspecialty curricula, banks of images, and board‐type questions with answers. Users are provided with a mechanism to provide immediate feedback to section editors with suggestions for changes, including new references. Access to all or part of the document can be controlled via passwords, but is potentially available to anyone with an Internet connection and a World Wide Web browser. The document may be viewed on the World Wide Web at: http:www.brown.eduAdministrationEmergency‐Medicinecurr.html
Evaluation of Pre‐ and Posttreatment Pulse Oximetry in Acute Childhood Asthma
Authors: Wright Robert O. , Santucci Karen A. , Jay Gregory D. , Steele Dale W.
Published: September 2008

Objectives: To evaluate the utility of pre‐ and posttreatment O2 saturation (SpO2) for prediction of admission or relapse after ED release in acute asthma exacerbations using a standardized treatment protocol.

Design: A prospective, double‐blind, observational study was performed at a pediatric ED. Children with acute asthma were enrolled upon ED presentation. SpO2 was measured prior to treatment and after disposition decision. Two experienced physicians determined disposition based on history and physical examination alone, while blinded to SpO2. Relapse of released patients was determined by telephone follow‐up.

Results: A pretreatment room‐air SpO2 of ≤91% had a sensitivity of 0.24, a specificity of 0.86, and a likelihood ratio of 1.77 to predict admission/relapse. A posttreatment room‐air SpO2 of ≤91% had a sensitivity of 0.34, a specificity of 0.98, and a likelihood ratio of 16.43 to predict admission/relapse.

Conclusions: As opposed to some previous studies, this study found pretreatment SpO2 to be a relatively poor predictor of admission. A posttreatment SpO2 of ≤91% occurred in a minority (32%) of patients, but increased the odds of admission 16‐fold and may be used as an adjunct to objectively confirm the need for admission.
Medical Clearance and Screening of Psychiatric Patients in the Emergency Department
Authors: Olshaker Jonathan S. , Browne Brian , Jerrard David A. , Prendergast Heather , Stair Thomas O.
Published: September 2008

Objectives: To study the frequency of medical complaints and need for routine ED medical, laboratory, and toxicologic clearance for patients presenting with psychiatric chief complaints.

Methods: A retrospective, observational analysis of psychiatric patients seen in an urban teaching hospital ED over a 2‐month period was performed. The individual sensitivities of history, physical examination, vital signs, and complete blood counts and chemistry panels for identifying medical problems were determined. The sensitivities and predictive values of patient self‐reporting of recent illicit drug and ethanol use were also determined.

Results: 352 patients were seen with psychiatric chief complaints. A complete data set was available for 345 patients (98%). Of those with complete data, 65 (19%) had medical problems of any type. History, physical examination, vital signs, and laboratory testing had sensitivities of 94%, 51%, 17%, and 20%, respectively, for identifying these medical problems. Screening without universal laboratory testing would have missed 2 asymptomatic patients with mild hypokalemia. Patient self‐reporting had a 92% sensitivity, a 91% specificity, an 88% positive predictive value (PPV), and a 94% negative predictive value (NPV) for identifying those with a positive drug screen, and a 96% sensitivity, an 87% specificity, a 73% PPV, and a 98% NPV for identifying those with a positive ethanol level.

Conclusion: The vast majority of medical problems and substance abuse in ED psychiatric patients can be identified by initial vital signs and a basic history and physical examination. Universal laboratory and toxicologic screening of all patients with psychiatric complaints is of low yield.
Comparison of Patient Satisfaction and Practitioner Satisfaction with Wound Appearance after Traumatic Wound Repair
Authors: Singer Adam J. , Church Adam L. , Forrestal Kerry , Werblud Marc , Valentine Sharon M. , Hollander Judd E.
Published: September 2008

Introduction: Existing cosmetic scales for wounds are based only on practitioners' evaluations. They have not been validated using the patient's assessment.

Objective: To validate a previously developed wound cosmesis scale by determining the relationship between patient and practitioner assessments of cosmetic outcome following traumatic wound repair. Methods: A convenience sample of patients with lacerations repaired in an ED were evaluated at the time of suture removal. Practitioners assigned 0 or 1 point each for the presence or absence of a step‐off of borders; contour irregularities; margin separation; edge inversion; excessive distortion; and overall appearance. A total cosmetic score was calculated by adding the categories above. As previously defined, a score of 6 was considered optimal; < s6 was considered “suboptimal.” Patients, blinded to the physician score, assessed their degrees of satisfaction with the cosmetic outcome of the wounds using a 100‐mm visual analog scale (VAS). Because VAS scores were not normally distributed, practitioner scores were compared with patient satisfaction scores using a Mann‐Whitney U test.

Results: 125 patients were enrolled, of whom 64% were male; the median age was 19.5 years (interquartile range = 8–33 years). Wounds were located predominantly on the face, scalp, or neck (47%) and upper extremity (35%), and had a median length of 2 cm. The 86 lacerations given optimal practitioner scores had a median patient satisfaction score of 97 mm; the 39 “suboptimal” lacerations had a median patient satisfaction score of 87 mm (p = 0.0006).

Conclusion: Lacerations that practitioners ponsidered to have optimal cosmetic appearances at the time of suture removal received higher patient satisfaction scores than did lacerations considered to be suboptimal. This provides a measure of validity to this 6‐item categorical cosmetic scale.
Respiratory Isolation of Patients with Suspected Pulmonary Tuberculosis in an Inner‐city Hospital
Authors: Gaeta Theodore J. , Webheh Webheh , Yazji Monzir , Ahmed Javid , Yap Wilson
Published: September 2008

Objective: To identify clinical factors that predict which patients presenting to the ED with pneumonia will require respiratory isolation for suspected tuberculosis and to evaluate a protocol for rapid identification of patients at risk for pulmonary tuberculosis (PTB).

Methods: To identify potential clinical indicators of PTB, a case‐control study was performed using patients admitted to an urban teaching hospital with the ED diagnosis of pneumonia (derivation sample). These predictors were then evaluated in a separate prospective observational study of 103 patients admitted to the same institution from July 1994 to February 1995. Adult patients with the admitting diagnosis of pneumonia were admitted to a respiratory isolation bed if they met 1 of the following criteria: 1) HIV‐positive or unknown HIV status with a history of injection drug use; 2) chest x‐ray consistent with PTB; or 3) pneumonia with 1 of the following: PPD conversion within 2 years, recent exposure to PTB, previous PTB, or hemoptysis. Patients who did not meet isolation criteria were admitted to the medical ward and had a PPD and anergy panel placed. Those who were anergic or PPD‐positive were transferred to respiratory isolation. Results: Predictor variables identified during the first study phase were incorporated into the isolation guidelines noted above. Only 36 of 50 (72%) PTB patients were admitted to an isolation bed during this phase. During the second phase, 103 patients were admitted with the ED diagnosis of pneumonia‐rule out PTB; 22 patients (22%) were culture‐confirmed positive for PTB. The guidelines predicted PTB as follows: sensitivity, 0.96 (95% CI, 0.88–1.0); specificity, 0.14 (95% CI, 0.08–0.24); positive predictive value, 0.23 (95% CI, 0.17–0.35); and negative predictive value, 0.92 (95% CI, 0.77–1.0). The 1 patient who was not isolated was found to be anergic after 48 hours and subsequently isolated.

Conclusion: Respiratory isolation guidelines for patients admitted from the ED with pneumonia were developed and validated. These guidelines provide satisfactory guidance for isolation of patients at risk for PTB in a high‐PTB‐prevalence population.
Statistical Methodology: II. Reliability and Validity Assessment in Study Design, Part B
Authors: Karros David J.
Published: September 2008

SUMMARY

Validity measures the correspondence between a test and other purported measures of the same or similar qualities. When a reference standard exists, a criterion‐based validity coefficient can be calculated. If no such standard is available, the concepts of content and construct validity may be used, but quantitative analysis may not be possible. The Pearson and Spearman tests of correlation are often used to assess the correspondence between tests, but do not account for measurement biases and may yield misleading results. Techniques that measure intertest differences may be more meaningful in validity assessment, and the κ statistic is useful for analyzing categorical variables.

Questionnaires often can be designed to allow quantitative assessment of reliability and validity, although this may be difficult. Inclusion of homogeneous questions is necessary to assess reliability. Analysis is enhanced by using Likert scales or similar techniques that yield ordinal data. Validity assessment of questionnaires requires careful definition of the scope of the test and comparison with previously validated tools.
Toxic Ingestions in Pregnancy: Abortifacient Use in a Case Series of Pregnant Overdose Patients
Authors: Perrone Jeanmarie , Hoffman Robert S.
Published: September 2008

Objectives: To profile young, pregnant patients with an overdose reported to an urban poison center; and to characterize the ingestions and short‐term outcomes of these overdose patients.

Methods: A prospective, observational study of female overdose patients was performed from November 1, 1994, through March 31, 1995. Consecutive cases were identified from all calls to the regional poison center (annual call volume = 70,000) regarding intentional overdose in women between the ages of 12 and 30 years. Pregnancy tests were recommended by the poison center during the study period in female patients aged 12—30 years who presented to a health care facility (usually an urban ED) with an intentional overdose. Pregnant patients were then followed during their hospitalizations, and the results of toxicology studies and maternal and short‐term fetal outcomes were recorded.

Results: Pregnancy tests were obtained for 371 (32%) of 1,142 eligible patients. Of patients with pregnancy tests, 43 (11.6%) were pregnant. Although most cases were comparable to general adult intentional ingestions, 5 of the 43 pregnant patients ingested known abortifacients. Most pregnant patients (35/43, 81%) had toxicity at or below American Association of Poison Control Centers (AAPCC) criteria for minimal toxicity, and all patients recovered completely.

Conclusion: Pregnancy was a common finding in this sample of young, female, intentional overdose patients reported to our regional poison control center. Frequent use of abortifacients for toxic ingestions has not been previously reported. A pregnancy test should be obtained for all female patients of childbearing age with an intentional ingestion to address the potential association of the ingestion with an unanticipated or undesired pregnancy.
A Survey of Adolescents' Knowledge Regarding Toxicity of Over‐the‐counter Medications
Authors: Huott Michael A. , Storrow Alan B.
Published: September 2008

Objective: With prior research suggesting that up to 17% of adolescents believe that acetaminophen (APAP) cannot cause death at any dose, this study surveyed adolescents regarding their knowledge of over‐the‐counter (OTC) medication toxicity.

Methods: A convenience sample of 13‐ to 18‐year‐olds presenting to the acute care clinic or ED at 2 teaching hospitals were given a survey requesting demographic data and information regarding common OTC medications. The respondents were asked to identify those OTC medications found at home, those they thought poisonous or lethal when taken in overdose, and those they thought contain alcohol. They also were asked to indicate whether they ever had made a suicidal overdose gesture.

Results: There were 203 of 210 (96% response rate) surveys completed. Recognition of the potential for overdose lethality with specific OTC medications was limited: aspirin (63%), APAP (57%), antihistamines (46%), iron (24%), camphor (22%), methyl salicylate (21%), and bismuth subsalicylate (19%). Additionally, adolescents commonly believed many OTC medications generally considered nonlethal would be fatal in an overdose: ibuprofen (51%), decongestants (45%), guaifenesin (29%), mouthwash (25%), kaolin‐pectin (22%), antacids (21%), and vitamin C (12%). More than half of the respondents correctly identified agents that normally contain alcohol. Also, of the 5 respondents who previously made suicidal gestures, 4 indicated the ingested item could kill them, reflecting serious intent.

Conclusion: Surveyed adolescents possess poor knowledge of the lethal potential of OTC medications; the fact that many adolescents believe several of these OTC medications are benign is concerning. Emergency physicians should adjust their assessments of individual overdose patients' suicidal intents accordingly.
The Development and Evaluation of a Geriatric Emergency Medicine Curriculum
Authors: Witzke Donald B. , Sanders Arthur B. ,   for the SAEM Geriatric Emergency Medicine Task Force
Published: September 2008

Objective: To summarize the processes used to develop a curriculum and model of care for the emergency medical treatment of elder patients and to assess the efficacy of the teaching material in a pilot course.

Methods: A survey of emergency medicine (EM) residency directors and geriatric fellowship directors was used to identify key topics for inclusion in the didactic material. An interdisciplinary consensus process was used to develop didactic as well as teaching material in geriatric EM. Pretests and posttests were administered to 46 participants in the initial course to assess knowledge gain. Subjective course evaluations were also done.

Results: Test scores significantly increased from 54% correct on the pretest to 77% correct on the posttest (p < 0.001). Significant improvement in knowledge as judged by pretest and posttest results occurred in 6 of the 7 teaching modules. Subjective evaluations demonstrated good to excellent ratings for each module as well as the overall workshop.

Conclusions: The process of developing a curriculum for geriatric EM is described. The initial training of instructors was effective in improving participants' knowledge of geriatric issues in EM. Participants considered the training to be effective. The effect of the training on the emergency care of elder persons remains to be determined.
Academic Associate Program: Integrating Clinical Emergency Medicine Research with Undergraduate Education
Authors: Hollander Judd E. , Valentine Sharon M. , Brogan Gerard X.
Published: September 2008

An educational program that teaches undergraduate students about clinical research related to emergency medicine is described. The students work as research assistants within the ED, thus providing a departmental framework for the enrollment of patients in clinical studies. Volunteers interested in the program undergo a physical examination, vaccination history, and standard serologic testing, and sit through a formal blood and body fluid exposure course offered by the university prior to their clinical research participation. A didactic curriculum on clinical research concepts and course examinations is provided. Over the 4 years since the department established its departmental research goals and this educational program, the departmental publication rate has increased from 2 to 20 manuscripts. While there was only 1 faculty member with a research publication in 1992, there were 9 faculty with manuscripts accepted for publication in the first 6 months of 1996. Similarly, more nurses and ancillary staff have become involved in prospective clinical research. Much of this success is attributed to the novel use of resources through the academic associate program.
The Use of Antibiotics to Prevent Serious Sequelae in Children at Risk for Occult Bacteremia: A Meta‐analysis
Authors: Bulloch Blake , Craig William R. , Klassen Terry P.
Published: September 2008

Objective: To determine whether antibiotics prevent serious bacterial infections in children at risk for occult bacteremia.

Methods: Meta‐analysis of randomized controlled trials involving children aged 3 months to 36 months without a focus of infection and randomized into 2 treatment groups: 1) no antibiotic vs antibiotic or 2) IM ceftriaxone vs oral antibiotic.

Results: The use of either an oral antibiotic or IM ceftriaxone did trend toward a reduced risk of serious infection, although neither reached statistical significance (OR = 0. 60; 95% CI 0. 10, 3. 49; and OR = 0. 38; 95% CI 0. 12, 1. 17, respectively). It would be necessary to treat 414 patients to prevent 1 serious bacterial infection. When only children with proven occult bacteremia were analyzed, the use of IM ceftriaxone was statistically significant in preventing serious bacterial infections (OR = 0. 25; 95% CI 0. 07, 0. 89).

Conclusions: Clinical judgment should not be replaced by widespread antibiotic use in the approach to a child with fever. If rapid methods to identify children with occult bacteremia, such as polymerase chain reaction, could be improved and become widely available, then antibiotics could be used judiciously on initial visits. Antibiotic use in all children at risk for occult bacteremia implies the treatment of many children unlikely to benefit from such therapy.
Recurrent Near‐syncope with Flushing
Authors: Suchard Jeffrey R.
Published: September 2008

Episodic vasomotor instability with flushing is an uncommon presentation that is suggestive of an endocrine etiology. This report is the case of a 42‐year‐old woman who presented to the ED 5 times in a 2‐week period for recurrent, self‐limited episodes of light‐headedness associated with tachycardia, hypertension, and flushing. The patient's diagnosis eluded detection in both the outpatient and the inpatient settings for several months. The clinical diagnosis was ultimately confirmed by biochemical test samples obtained in the ED during a subsequent symptomatic event. The differential diagnosis of this patient's presentation includes pheochrom‐ocytoma, carcinoid syndrome, medullary thyroid carcinoma, systemic mastocytosis, and other endocrine and toxicologic diseases. ED management of the patient with transient yet significant vasomotor changes includes a workup for syncope, initiation of focused biochemical investigations, referral to the appropriate consultant, and consideration for admission.
Ankle Radiograph Utilization after Learning a Decision Rule: A 12‐month Follow‐up
Authors: Verbeek P. Richard , Stiell Ian G. , Hebert Guy , Sellens Cathy
Published: September 2008

Objective: To test whether the reduction in ankle radiograph ordering was sustained during a 12‐month period after a formal trial to introduce the Ottawa ankle rules

Methods: A before‐after clinical trial of ankle radiograph ordering practice was performed in a university‐based ED. All 1,884 (947 “during intervention,” 937 “postintervention”) adults seen with acute ankle injuries during 2 12‐month trial periods were evaluated. The behavioral intervention was the teaching of the Ottawa ankle rules and feedback of compliance with the rules during the intervention period. No further education about the ankle rules or feedback regarding compliance occurred during the postintervention year. Physicians were unaware of any postintervention surveillance. The primary outcome was the proportion of eligible patients referred for an ankle radiograph during the intervention and postintervention periods.

Results: During the intervention period (January 1‐December 31, 1993), the proportion of patients who received an ankle radiograph [609 x‐rayed of 947 patients seen (64.3%; 95% Cl 61.2–67.4%)] did not differ from the proportion who received an x‐ray in the postintervention period (January 1‐December 31, 1994) [583 x‐rayed of 937 patients seen (62.2%; 95% Cl 59.1–65.3%), p = 0.65, power > 0.80 to detect a 10% increase in the radiograph ordering rate]. There was also no difference in the radiograph ordering rate in the first 3 months of the postintervention period compared with the last 3 months of the postintervention period (68.8% vs 64.7%, respectively, p > 0.30).

Conclusions: Compliance with the Ottawa ankle rules was sustained during a 12‐month postintervention surveillance period when physicians did not know they were being observed. Physicians will continue to use a simple clinical guideline once it has been learned.
Effectiveness of Selective Use of Intravenous Pyelography in Patients Presenting to the Emergency Department with Ureteral Colic
Authors: Tasso Silvio R. , Shields Christopher P. , Rosenberg Carl R. , MD Diane M. Sixsmith. , Pang Dorothy S.
Published: September 2008

Objective: To determine whether IV pyelography (IVP) is required routinely for all patients presenting to the ED with ureteral colic.

Methods: A randomized prospective study was conducted with 2 patient groups—a routine IVP group, in which all patients underwent IVP, and a selective IVP group, in which patients were treated, observed, and released without undergoing IVP unless they experienced continued symptoms. The study was performed in a large university‐affiliated, community hospital ED. Participants were patients aged 18–65 years with signs and symptoms consistent with ureteral colic.

Results: Among the 40 patients enrolled in the routine IVP group, 26 had positive studies, 8 of which necessitated hospitalization. Among the 41 patients randomized to the selective IVP group, there were only 19 IVPs performed, of which 6 were positive and 4 necessitated hospitalization. Compared with the routine IVP group, there were 54% fewer FVPs performed and a 51 % lower admission rate in the selective IVP group.

Despite the fact that fewer IVPs were performed in the selective IVP group, clinical outcomes in the 2 groups were similar, without significant complication in either group.

Conclusions: IVPs do not need to be routinely performed for all patients presenting to the ED with ureteral colic. The decision to perform an IVP may be dictated by symptoms that persist after initial evaluation and treatment.
Failure of the Miller Criteria to Predict Significant Intracranial Injury in Patients with a Glasgow Coma Scale Score of 14 after Minor Head Trauma
Authors: Holmes James F. , Baier Mark E. , Derlet Robert W.
Published: September 2008

Objective: To determine the utility of the Miller criteria (presence of headache, nausea, vomiting, and signs of depressed skull fracture) for predicting the need for CT in patients with minor head trauma and a Glasgow Coma Scale score (GCS) of 14.

Methods: The study was a prospective, consecutive series of all patients undergoing head CT scans with a GCS of 14 following head trauma. A data sheet was completed for all patients prior to obtaining a head CT scan.

Results: 264 patients were entered into the study and 35 patients were found to have traumatic abnormalities on head CT scan. The use of the Miller criteria to select those patients who would require head CT scan would have resulted in missing 17 of the 35 abnormal scans, including 2 patients who required neurosurgical intervention. These 2 patients were markedly intoxicated upon presentation.

Conclusion: The use of the Miller criteria as the only criteria for screening patients with a GCS of 14 after minor head trauma who require a head CT scan is not recommended. While the authors have identified ethanol intoxication as one confounding factor, further refinement of this risk‐stratification tool is required.
Utility of Urine and Blood Cultures in Pyelonephritis
Authors: Thanassi Mark
Published: September 2008

Objective: To determine how often the results of urine and blood cultures led to changes in antibiotic therapy for patients discharged from the hospital with the diagnosis of pyelonephritis.

Methods: A retrospective chart review was performed of consecutively admitted patients, 10–90 years old, with an ICD‐9 discharge diagnosis of acute pyelonephritis. All patients were admitted to a university‐based, tertiary care center and a large HMO medical center from 1993 to 1994. The association of urine and blood culture results with a change in antibiotic therapy was assessed.

Results: Of the 194 patients who met inclusion criteria, 189 (97%) had urine cultures obtained at the time of admission and 139 (71%) had blood cultures obtained. Ampicillin, gentamicin, or both were given as initial antibiotics 81% of the time, and isolated organisms from urine or blood were sensitive to the empiric antibiotics 95% of the time. Most (171/189; 90%) urine cultures were positive, but only 9 (5%) of these led to a change in antibiotic therapy. 80% of the urinary pathogens were Escherichia coli, 5% Enterococcus, 5% Proteus, and 4% Klebsiella. Only 40 (29%) of the 139 blood cultures were positive; none prompted a change in antibiotics. There were no cases in which blood and urine cultures grew different pathogens.

Conclusions: Urine cultures are useful in directing antibiotic therapy in patients with the discharge diagnosis of acute pyelonephritis and support a change in therapy in 5% of cases. Among the patients in this study, blood culture results did not lead to changes in antibiotic therapy. These findings warrant prospective, mul‐ticenter evaluation.
Predictive Value of Letters of Recommendation vs Questionnaires for Emergency Medicine Resident Performance
Authors: Schaider Jeffrey J. , Rydman Robert J. , Greene Constance S.
Published: September 2008

Objective: To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program.

Methods: A retrospective association of LORs and PPQs with intraining resident performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the speciality of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings.

Results: Statistically, no differences were found between the LORs and PPQs in predicting resident performance.

Conclusions: PPQs may substitute for LORs in the evaluation of resident applicants.
Statistical Methodology: III. Receiver Operating Characteristic (ROC) Curves
Authors: Grzybowski Mary , Younger John G.
Published: September 2008

Measures including sensitivity, specificity, and positive and negative predictive values have been traditionally used to assess a diagnostic test's ability to detect the presence or absence of disease. Receiver operating characteristic (ROC) curve analysis allows visual evaluation of the trade‐offs between sensitivity and specificity associated with different values of the test result, or different “cutpoints” for defining a positive result. The purpose of this article is to define, construct, and interpret a ROC curve using a hypothetical example applicable to emergency medicine practice.
Response to Dopamine vs Norepinephrine in Tricyclic Antidepressant‐induced Hypotension
Authors: Tran T. Paul , Panacek Edward A. , Rhee Kenneth J. , Foulke Garrett E.
Published: September 2008

Objective: To compare the efficacy of dopamine (DA) with that of norepinephrine (NE) in the treatment of refractory hypotension caused by tricyclic antidepressants (TCAs).

Methods: A retrospective analysis was used to compare blood pressure responses in concurrent case series of patients treated with vasopressors for TCA‐associated hypotension. The patients were adults (aged ≥16 years) treated at 2 urban teaching hospitals from 1983 to 1994. All patients were diagnosed as having TCA ingestion (positive serum toxicologic assay), were hypotensive [systolic blood pressures (SBPs) ≤90 mm Hg], and required vasopressor therapy. The patients were grouped by initial vasopressor treatment (i.e., NE vs DA).

Results: There were 26 hypotensive adult patients who met study criteria. All 26 patients remained hypotensive after initial treatment of their TCA‐associated hypotension with crystalloid infusion and alkalinization. The NE and DA groups were similar in age, sex, and proportion of patients with single and co‐drug ingestion. The NE group, however, had a significantly lower average SBP at study entry (56 vs 74 mm Hg, p = 0.04). Nine of 15 (60%) patients responded to DA (5–10 μg/kg/min) and 11/11 (100%) patients responded to NE (5–53 μg/min). The difference in response rates was statistically significant (p = 0.02). Six patients in whom DA (max rate 10–50 μg/min/kg) failed to raise the SBP subsequently responded to NE (max rate 5–74 μg/ min) when this drug was later used. One patient receiving NE (12 μg/min) developed ventricular ectopy, successfully treated with lidocaine. There were no ischemic complications from either NE or DA. Patients who failed DA therapy tended to be older (39 vs 30 years, p = O.OS), to be more hypotensive at study entry (64 vs 81 mm Hg, p = 0.008), and to remain hypotensive even at higher doses of DA (24 vs 7 p, g/min/kg, p = 0.002).

Conclusion: While this was not a prospective randomized study, NE appears advantageous over DA as the first‐line vasopressor agent for those patients who require vasopressor support in the setting of TCA‐induced hypotension that is refractory to IV fluid and serum alkalinization.
Serial Creatine Kinase‐MB Results Are a Sensitive Indicator of Acute Myocardial Infarction in Chest Pain Patients with Nondiagnostic Electrocardiograms: The Second Emergency Medicine Cardiac Research Group Study
Authors: Young Gary P. , Gibler W. Brian , Hedges Jerris R. , Hoekstra James W. , Slovis Corey , Aghababian Richard , Smith Mark , Rubison Mike , Ellis Jack
Published: September 2008

Objective: To determine the test performance characteristics of serial creatine kinase‐MB (CK‐MB) mass measurements for acute myocardial infarction (MI) in patients presenting to the ED with chest pain and nondiagnostic ECGs.

Methods: A prospective, observational test performance study was conducted. Hemodynamically stable patients aged ≥25 years with chest discomfort, but without ECGs diagnostic for MI, were enrolled at 7 university teaching hospitals. Presenting ECGs showing >1‐mV ST‐segment elevation in ≥2 electrically contiguous leads were considered diagnostic for MI; patients with diagnostic ECGs on presentation were excluded. Real‐time, serial CK‐MB mass levels were obtained using a rapid serum immunochernical assay at the time of ED presentation (0‐hour) and 3 hours later (3‐hour). The following testing schemes were evaluated for their sensitivity and specificity for detection of MI during patient evaluation in the ED: 1) an elevated (≥8 ng/mL) presenting CK‐MB level; 2) an elevated presenting and/or 3‐hour CK‐MB level; 3) a significant increase (i.e., ≥3 ng/mL) within the range of normal limits for CK‐MB concentrations during the 3‐hour period (A CK‐MB); andor 4) development of ST‐segment elevation during the 3 hours (second ECG).

Results: Of the 1,042 patients enrolled, 777 (74.6%) were hospitalized, including all 67 MI patients (8.6% of admissions). As a function of duration of time in the ED, the test performance characteristics of serial CK‐MBs for MI (and cumulative data for the additional ECG) were:

0‐hour CK‐MB Plus 3‐hour CK‐MB Plus A CK‐MB Plus Second ECG

Sensitivity 38/67 = 57% 59/67 = 88% 62/67 = 93% 64/67 = 96%

(95% CI) (44–69%) (78–95%) (83–98%) (88–99%)

Specificity 9431976 = 97% 9351976 = 96% 9291976 = 95% 9311976 = 95%

(95% CI) (95–98%) (94–97%) (94–96%) (94–97%)

The 0‐hour to 3‐hour CK‐MB positive and negative predictive values were 52% to 55% and 96% to 99%, respectively. The sensitivities of serial CK‐MB results as a function of the interval following chest discomfort onset were:

Interval Since Onset Sensitivity (95% CI) Interval Since Onset Sensitivity (95% CI)

Less than 3 hours 38% (21–58%) 6 hours to 12 hours 92% (78–98%)

3 hours to 6 hours 75% (60–87%) More than 12 hours 100% (77–100%)

Conclusion: Serial CK‐MB monoclonal antibody mass measurements in the ED can identify MI patients with initially nondiagnostic ECGs. CK‐MB sensitivity significantly increases over 3 hours of observation of stable chest discomfort patients in the ED; it also increases as a function of the total interval from onset until enzyme measurement.
Termination of Nontraumatic Cardiac Arrest Resuscitative Efforts in the Field: A National Survey
Authors: Jaslow David , Barbera Joseph A. , Johnson Erik , Moore Wayne
Published: September 2008

Objectives: 1) To describe elements of adult nontraumatic cardiac arrest protocols in those U.S. cities in which resuscitative efforts are being terminated in the out‐of‐hospital setting. 2) To determine the prevalence and methods of on‐scene family grief counseling delivered in this setting.

Methods: Emergency medical services (EMS) systems in each of the 200 largest cities in the United States were surveyed by telephone regarding the content of their adult cardiac arrest protocols. Type of arrest (medical vs trauma), final dysrhythmia, termination policies, and presence or absence of a grief counseling protocol were recorded.

Results: All of the target population responded to the telephone survey. Most (135; 68%) EMS systems currently have written protocols that allow in‐field termination of resuscitative efforts for adult nontraumatic cardiac arrest patients who remain asystolic. Only 47 (24%) EMS systems allow cessation of efforts for patients without return of spontaneous circulation regardless of the dysrhythmia. Base station contact is required for authorization to end resuscitative efforts in 120/135 (89%) EMS systems. Only 26/135 (19%) EMS systems that cease efforts in the field have written policies concerning on‐scene family grief counseling. This counseling is most likely to be conducted by the out‐of‐hospital providers themselves.

Conclusion: Many U.S. urban EMS systems are terminating efforts for selected adult nontraumatic cardiac arrest patients, although few have written policies to address grief intervention for family members at the scene.
Lidocaine in the Treatment of Status Epilepticus
Authors: MD L. Anderson Walkes , Slovis Corey M.
Published: September 2008

Intravenous lidocaine has the potential to control seizures. This article reviews the available evidence related to lidocaine's efficacy and clarifies its potential role in the management of status epilepticus (SE). Although there are no large, double‐blind, placebo‐controlled studies of lidocaine's efficacy in SE, numerous case reports and case series support its use. Most of the reported cases involve patients who were refractory to multiple antiseizure medications. Additional support for lidocaine's efficacy in SE comes from the pediatric literature, where lidocaine has been very effective in controlling SE in neonates who have not responded to barbiturates. Initial lidocaine doses used to stop seizures have ranged from 1 to 3 mag. Most reports recommend a maintenance infusion of lidocaine after initial termination of SE, and a continuous infusion is almost universally recommended for neonates. Toxicity from a 1.5–2.0 mgkg dose of lidocaine for the control of SE is rare; the authors found only 1 case of a possible side effect at that dose. The article provides a 5‐step approach to treating SE that includes lidocaine.
Low‐carbohydrate (low & high‐fat) versus high‐carbohydrate low‐fat diets in the treatment of obesity in adolescents
Authors: Demol S , Yackobovitch‐Gavan M , Shalitin S , Nagelberg N , Gillon‐Keren M , Phillip M
Published: September 2008

Aim: To compare the impact of low‐carbohydrate diets of different fat content to high‐carbohydrate low‐fat diet on weight and metabolic parameters in obese adolescents.

Methods: Fifty‐five patients aged 12–18 years with a body mass index (BMI) above the 95th percentile were randomly allocated to one of three isoenergetic diet regimens. Anthropometric and metabolic measurements were taken after overnight fast, at baseline, after the 12‐week intervention and after nine month of follow‐up.

Results: No significant differences were found among the groups in changes in BMI, BMI‐percentile, fat percentage, or metabolic markers at the end of the intervention and at the end of follow‐up. Insulin level and homeostasis model assessment (HOMA) level decreased significantly at both time points only in the two low carbohydrate diet groups.

Conclusion: All diet regimens are associated with a significant reduction in BMI and improvement of some metabolic parameters in obese adolescents. Low‐carbohydrate diets apparently have no advantage over high‐carbohydrate low‐fat diets. The significant drop in insulin level and HOMA in the low carbohydrate diet groups is noteworthy given the increasing frequency of type‐2 diabetes as part of metabolic syndrome in children and youth. The impact of low carbohydrate diets in obese and insulin‐resistant youth warrants further investigation.
Epigenetic Changes in Cancer as Potential Targets for Prophylaxis and Maintenance Therapy
Authors: Grønbæk Kirsten , Treppendahl Marianne , Asmar Fazila , Guldberg Per
Published: September 2008

Abstract:  Epigenetic silencing of gene transcription by methylation of DNA or modification of histones is a key event in neoplastic initiation and progression. Alterations of the epigenome have been identified in virtually all types of cancer and involve multiple genes and molecular pathways. Recent studies have suggested that epigenetic gene inactivation may represent the first step in tumorigenesis, possibly by affecting the normal differentiation of stem cells and by predisposing these cells to additional oncogenic insults. The mechanisms that drive epigenetic silencing in pre‐malignant cells are still unknown, but may reflect simple stochastic events that are beneficial to cancer precursor cells. It is now well established that epigenetically silenced genes may be reactivated pharmacologically. Some inhibitors of DNA methyltransferases (5‐aza‐cytidine and 5‐aza‐2′‐deoxycytidine) or histone deacetylases (vorinostat) have been approved for clinical use by the US Food and Drug Administration and have reached clinical phase III trials elsewhere. The prospect that epigenetic alterations may play an essential role in renewing and maintaining the malignant clone has opened up new perspectives for the use of epigenetic therapy in cancer prevention and maintenance.
A Preliminary Study of the Temporal and Spatial Biomass Patterns of Herbaceous Vegetation Consumed by Mountain Gorillas in an Afromontane Rain Forest
Authors: Ganas Jessica , Nkurunungi John Bosco , Robbins Martha M.
Published: September 2008

Although many animal species consume herbaceous vegetation found in African tropical forests, little is known of the temporal and spatial availability of these plants. From September 2004 to August 2005 we conducted a study that quantified the temporal and spatial biomass availability of 20 species of herbs frequently consumed by endangered mountain gorillas at two locations (Buhoma and Ruhija) in Bwindi Impenetrable National Park, Uganda. In general, the biomass of herbs varied over the study period, but these changes were relatively small. For 12 of 18 and nine of 11 species in Buhoma and Ruhija, respectively, herb biomass differed significantly among habitat types. Of the nine species found in both locations, seven species had a higher biomass at Ruhija, one species had a higher biomass at Buhoma, and one species showed no difference. These results demonstrate that herb biomass varied little temporally but spatial differences in herb biomass were more pronounced. Future studies should investigate the variables that may influence herb phenological patterns such as rainfall, light, soil quality, previous disturbance regimes, and animal foraging and trampling damage.
Ulrich Zwingli
Authors: Opitz Peter
Published: September 2008

Ulrich Zwingli1 can be called the father of Reformed Protestantism, which has its historical origins in Zurich. Zwingli's role as a reformer was deeply influenced by his already developed humanist values, integrating them into his reformation theology. Although his final development into a reformer and the Zurich Reformation could hardly be imagined without Luther and the events around the ‘Luther‐Affair’, Zwingli represents an independent form of reformation theology. Different perspectives, which have their origin in different biographical roots and circumstances, play a role here. Although Reformed Protestantism was later equated with ‘Calvinism’, it owes its fundamental design to a considerable degree to the Zurich reformer.
Interrenal, Thyroidal, and Carbohydrate Responses of Rainbow Trout (Salmo gairdneri) to Environmental Acidification
Authors: Brown S. B. , Eales J. G. , Evans R. E. , Hara Toshiaki J.
Published: September 2008

Exposure to acid-treated water (H2SO4, pH 6.0–4.2) for 21 d altered interrenal and thyroid function in immature rainbow trout, Salmo gairdneri. At a pH < 5.2 plasma Cortisol increased, implying sustained interrenai Cortisol release. Interrenal histology showed hyperplasia and elevated nuclear diameter at pH 4.7. Eight days of acid exposure (pH 4.7) were required to raise plasma Cortisol significantly. At a pH < 4.7 the ratio of plasma T4(L-thyroxine) to T3(3,5,3′-triiodo-L-thyronine) tended to increase in relation to the controls. Depending on the experiment, this was due to either a significant elevation in plasma T4or a decrease in plasma T3. No histological changes were evident in the thyroid of acid-treated trout. Eight days of acid exposure (pH 4.7) were required to depress plasma T3. Coincidental with higher interrenal activity, plasma glucose was elevated in acid-treated fish (pH < 5.2) after 4 d of exposure. The possible relationships of the endocrinde changes to accompanying acid-induced elevations in plasma glucose and protein and hepatocyte histochemistry are considered, and their possible roles as indices of acid stress are discussed.
Lake Mixing and Its Relationship to Epilimnetic Phosphorus in Shagawa Lake, Minnesota
Authors: Stauffer Robert E. , Armstrong David E.
Published: September 2008

Using thermometry, the mixing regime was intensively studied in each of the two principal basins of Shagawa Lake. After the thermocline had migrated past the interbasin sill depth (6 m), it migrated more rapidly in the larger, windswept western basin than in the smaller, sheltered eastern basin. The metalimnetic eddy conductivities (Kz) were also larger in the west basin, ranging from 0.025 cm2∙s−1 during intervals of low wind energy up to 0.25 cm2∙s−1 during intervals bracketing powerful cold fronts. The bottom temperature increased rapidly in the west basin in response to mixing, reducing total water column stability and increasing susceptibility to a sudden "turnover." Because of these warm bottom temperatures and drainage basin influence, density currents sometimes carry cold water into the benthic zone of the west basin following heavy, cold rains in midsummer. Epilimnetic phosphorus concentrations in Shagawa Lake depend on linkages among weather, basin morphometry, and water column redox. Time series analysis of 8 yr of record reveals the special importance of two factors. First, the anoxic zone below the mixed layer must include an important fraction of the metalimnetic shelf sediments in the western basin (6–10 m zone). Second, the mixed layer must migrate downward and directly entrain water overlying the anoxic sediments. Time series analysis excludes the possibility of sediment release of phosphorus within the epilimnetic zone as the principal control on phosphorus in the pelagic mixed layer. For lakes with similar morphometry and climatic setting, and a previous history of sewage inputs, lake mixing complicates the trophic adjustment of the lake to a reduction in external phosphorus loading.