bluuebunny/crossref_metadata_2025 huggingface dataset:
Waste paper
Authors: Appleby Louis
Published: September 2002

One of my favourite publications does not even appear on my curriculum vitae because I am not sure how to classify it. It is a photograph of two of my research staff standing beside floor-to-ceiling piles of paper – all the forms that now have to be completed for a local ethics committee before you can get started on a national study. After the butter mountain and the wine lake, it is the paper avalanche.
Psychiatry in post-apartheid Namibia: a troubled legacy
Authors: Feinstein Anthony
Published: September 2002

I recently spent 6 months in Namibia as a Fellow of the John Simon Guggenheim Foundation. The purpose of my visit was twofold: the establishment of a database for trauma-related mental health disorders and the development of a validated, self-report screening instrument for mental illness. In the process, I was able to meet with Namibian colleagues and visit a number of health care centres in the country. This article will focus on my impressions of psychiatry in Namibia that were formed during my visit. A brief summary of Namibian history, in particular the country's relations with neighbouring South Africa, will help place my observations in a more meaningful context.
The research day: a suitable case for treatment?
Authors: Vassilas C. , Tadros G. , Day E.
Published: September 2002

Aims and Method

The research day accounts for 20% of time spent in higher training in psychiatry. We sought the views of both trainers and trainees through a postal questionnaire.

Results

Twenty-six schemes were identified nationally and replies were received from 93% of programme directors and 77% of specialist registrar peer group representatives. Only 38% of programme directors and 30% of trainees agreed with the statement that ‘specialist registrars use the research day satisfactorily’. Forty-six per cent of programme directors believed that the research day should be abolished in its present form.

Clinical Implications

This survey confirms widespread concern with the way that the research day is organised. We make some suggestions as to how it could be developed into a more effective part of the training process.
The 17 August 1999 Kocaeli (İzmit) Earthquake: Historical Records and Seismic Culture
Authors: Homan Jacqueline , Eastwood Warren J.
Published: September 2002

The 17 August 1999 İzmit, Turkey, earthquake (M∼7.4) was the latest in a long series of large seismic events to occur along the North Anatolian Fault Zone. The detailed recording of earthquakes in the İzmit region, from anti-quity to recent times, has allowed a unique archive to be developed that is invaluable to present day seismologists. Additionally, historical building practices, in particular the incorporation of the hatıl or ringbeam, indicate that adaptations to earthquakes in the form of seismic cultures were present in Turkey during Byzantine and Ottoman times and can be re-evaluated in relation to contemporary building practices. This is particularly important with respect to the potential threat now facing the population of İstanbul, a large proportion of which are in a highly vulnerable position. This paper suggests that “experts” use this seismic knowledge to produce a meaningful account of earthquake hazard for local people in order to reduce marginalization in case of a future event.
Flexural-Shear Behavior of High-Strength Concrete Short Columns
Authors: Martirossyan Armen , Xiao Yan
Published: September 2002

This paper discusses the seismic performance of high-strength concrete columns. The research is a part of an ongoing comprehensive experimental program to investigate seismic design methods of high-strength concrete structures. The first stage of the program involved testing of fifteen high-strength concrete stub columns under concentric axial compression. The concrete compressive strength was about 69 MPa (10,000 psi). In addition, a large database including eighty-six similar tests conducted by other researchers was constructed, and stress-strain behavior of high-strength concrete was investigated. Based on the analysis, a stress-strain relationship for high-strength concrete columns was proposed. Secondly, six 1/3-1/2 scale high-strength concrete short columns were tested under combined axial load and cyclic shear, with double curvature condition. The primary experimental parameters included axial load ratio, longitudinal reinforcement ratio, and volumetric ratio of transverse reinforcement. The proposed stress-strain relationship was used in the analysis of the lateral force–displacement relationship for high-strength concrete columns. Moment-curvature analysis, based on proposed equivalent stress block approach, as well as plastic hinge mechanism, has been incorporated in this analytical tool. The analytical results agreed well with the primary load-deflection envelopes obtained from the tests.
Societal Perspectives about Earthquake Performance: The Fallacy of “Acceptable Risk”
Authors: May Peter J.
Published: September 2002

Seismic safety is a matter of public welfare involving potential loss of life or injury, disruption of communities, and costs to governments for addressing earthquake losses and recovery. Societal perspectives are incorporated into minimum seismic performance standards for codes and other guidelines. Discussion of revisions to these often entails consideration of acceptable levels of risk from a societal perspective. However, there is a fundamental Catch-22 in addressing acceptable levels of risk. On the one hand, determining these is fundamentally a value judgment that presumably requires some form of collective decision making. On the other hand, knowledge of relevant risk considerations, technical details, and costs and benefits are important for establishing meaningful standards. The first consideration argues for public processes for establishing safety goals. The second argues for deference to technical experts. Finding the appropriate middle ground is a serious challenge. I argue that a recasting of the discussion of acceptable risk is important for advancing seismic safety.
A Proposal of Instrumental Seismic Intensity Scale Compatible with MMI Evaluated from Three-Component Acceleration Records
Authors: Shabestari Khosrow T. , Yamazaki Fumio
Published: September 2002

Seismic intensity provides useful information on the regional distribution of earthquake effects and has been used to assess seismic hazards and damages. The concept of intensity has been considered as a method to classify severity of the ground motion on the basis of observed effects in the stricken area. In 1996, the Japan Meteorological Agency (JMA) developed a new seismic intensity measurement scale using three-component strong ground motion records in order to provide a measure of the strength of the seismic motion, which is compatible with the existing JMA intensity scale. By applying a band-pass filter to the frequency domain and a vectoral composition of the three components in the time domain, the JMA seismic intensity scale (IJMA) can be calculated without subjective judgement. In this study, we apply the IJMA method to the acceleration records of three recent significant earthquakes in California. For a Modified Mercalli Intensity (MMI) between IV and VIII, a new relation between MMI and log a0, obtained in the process of calculating the new IJMA, is given by the equation MMI=3.93 log a0−1.17. We propose this relation as a new instrumental seismic intensity (IMM) compatible with the California region MMI.
GPS in Pioneering Dynamic Monitoring of Long-Period Structures
Authors: Çelebi Mehmet , Sanli Ahmet
Published: September 2002

Global Positioning System (GPS) technology with 10–20-Hz sampling rates allows scientifically justified dynamic measurements of relative displacements of long-period structures. The displacement response of a simulated tall building in real time and permanent deployment of GPS units at the roof of a building are described. To the authors’ best knowledge, this is the first permanent deployment of GPS units (in the world) for continuous dynamic monitoring of a tall building. Data recorded from the building during a windy day is analyzed to determine the structural characteristics. When recorded during extreme motions caused by earthquakes and strong winds, such measurements can be used to compute average drift ratios and changes in dynamic characteristics, and therefore can be used by engineers and building owners or managers to assess the structural integrity and performance by establishing pre-established thresholds. Such information can be used to secure public safety and/or take steps to improve the performance of the building.
Strengthening URM with GFRP Composites and Ductile Connections
Authors: Holberg A. M. , Hamilton H. R.
Published: September 2002

Research on the use of fiber-reinforced polymer (FRP) composites for strengthening of unreinforced or inadequately reinforced hollow concrete masonry is covered in this paper. Quasi-static shear wall tests were conducted on unreinforced concrete masonry specimens that had been strengthened with unidirectional glass fiber strips applied to the surface of the masonry using a two-part epoxy to form a surface-bonded GFRP composite. The strips were strategically placed to improve both flexural and shear strength in the in-plane direction. The GFRP composite system was combined with conventional structural steel and reinforcing steel connections that were designed to yield before the composite ruptured, resulting in a ductile failure mode under cyclic testing. The drift capacities of the tested specimens ranged from 0.6% to 1.7%.
Seismic Intensity and Fourier Acceleration Spectra: Revised Relationship
Authors: Sokolov Vladimir Yu
Published: September 2002

This paper presents a revised method for estimating the seismic intensity (MMI or MSK scale) using Fourier amplitude spectra (FAS) of ground acceleration. The improvement of the recently proposed technique (Sokolov and Chernov 1998) has been made on the basis of the data, which were obtained recently during strong earthquakes that occurred throughout the world. The total amount of the used data (horizontal components of ground-motion recordings) is about 1,150 records, while the database of 300 recordings was used in the previous study. The method implies that the seismic intensity is determined by the level of ground motion spectral amplitudes in the frequency range of 0.4–13 Hz. The corresponding empirical relationships between FAS and each intensity level were developed. The method is validated by comparison of the results of the technique application with the empirical data, which have not been included in the database. The Romanian earthquakes (intermediate-depth events of 1977, 1986, and 1990) and the recent 1999 Hector Mine earthquake in southern California were used for this purpose. In general, the FAS intensity shows a good agreement with the reported intensity, and the average residuals do not exceed ±0.3 intensity units and standard deviation is about 0.4-0.6. Evaluation of seismic intensity distribution using region- and site-dependent spectral models, as well as calculation of instrumental intensity map for the recent 1999 Chi-Chi earthquake, Taiwan, show that the FAS intensity clearly reflects the regional (source scaling and attenuation relation) and local (soil response) peculiarities of ground motion.
Seismic Performance of Perimeter Lateral-System Structures with Highly Flexible Diaphragms
Authors: Fleischman Robert B. , Farrow Kenneth T. , Eastman Kristin
Published: September 2002

Building structures are typically designed using the assumption that the floor systems serve as a rigid diaphragm between the vertical elements of the lateral force-resisting system (lateral system). However, perimeter lateral-system structures with long floor spans possess diaphragms that behave quite flexibly. Difficulty can exist in predicting diaphragm force demand in these structures. Thus, current design may provide insufficient strength to maintain elastic diaphragm response. Inelastic diaphragm response exacerbates the effects of diaphragm flexibility. Such response may lead to poor seismic performance, including nonductile diaphragm failure or structural instability due to high drift demands in the gravity system. An analytical study was performed to determine the effect of diaphragm flexibility and strength on the seismic performance of perimeter lateral-system structures with highly flexible diaphragms. Nonlinear transient analyses were performed using ground motions suites corresponding to multiple levels of hazard for high seismic zones. Design recommendations for flexible diaphragms are presented.
A Randomized Controlled Trial of Mist in the Acute Treatment of Moderate Croup
Authors: Neto Gina M. , Kentab Osama , Klassen Terry P. , Osmond Martin H.
Published: September 2002

Objective: To determine whether the use of mist improves clinical symptoms in children presenting to the emergency department (ED) with moderate croup. Methods: Children 3 months to 6 years of age were eligible for the study if they presented to the ED with moderate croup. Moderate croup was defined as a croup score of 2‐7. The patients were randomly assigned to receive either mist (humidified oxygen) via mist stick or no mist. The patients had croup scores measured at baseline and every 30 minutes for up to two hours. At these intervals the following parameters were also measured: heart rate, respiratory rate, oxygen saturation, and patient comfort score. The patients were treated until the croup score was less than 2 or until two hours had elapsed. All patients initially received a dose of oral dexamethasone (0.6 mg/kg). Other treatments, such as racemic epinephrine or inhaled budesonide, were given at the discretion of the treating physician. The research assistants were unaware of the assigned treatments. Results: There were 71 patients enrolled in the study; 35 received mist and 36 received no mist. The two treatment groups had similar characteristics at baseline. The median baseline croup score was 4 in both groups. The outcomes were measured as the change from baseline at 30, 60, 90, and 120 minutes. The change in the croup score from baseline in the mist group was not statistically different from the croup score change in the group that did not receive mist (p = 0.39). There was also no significant difference in improvement of oxygen saturation, heart rate, or respiratory rate at any of the assessment times. There was no adverse effect from the mist therapy. Conclusions: Mist therapy is not effective in improving clinical symptoms in children presenting to the ED with moderate croup.
Emergency Department Triage of Patients Infected with HIV
Authors: Haukoos Jason S. , Witt Mallory D. , Zeumer Christel M. , Lee Thomas J. , Halamka John D. , Lewis Roger J.
Published: September 2002

Objective: The emergency department (ED) and HIV specialty clinics are primary sources of care for persons infected with HIV. HIV disease may be complicated by vague and complex symptomatology, and determining the degree of illness at triage is often difficult. The goals of this project were to characterize the ED presentation of HIV‐related conditions, to develop a clinical decision rule to triage HIV‐infected patients, and to validate the rule in clinical practice. Methods: The study population consisted of ambulatory patients with self‐reported HIV infection who presented for care to the ED of a 553‐bed public hospital that serves a medically indigent, minority population. An Illness Severity Instrument was developed by an expert panel to serve as the criterion standard for defining medical urgency for HIV‐infected patients presenting to the ED for care. Two phases of the study were conducted. Data from the first phase, a noninterventional cohort study, were used to develop a clinical decision rule for the ED triage of HIV‐infected patients. The second phase was a prospective validation of the clinical decision rule. Results: During phase I, data from 542 patient visits were collected. Data from 441 (81%) patient visits were used in a classification and regression tree (CART) analysis to produce a decision rule, the Clinical Triage Instrument. During phase II, the prospective validation of the Clinical Triage Instrument, 156 patient visits occurred. Of these, 88 (56%) patient visits were triaged using the Clinical Triage Instrument and could be scored using the Illness Severity Instrument. The Clinical Triage Instrument accurately triaged 45 [51%; 95% confidence interval (95% CI) = 40% to 62%] patient visits, undertriaged 11 (13%; 95% CI = 6% to 21%) patient visits, and overtriaged 32 (36%; 95% CI = 26% to 47%) patient visits. Sensitivities and specificities for determining emergent, urgent, and nonurgent medical conditions by the Clinical Triage Instrument were 56% (95% CI = 31% to 75%) and 84% (95% CI = 74% to 92%), 71% (95% CI = 55% to 84%) and 39% (95% CI = 25% to 55%), and 18% (95% CI = 6% to 37%) and 93% (95% CI = 84% to 98%), respectively. The positive and negative predictive values for determining an emergent medical condition using the Clinical Triage Instrument were 48% (95% CI = 26% to 70%) and 88% (95% CI = 78% to 95%), respectively. The positive and negative predictive values for determining a nonurgent medical condition using the Clinical Triage Instrument were 56% (95% CI = 21% to 86%) and 71% (95% CI = 60% to 81%), respectively. Conclusions: The Clinical Triage Instrument was not sufficiently accurate for clinical use. Until accurate and reliable triage methods are developed, all patients infected with HIV who present to the ED for care should receive timely evaluation and care.
Predictive Validity of the Global Assessment Form Used in a Final‐year Undergraduate Rotation in Emergency Medicine
Authors: Bandiera Glen W. , Morrison Laurie J. , Regehr Glenn
Published: September 2002

Objectives:To determine whether the predictive validity of Global Assessment Form (GAF) knowledge subdomain marks exceeds that of the overall GAF marks with respect to written examination marks for an undergraduate rotation in emergency medicine, and to determine the interdependence between subdomain marks on the GAF.Methods:Final‐year clinical clerks completing a four‐week rotation through the emergency departments of a university teaching center were evaluated using both a ten‐subdomain GAF for clinical performance and an independent written examination. The GAF and examination marks were prospectively obtained for clinical clerks over a two‐year period. Pearson correlations were calculated between examination marks and both the GAF knowledge subdomain and the GAF overall mark. Olkin's Z score was calculated to determine the significance of the difference between correlations. Interdependencies between subdomains of the GAF were calculated using an alpha coefficient and inter‐item correlations.Results:Data sets were reviewed for 347 clinical clerks. Nine sets of data were excluded (incomplete evaluations); 338 sets were analyzed. Means for overall clinical mark and examination mark were 80.11% (SD = 4.375) and 81 (SD = 7.66). Among subdomains, knowledge had the highest correlation with the examination mark (0.19). Overall clinical marks had lower correlation with the examination marks (0.169); the difference was not significant (Olkin's Z = 0.40). The correlation of the examination marks with the average marks of all subdomains excluding knowledge was even lower (0.12). The tenitem alpha for the GAF was 0.92.Conclusions:Clinical GAF assessments of knowledge, as measured by written examination, do not appear to be any more predictive than overall clinical impression. There is substantial consistency between subdomain scores, suggesting that assessors are not effectively discriminating between them when assigning marks.
Adverse Cardiac Events in Emergency Department Patients with Chest Pain Six Months after a Negative Inpatient Evaluation for Acute Coronary Syndrome
Authors: Manini Alex F. , Gisondi Michael A. , Van Der Vlugt Theresa M. , Schreiber Donald H.
Published: September 2002

Objective: To evaluate the impact of the diagnostic test setting—inpatient versus outpatient—on adverse cardiac events (ACEs) after six months in emergency department (ED) patients with chest pain who were admitted to the hospital and subsequently had a negative evaluation for acute coronary syndrome (ACS). Methods: The authors retrospectively studied a consecutive sample of ED patients with chest pain over a nine‐month period. All patients were admitted to the hospital and underwent negative evaluations for ACS, defined as the absence of diagnostic changes on serial electrocardiograms or cardiac markers (creatine kinase—MB and troponin T), and a negative diagnostic cardiac study. Subjects were classified according to cardiac diagnostic study setting—either inpatient or outpatient. Diagnostic testing included exercise treadmill, angiography, stress echocardiography, or stress thallium scans. Acute cardiac events at six months were defined as cardiac death, myocardial infarction, unstable angina, cardiac arrest, or emergent revascularization. Results: The six‐month rate of ACEs among 157 subjects was 14%, with 2% cardiac mortality. The outpatient group had higher ACE risk when compared with the inpatient group using multivariate logistic regression, both for the entire cohort (OR 3.5, p < 0.03) and for a subgroup excluding patients with prior coronary artery disease (OR 6.7, p < 0.05). The outpatient group included 19 of 52 (37%) noncompliant subjects who did not receive a diagnostic study. Conclusions: Long‐term cardiac morbidity of patients after a negative ACS evaluation may be higher than previously thought. Risk of ACE is significantly higher in subjects scheduled for outpatient diagnostic tests. Inpatient diagnostic testing is justified for subjects at risk for poor compliance.
Congestive Heart Failure Patients with Chest Pain: Incidence and Predictors of Acute Coronary Syndrome
Authors: Lettman Nadine A. , Sites Frank D. , Shofer Frances S. , Hollander Judd E.
Published: September 2002

Objective: New diagnostic and treatment options for emergency department (ED) patients with congestive heart failure (CHF) may facilitate the ED discharge of some patients. However, some patients require admission to exclude concurrent acute coronary syndrome (ACS) as the precipitant of CHF. The objective of this study was to identify the incidence, clinical characteristics, and hospital course of CHF patients who present to the ED with and without concurrent ACS. Methods: This was a prospective cohort study of consecutive patients >23 years of age who presented to the ED with chest pain, received an electrocardiogram (ECG), and either had a known history of CHF or presented with new‐onset CHF, between July 1999 and April 2001. The hospital course of each patient was followed daily, and telephone follow‐up occurred at 30 days. The main outcomes were the incidence of ACS and comparisons of lengths of hospital stay (LOSs), rates of admission to the intensive care unit (ICU), intubations, and death rates among patients with and without ACS. Results: Two hundred ninety‐eight CHF patients presented 380 times. The incidence of ACS in the 380 patient visits was 32% (95% CI = 27% to 36%). Compared with patients who did not have ACS, patients who had concurrent ACS were more likely to have known coronary artery disease (CAD) (67% vs. 42%; p < 0.0001) and hypercholesterolemia (36% vs. 18%; p = 0.0002). Patients with concurrent ACS were also more likely to be admitted to the hospital (97% vs 82%; p < 0.0001), had a longer LOS (5.2 [3.9‐6.5] vs 3.2 [2.6‐3.8] days; p = 0.006), had higher rates of ICU admission (44% vs. 13%; p < 0.0001), were more likely to be intubated (8% vs. 1%, p = 0.002), and were more likely to die (15 vs 7 deaths; p < 0.0001). Conclusions: The incidence of ACS in ED CHF patients with chest pain was 32%. Patients with CHF complicated by ACS had more prolonged hospital stays, required higher levels of care, and had a higher incidence of death than those patients without ACS. Strategies tailored to early identification and management of these patients would be desirable.
Lack of Association between Patient Ethnicity or Race and Fracture Analgesia
Authors: Fuentes Eloisa F. , Kohn Michael A. , Neighbor Martha L.
Published: September 2002

Objective: Ethnic and racial differences in the provision of emergency department (ED) analgesia for long‐bone fractures have recently been reported in two large cities. The authors sought to determine, in a third city, whether nonwhite patients with long‐bone fractures were less likely to receive analgesics than white patients with similar injuries. Methods: At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study was conducted of all ED patients aged 18 to 55 years seen from July 1, 1998, through June 30, 1999, with an ED discharge diagnosis of isolated long‐bone fracture identified by ICD‐9 codes 812, 813, 821, and 823. Exclusion criteria included injury more than 12 hours prior to presentation or a Glasgow Coma Scale score of less than 14. The main outcome measure was ED analgesia administration. Results: Three hundred twenty‐three patients met inclusion criteria; 181 were white, 58 African American, 46 Hispanic, 38 Asian. All ethnic/racial groups were equally likely to receive no analgesia or no parenteral analgesia. The overall risk for no analgesia was 20% and for no parenteral analgesia was 31%. Stratification and multiple logistic regression to control for gender, bone fractured, and need for reduction failed to identify any trend toward reduced analgesia administration in any ethnic/racial group. Conclusions: In contrast to two recently reported studies, at this urban trauma center and teaching hospital ED, there was no difference in the administration of analgesics to white and nonwhite patients with long‐bone fractures.
Usual Source of Care and Nonurgent Emergency Department Use
Authors: Sarver Joshua H. , Cydulka Rita K. , Baker David W.
Published: September 2002

Objective: To examine whether dissatisfaction with one's usual source of care (USC) and perceived access difficulties to one's USC were associated with nonurgent emergency department (ED) use. Methods: Variables that measured USC satisfaction and access were identified in the 1996 cohort of the Medical Expenditure Panel Survey (MEPS), a nationally representative sample administered by the Agency for Healthcare Research and Quality. The main outcome measured was nonurgent ED use at least once during 1996. Results: A total of 9,146 adults had a USC other than the ED, had at least one contact with the health care system or were unable to get needed care, and had complete data for all the variables in the final model. Dissatisfaction with the USC, dissatisfaction with the USC staff, lack of confidence in the USC's ability, difficulty scheduling an appointment, difficulty reaching the USC by phone, and long waiting times with an appointment were all associated with having a nonurgent ED visit in 1996 (all at p < 0.05). The positive associations between both dissatisfaction and perceived access barriers and nonurgent ED use persisted even in multiple logistic regression that adjusted for age, sex, race, education, health status, employment status, income, insurance, region of residence, and rural vs. urban residence. Conclusions: Patients who are dissatisfied with their USC or perceive access barriers to their USC are more likely to have a nonurgent ED visit.
Crash Scene Photography in Motor Vehicle Crashes without Air Bag Deployment
Authors: Newgard Craig D. , Martens Katherine A. , Lyons Evelyn M.
Published: September 2002

Objective: To determine whether vehicle characteristics, measured using crash scene photography, are associated with anatomic patterns of injury and severity of injury sustained in motor vehicle crashes (MVCs) without air bag deployment. Methods: A prospective observational study was conducted over 22 months, using 12 fire departments serving two hospitals. Two vehicle photographs (exterior and interior) were taken at each MVC. Vehicular variables were assigned by grading the photographs with a standardized scoring system, and outcome information on each patient was collected by chart review. Results: Five hundred fifty‐nine patients were entered into the study. Frontal crashes and increasing passenger space intrusion (PSI) were associated with head, facial, and lower‐extremity injuries, while rear crashes were associated with spinal injuries. Restraint use had a protective effect in head, facial, and upper and lower extremity injuries, yet was associated with higher odds of spinal injury. Lack of restraint use, increasing PSI, and steering wheel deformity were associated with an increased hospital length of stay and hospital charges, yet only steering wheel deformity was associated with increasing injury severity when adjusting for other crash variables. Conclusions: Out‐of‐hospital variables, as obtained from crash vehicle photography, are associated with injury site, injury severity, hospital length of stay, and hospital charges in patients involved in MVCs without air bag deployment.
Bench to Bedside: Brain Edema and Cerebral Resuscitation: The Present and Future
Authors: Xiao Feng
Published: September 2002

Sudden cardiac arrest (CA) claims approximately 1,200 lives daily in the United States. Cardiopulmonary resuscitation attempts have so far achieved suboptimal results, and even when restoration of spontaneous circulation (ROSC) is achieved, about 30% of survivors suffer permanent brain damage. This illustrates the need for an improved basic scientific understanding of the pathophysiology of global cerebral injury caused by whole‐body ischemia/reperfusion (I/R) injury following CA. Brain edema has been recently documented in experimental CA followed by one hour of ROSC. Brain edema has also been documented in CA and stroke patients by computed tomography or magnetic resonance imaging scanning, and has been shown to predict a poor neurologic outcome. The mechanisms underlying brain edema formation elicited by CA are unclear. New scientific findings of the roles of blood—brain barrier (BBB) permeability, matrix metalloproteinases (MMPs) of a family of proteases, aquaporin 4 (AQP4) of a family of membrane water‐channel proteins, and the N‐methyl‐D‐aspartate (NMDA) receptors in the mechanisms underlying CA‐elicited brain edema were reviewed. By defining the roles of BBB permeability, MMPs, AQP4, and NMDA receptors in CA‐induced brain edema formation, effective new therapeutic strategies to extend cellular and tissue survival, and preserve neurologic function following CA may be feasible.
Emergency Medicine: Competencies for Youth Violence Prevention and Control
Authors: Denninghoff Kurt R. , Knox Lyndee , Cunningham Rebecca , Partain Sandi
Published: September 2002

By any standard one wishes to apply, the impact of violence on the health and safety of the public is significant. The expression of violence among children in the United States has increased significantly during the modern era. Homicide and suicide are the second and third leading causes of death in youths 15‐24 years of age. The emergency department (ED) is a common site for the care of these victims, and because victims often become assailants, the emergency care provider needs to know the epidemiology, treatment, and methods for prevention of youth violence in order to curtail the cycle. A multidisciplinary task force was convened by the Centers for Disease Control and Prevention (CDC)‐funded Southern California Center of Academic Excellence on Youth Violence Prevention and the Keck School of Medicine at the University of Southern California to define competencies for health professionals in youth violence prevention and control. Three levels of competence were identified: the generalist level, which should be obtained by all health professionals; the specialist level, which should be obtained by health professionals such as emergency medicine providers, who frequently work with populations affected by violence; and a third, or scholar level, to be acquired by health professionals who wish to become experts not only in the care, but also in research and advocacy. This article reports the details of this group's efforts and applies them to emergency care provider education. These competencies should shape the development of curricula for the span of emergency medical training from emergency medical services scholastic training to postgraduate continuous medical education.
A Comparison of the Antemortem Clinical Diagnosis and Autopsy Findings for Patients Who Die in the Emergency Department
Authors: O'Connor Alan E. , Parry Jeremy T. , Richardson Drew B. , Jain Sanjiv , Herdson Peter B.
Published: September 2002

Objectives: In spite of advances in medical technology, there remains a high discrepancy rate between the antemortem clinical diagnosis and postmortem examination diagnosis for patients who die in hospitals. The aim of this study was to compare the clinical and postmortem examination diagnoses of patients who died in the emergency department (ED) of a tertiary hospital, and to analyze any discrepancy between them. Methods: The study was a retrospective chart review of patients who died in the ED of a tertiary referral teaching hospital and a comparison of the antemortem diagnosis with the autopsy diagnosis. Any missed diagnosis was classified, according to the Goldman criteria, into major and minor missed diagnoses. Results: A total of 59 patients were eligible for inclusion in the study. There was complete agreement between the antemortem diagnosis and the autopsy result in 51% of cases. The incidence of major missed diagnoses—where if the diagnosis had been known before the patient died, treatment may have been altered or survival may have been prolonged—was 7%. Conclusions: There is a significant discrepancy rate between the antemortem diagnosis and the autopsy diagnosis. However, in this study, serious missed diagnoses in which outcome may have been significantly altered are unusual among those who die in the ED of a tertiary referral hospital.
Altered Responsiveness of the Hypothalamus-Pituitary-Adrenal Axis and the Sympathetic Adrenomedullary System to Stress in Patients with Atopic Dermatitis
Authors: Buske-Kirschbaum Angelika , Geiben Andrea , Höllig Heike , Morschhäuser Ellen , Hellhammer Dirk
Published: September 2002

A growing number of animal data strongly suggest that a hyporeactive hypothalamus-pituitary adrenal (HPA) axis may be pathologically significant by increasing the susceptibility to chronic inflammation. Following this line of evidence, the specific goal of the present study was to investigate the HPA axis in patients with atopic dermatitis (AD), a chronic allergic inflammatory disease. In addition, the sympathetic adrenomedullary (SAM) system as a second potent immunoregulatory and anti-inflammatory stress-response system has been examined.

AD patients (n = 36) and nonatopic control subjects (n = 37) were exposed to a standardized laboratory stressor consisting of a free speech and mental arithmetic task in front of an audience. Cortisol, ACTH, and catecholamine concentrations were assessed before and after the stressor. To investigate feedback sensitivity of the HPA axis, a low dose (0.5 mg) dexamethasone suppression test was also performed. AD patients showed significantly attenuated cortisol and ACTH responses to the stressor, whereas catecholamine levels were significantly elevated in atopic patients. No difference between the experimental groups was found in basal cortisol and ACTH concentrations, whereas basal catecholamine levels were significantly elevated. Analysis of cortisol levels after dexamethasone treatment suggested an intact feedback sensitivity in AD sufferers at the pituitary level. The present findings suggest that patients with AD demonstrate a blunted HPA axis responsiveness with a concurrent overreactivity of the SAM system to psychosocial stress. Considering the important immunoregulatory role of the HPA axis and the SAM system, especially under stressful conditions, an aberrant responsiveness of these neuroendocrine systems may increase the susceptibility to (allergic) inflammation and may be one psychobiological mechanism of stress-related aggravation of the disease.
Ablation of Thyroid Residues with 30 mCi 131I: A Comparison in Thyroid Cancer Patients Prepared with Recombinant Human TSH or Thyroid Hormone Withdrawal
Authors: Pacini Furio , Molinaro Eleonora , Castagna Maria Grazia , Lippi Francesco , Ceccarelli Claudia , Agate Laura , Elisei Rossella , Pinchera Aldo
Published: September 2002

The aim of the study was to assess whether stimulation by recombinant human TSH (rhTSH) may be used in patients with differentiated thyroid carcinoma for postsurgical ablation of thyroid remnants using a 30-mCi standard dose of 131I during thyroid hormone therapy. The rate of ablation was prospectively compared in three groups of patients consecutively assigned to one of three treatment arms: in the first arm, patients (n = 50) were treated while hypothyroid (HYPO); in the second arm, patients (n = 42) were treated while HYPO and stimulated in addition with rhTSH (HYPO + rhTSH); in the third arm, patients (n = 70) were treated while euthyroid (EU) on thyroid hormone therapy and stimulated with rhTSH (EU + rhTSH). The outcome of thyroid ablation was assessed by conventional HYPO 131I scan performed in HYPO state 6–10 months after ablation.

Basal serum TSH was elevated in the HYPO and HYPO + rhTSH groups. In the EU + rhTSH group, basal serum TSH was 1.3 ± 2.5 μU/ml (range, <0.005–11.9 μU/ml). After rhTSH, serum TSH significantly increased in the HYPO + rhTSH group and the EU + rhTSH group.

Basal 24-h radioiodine thyroid bed uptake was 5.8 ± 5.7% (range, 0.2–21%) and 5.4 ± 5.7% (range, 0.2–26%) in the HYPO and HYPO + rhTSH groups, respectively. In the HYPO + rhTSH group, mean 24-h thyroid bed uptake rose to 9.4 ± 9.5% (range, 0.2–46%) after rhTSH (P < 0.0001). The 24-h uptake after rhTSH in the EU + rhTSH group was 2.5 ± 4.3% (range, 0.1–32%), significantly lower (P < 0.0001) than that found in the HYPO and HYPO + rhTSH groups.

The rate of successful ablation was similar in the HYPO and HYPO + rhTSH groups (84% and 78.5%, respectively). A significantly lower rate of ablation (54%) was achieved in the EU + rhTSH group.

Mean initial dose rate (the radiation dose delivered during the first hour after treatment) was significantly lower in the EU + rhTSH group (10.7 ± 12.6 Gy/h) compared with the HYPO + rhTSH group (48.5 ± 43 Gy/h) and the HYPO group (27.1 ± 42.5 Gy/h).

In conclusion, our study indicates that by using stimulation with rhTSH, a 30-mCi standard dose of radioiodine is not sufficient for a satisfactory thyroid ablation rate. Possible reasons for this failure may be the low 24-h radioiodine uptake, the low initial dose rate delivered to the residues, and the accelerated iodine clearance observed in EU patients. Possible alternatives for obtaining a satisfactory rate of thyroid ablation with rhTSH may consist of increasing the dose of radioiodine or using different protocols of rhTSH administration producing more prolonged thyroid cells stimulation.
Intense Expression of the B7-2 Antigen Presentation Coactivator Is an Unfavorable Prognostic Indicator for Differentiated Thyroid Carcinoma of Children and Adolescents
Authors: Shah Rima , Banks Kevin , Patel Aneeta , Dogra Shalini , Terrell Richard , Powers Patricia A. , Fenton Cydney , Dinauer Catherine A. , Tuttle R. Michael , Francis Gary L.
Published: September 2002

Previous observations suggest that an immune response against thyroid carcinoma could be important for long-term survival. We recently found that infiltration of thyroid carcinoma by proliferating lymphocytes is associated with improved disease-free survival, but the factors that control lymphocytic infiltration and proliferation are largely unknown. We hypothesized that the antigen presentation coactivators (B7-1 and B7-2), which are important in other immune-mediated thyroid diseases, might be important in lymphocytic infiltration of thyroid carcinoma. To test this, we determined B7-1 and B7-2 expression by immunohistochemistry [absent (grade 0) to intense (grade 3)] in 27 papillary (PTC) and 8 follicular (FTC) thyroid carcinomas and 9 benign thyroid lesions. B7-1 and B7-2 were expressed by the majority of PTC and FTC (78% of PTC and 100% of FTC expressed B7-1; 88% of PTC and 88% of FTC expressed B7-2). B7-1 expression was more intense in PTC (1.4 ± 0.2; P = 0.01) and FTC (2.6 ± 0.2; P < 0.001) than in benign tumors (0.57 ± 0.30) or presumably normal adjacent thyroid (0.07 ± 0.07) and was more intense in carcinoma that contained lymphocytes (1.95 ± 0.21) than in carcinoma that did not (1.08 ± 0.26; P = 0.016). B7-2 expression was of similar intensity in benign and malignant tumors (PTC, 1.6 ± 0.2; FTC, 2.1 ± 0.4; benign, 1.86 ± 0.4), but was more intense than in presumably normal adjacent thyroid (0.64 ± 0.25; P ≤ 0.013). B7-2 expression also correlated with the number of tumor-associated lymphocytes per high power field (r = 0.38; P = 0.02). Recurrence developed exclusively from tumors that expressed B7-2, and intense B7-2 expression was associated with a reduced probability of remission (P = 0.04). In conclusion, these data support the hypothesis that the antigen presentation coactivators B7-1 and B7-2 may be important for lymphocytic infiltration and the immune response against thyroid carcinoma.
High Reliability of Neonatal Screening for Congenital Adrenal Hyperplasia in Switzerland
Authors: Steigert Michael , Schoenle Eugen J. , Biason-Lauber Anna , Torresani Toni
Published: September 2002

Newborn screening for congenital adrenal hyperplasia (CAH) is justified by the sometimes difficult clinical diagnosis and the risks associated with missed diagnosis, particularly the life-threatening salt-wasting crisis. In Switzerland, nationwide screening for CAH by measuring 17-hydroxyprogesterone levels in dried blood spots was introduced in 1992. At the Zurich University Children’s Hospital, 50% of the population of Switzerland is screened. The aim of the study was to evaluate the efficiency of the Zurich screening program. Between January 1, 1993, and May 31, 2001, 333,221 newborns were screened for CAH. Thirty-one newborns had CAH (incidence, 1 in 10,749); 30 were detected through screening (sensitivity, 97%). A recall for suspected CAH was performed in only 60 cases, corresponding to a very low recall rate (0.0018%). In 30 recalls CAH was confirmed (positive predictive value, 50%; specificity, 99.99%). Fifteen of 31 patients profited from screening, as CAH had not been recognized clinically. The timely availability of screening results made therapy possible within the first week of life in most cases and helped in preventing salt-wasting crisis in all patients. With a sensitivity of 97%, a specificity of 99.99%, and a positive predictive value of 50%, the Zurich neonatal screening program for CAH can be considered highly reliable.
Relationship of Insulin Receptor Substrate-1 and -2 Genotypes to Phenotypic Features of Polycystic Ovary Syndrome
Authors: Ehrmann David A. , Tang Xu , Yoshiuchi Issei , Cox Nancy J. , Bell Graeme I.
Published: September 2002

Insulin resistance is a key component in the pathogenesis of polycystic ovary syndrome (PCOS) and type 2 diabetes. Polymorphisms in the genes encoding the insulin receptor substrate (IRS) proteins, IRS-1 (Gly972Arg) and IRS-2 (Gly1057Asp), influence susceptibility to type 2 diabetes. This study was undertaken to assess the influence of these polymorphisms on insulin resistance, glucose tolerance, and androgen levels in nondiabetic PCOS women.

We studied 227 PCOS subjects including 126 and 48 nondiabetic white and African-American subjects, respectively. The IRS-1 Gly972Arg allele frequencies were identical in whites and African-Americans [0.95 (Gly) and 0.05 (Arg)]. The IRS-2 Gly1057Asp allele frequencies were 0.85 (Gly) and 0.15 (Asp) in African-Americans and 0.59 (Gly) and 0.41 (Asp) in whites. There was no association of IRS-1 genotype with any clinical or hormonal measure in nondiabetic white or African-American PCOS subjects. However, nondiabetic subjects with the IRS-2 Gly/Gly genotype had significantly higher 2-h oral glucose tolerance test glucose levels compared with those with Gly/Asp and Asp/Asp genotypes in whites or Gly/Asp genotype in African-Americans (there were no Asp/Asp subjects in our modest size African-American sample). These results suggest that the IRS-2 Gly1057Asp polymorphism influences blood glucose levels in nondiabetic white and African-American women with PCOS. Thus, individuals with the common IRS-2 Gly/Gly genotype may be at increased risk of developing type 2 diabetes.
Expression of Activin/Inhibin Receptor and Binding Protein Genes and Regulation of Activin/Inhibin Peptide Secretion in Human Adrenocortical Cells
Authors: Vänttinen Teemu , Kuulasmaa Tiina , Liu Jianqi , Voutilainen Raimo
Published: September 2002

Activins and inhibins are glycoprotein hormones produced mainly in gonads but also in other organs. They are believed to be important para/autocrine regulators of various cell functions. We investigated activin/inhibin receptor and binding protein gene expression and the regulation of activin/inhibin secretion in human adrenal cells. RT-PCR revealed inhibin/activin α-, βA/B-subunit, follistatin, activin type I/II receptor, and inhibin receptor (betaglycan and inhibin-binding protein) mRNA expression in fetal and adult adrenals and cultured adrenocortical cells. Cultured cells secreted activin A and inhibin A/B as determined by specific ELISAs. ACTH stimulated inhibin A/B secretion in fetal (1.8- and 1.8-fold of control, respectively) and in adult cells (3.4- and 1.7-fold of control, respectively) without significant effect on activin A. 8-bromoadenosine cAMP (protein kinase A activator) increased activin A and inhibin A/B secretion in the human adrenocortical NCI-H295R cell line (32-, 17-, and 3-fold of control, respectively). 12-O-tetradecanoyl phorbol-13-acetate (protein kinase C activator) stimulated both activin A and inhibin A secretion (764- and 32-fold of control, respectively), and activin treatment increased inhibin B secretion in these cells (25-fold of control). In conclusion, human adrenocortical cells produce dimeric activins and inhibins. ACTH stimulates inhibin secretion and decreases activin/inhibin secretion ratio, probably via the protein kinase A signal transduction pathway. This, together with the adrenocortical activin/ inhibin receptor and binding protein expression, suggests a physiological role for activins and inhibins in the human adrenal gland.
Self‐perception of cognitive changes during pregnancy and the early postpartum: salience and attentional effects
Authors: Crawley Ros
Published: September 2002

The reports from 198 pregnant women of changes experienced during pregnancy suggested that cognitive changes are not salient since only 2% of women spontaneously mentioned such changes. When asked specifically about cognitive changes, the majority reported no change although most who reported a change indicated it was for the worse. In this respect they differed from a group of 132 students who had recently left home. In a second study, 13 women were asked to rate a range of cognitive functions during pregnancy and the postpartum period. Their ratings for certain aspects of cognition were lower than those of a group of non‐pregnant women. They also reported more cognitive failures and readily provided examples of perceived impairments in cognition. It would appear that cognitive deficits are of low salience to pregnant women but, if prompted, impairments in memory, concentration, clarity of thought and attention will be reported by women both during pregnancy and the first‐year postpartum. Copyright © 2002 John Wiley & Sons, Ltd.