bluuebunny/crossref_metadata_2025 huggingface dataset:
Patterns of Compliance with the German Corporate Governance Code
Authors: Talaulicar Till , V. Werder Axel
Published: September 2008

Manuscript Type: Empirical

Research Question/Issue: This study investigates whether the form of compliance with the recommendations of the German Corporate Governance Code (GCGC) appears to be idiosyncratic to a specific company or features similarities across firms. The major aim of this research is thus to explore the ability of a classification of compliance patterns to account for the similarities and differences between firms regarding their conformity with the GCGC.

Research Findings/Insights: Based on seven dimensions of code compliance, cluster analysis is used to identify discrete groups of companies with similar patterns of code observance. We determine eight patterns of compliance which are characterized by distinct forms of code conformity.

Theoretical Academic Implications: The identified cluster solution does not merely reflect the number of rejected code recommendations. Rather, companies with very similar rates of overall compliance with the GCGC are assigned to different clusters because they feature, at the same time, different patterns of code conformity. These findings imply that governance prediction and governance performance studies have to overcome overly aggregated measures of code compliance which only incorporate the number of rejected code recommendations.

Practitioner/Policy Implications: This study provides evidence to practitioners and policy makers that firms can be classified regarding their compliance with the code recommendations. In‐depth analyses of the identified patterns of compliance furthermore reveal that some patterns may indicate less well substantiated deviations from the code and partly even decouplings of the declared compliance practices.
Approximate Bayesian Inference in Spatial Generalized Linear Mixed Models
Authors: EIDSVIK JO , MARTINO SARA , RUE HÅVARD
Published: September 2008

Abstract. In this paper we propose fast approximate methods for computing posterior marginals in spatial generalized linear mixed models. We consider the common geostatistical case with a high dimensional latent spatial variable and observations at known registration sites. The methods of inference are deterministic, using no simulation‐based inference. The first proposed approximation is fast to compute and is ‘practically sufficient’, meaning that results do not show any bias or dispersion effects that might affect decision making. Our second approximation, an improvement of the first version, is ‘practically exact’, meaning that one would have to run MCMC simulations for very much longer than is typically done to detect any indication of error in the approximate results. For small‐count data the approximations are slightly worse, but still very accurate. Our methods are limited to likelihood functions that give unimodal full conditionals for the latent variable. The methods help to expand the future scope of non‐Gaussian geostatistical models as illustrated by applications of model choice, outlier detection and sampling design. The approximations take seconds or minutes of CPU time, in sharp contrast to overnight MCMC runs for solving such problems.
Normal Mixture Quasi‐maximum Likelihood Estimator for GARCH Models
Authors: LEE TAEWOOK , LEE SANGYEOL
Published: September 2008

Abstract. The generalized autoregressive conditional heteroscedastic (GARCH) model has been popular in the analysis of financial time series data with high volatility. Conventionally, the parameter estimation in GARCH models has been performed based on the Gaussian quasi‐maximum likelihood. However, when the innovation terms have either heavy‐tailed or skewed distributions, the quasi‐maximum likelihood estimator (QMLE) does not function well. In order to remedy this defect, we propose the normal mixture QMLE (NM‐QMLE), which is obtained from the normal mixture quasi‐likelihood, and demonstrate that the NM‐QMLE is consistent and asymptotically normal. Finally, we present simulation results and a real data analysis in order to illustrate our findings.
Consensual NIMBYs, Contentious NIABYs: Explaining Contrasting Forms of Farmers GMO Opposition in Austria and France
Authors: Seifert Franz
Published: September 2008

This article contrasts forms of farmers’ resistance to genetically modified organisms (GMOs) in Austria and France. While Austrian farmers take a back seat in public opposition to GMOs, Austria's national GMO policy is designed to protect farmers, particularly organic farmers, by banning the unwanted technology. It thus mitigates both public controversy and the potential framing of the GMO issue which might go beyond a merely defensive ‘not in my back yard’ (NIMBY) rationale. French farmers’ protest, by contrast, is highly argumentative and is very much shaped by farmers’ protests. Its leading voice is the farmers’ union Confédération Paysanne and its spokesman José Bové, who employ spectacular protest strategies involving the destruction of GMO fields and acts of civil disobedience and figure prominently in the anti‐globalisation movement. In discussing the reasons for these differences, the analysis examines two approaches to political opportunity structures: a general and a dynamic, policy‐specific approach.
Where did Late Merge go? Grammaticalization as feature economy
Authors: Van Gelderen Elly
Published: September 2008

Abstract. Within early Minimalism, there are Economy Principles such as ‘Last Resort’, ‘Least Effort’, and also ‘Merge as Late as Possible’. The latter principle makes it possible to explain grammaticalization, an important phenomenon in language change. The general direction of change is one where lexical items are reanalyzed as grammatical (or functional) categories, e.g. verbs as auxiliaries and prepositions as complementizers. One explanation in terms of Late Merge is that if a lexical item is not immediately relevant for theta‐structure, it can wait and merge later, rather than merge early with additional movement. In later Minimalism, move is reformulated as internal merge and not considered more uneconomical than regular merge, renamed as external merge. This paper will provide ample examples of the workings of Late Merge and examine how we can capture the grammaticalization effects through an Economy Principle, Feature Economy, that is at work when children acquire a language as well as when language changes.
Types of DPs in OV order
Authors: Hróarsdóttir Þorbjörg
Published: September 2008

Abstract. This paper focuses on the loss of OV orders in the history of Icelandic, showing that change in word order cannot always be explained in terms of changes in morphology (loss of case). A modified version of earlier analyses of OV orders in Older Icelandic illustrates how mixed OV/VO word order patterns are due to a) information structure and prosodic parameters and b) that the pertinent change in the history of Icelandic can be adduced to one rule, namely the extraction of non‐finite VPs out of complex finite VP.
Not Enough Science or Not Enough Learning? Exploring the Gaps between Leadership Theory and Practice
Authors: Middlehurst Robin
Published: September 2008

This paper addresses the relationships between leadership theory, practice and development, drawing on both the higher education and wider leadership literature. It explores why challenges and problems exist within the contested field of leadership theory and why gaps remain between theory and practice after more than a century of research – and indeed, with increasing levels of research, scholarship and development in the last 25 years. After highlighting the importance of context for theory, practice and development, the first section of the paper examines a range of factors that contribute to theoretical ‘contests’ including different starting assumptions made by researchers, the different focus of studies, examination of different causal links to explain leadership, differences in values and cultural lenses and different constructs, terminology and perspectives. The second section examines the challenges faced by leadership practitioners, as individuals, and through exercising leadership as a collective responsibility in the context of changing operating environments within higher education institutions and across sectors and countries. The author highlights three areas where some re‐thinking of the links between theory and practice are necessary – at the input stage, linking research findings and recruitment practices; in terms of outcomes, by researching links between leaders, leadership and performance; and in process terms, to examine more deeply complex and relational dynamic of leadership in action. The third section offers a number of specific suggestions as to how closer alignment between theory, practice and development can be achieved. The paper concludes by arguing for greater maturity (in research, practice and development) that acknowledges that leadership is played out in complex, dynamic and changing social systems. A stronger emphasis on ‘leadership learning’ should deliver both better science and better outcomes for leaders and led in higher education.
MEMORY, MEMORIALS, AND COMMEMORATION1
Authors: KASABOVA ANITA
Published: September 2008

According to a popular view, the past is present here and now. This is presentism combined with endurantism: the past continuously persists through time to the present. By contrast, I argue that memories, memorials, and histories are of entities discontinuous with present experiences, and that the continuity between past and present in them is a construct. Memories, memorials, and histories are semantic means for dealing with the past. My presupposition that past and present are different is supported by grammar: as verbal tenses show, the past is not present here and now, for otherwise it would not be past. A failure to note this difference is a lack of chronesthesia, a sense of time specific to human beings. I argue that presentism fails to account for the temporal structures of memory and the changes in perspective as we switch from the present to a past situation. My account is perdurantist in the sense that it allows for temporal parts of things such as memorials or tombstones, as well as events such as wars or commemorations. But my main goal is to outline a semantic approach to the past: the tie between past and present actions and events is the semantic ground–consequence relation: a past event is the antecedent grounding a present situation, explaining why it is the case. In addition, I show how we refer to the past by means of two rhetorical figures of speech: synecdoche, using the (emblematic‐) part‐whole relation for relating the past to the present by transposing its sense; and anaphor, which has a deictic function—it points back toward the past. In references to the past, the deictic field is a scene visualized by the speaker and addressees: the deictic field is transposed from a perceptual to an imaginary space.
MAKING SENSE OF CONCEPTUAL CHANGE
Authors: KUUKKANEN JOUNI‐MATTI
Published: September 2008

Arthur Lovejoy's history of unit‐ideas and the history of concepts are often criticized for being historically insensitive forms of history‐writing. Critics claim that one cannot find invariable ideas or concepts in several contexts or times in history without resorting to some distortion. One popular reaction is to reject the history of ideas and concepts altogether, and take linguistic entities as the main theoretical units. Another reaction is to try to make ideas or concepts context‐sensitive and to see their histories as dynamic processes of transformation. The main argument in this paper is that we cannot abandon ideas or concepts as theoretical notions if we want to write an intelligible history of thought. They are needed for the categorization and classification of thinking, and in communication with contemporaries. Further, the criterion needed to subsume historical concepts under a general concept cannot be determined merely on the basis of their family resemblances, which allows variation without an end, since talk of the same concepts implies that they share something in common. I suggest that a concept in history should be seen to be composed of two components: the core of a concept and the margin of a concept. On the basis of this, we can develop a vocabulary for talking about conceptual changes. The main idea is that conceptual continuity requires the stability of the core of the concept, but not necessarily that of the margin, which is something that enables a description of context‐specific features. If the core changes, we ought to see it as a conceptual replacement.
The Laccaria genome: a symbiont blueprint decoded
Authors: Martin Francis , Selosse Marc‐André
Published: September 2008

Contents

Summary
296

I.
Introduction
297

II.
The ectomycorrhizal basidiomycete Laccaria bicolor
297

III.
Sequencing and assembly of the Laccaria bicolor genome
298

IV.
Synteny between genomes of symbiotic and saprotrophic fungi
300

V.
What's there and what's not
300

VI.
Expansion of multigene families
301

VII.
A niche for transposons
301

VIII.
The trading post for symbionts
302

IX.
Saprotrophic capabilities
302

X.
Laccaria secretome
303

XI.
Signalling pathways
304

XII.
Sex genes in Laccaria bicolor 
304

XIII.
Impact on the understanding of symbiotic and ecological evolution
305

XIV.
Tools and questions for population genetics and ecological genomics
306

XV.
More genomes of ectomycorrhizal fungi to come
306

XVI.
Conclusions
307

Acknowledgements
307

References
307
Ethnic competition and the logic of party system transformation
Authors: COAKLEY JOHN
Published: September 2008

This article adapts and expands a recent model of ethnic competition by exploring its implications over a long period spanning crucial stages in the modernisation of the political system. It illustrates the model by reference to developments in Northern Ireland since its modern party system was launched in the 1880s. This offers an exceptionally clear example of the interaction of central elements of the model: the initial bedding down of a system of bipartisan ethnic competition, with two parties having a remarkable capacity to resist ethnic outbidding; the fragmentation of this system following the introduction of a set of major institutional forms that facilitated ethnic outbidding; and the continuing resilience of ethnically based parties in warding off challenges from groups seeking to prioritise other political dimensions. The model's implications are tested against a comprehensive collection of ecological and survey data.
Costimulation blockade in transplantation of nerve allografts: long‐term effects
Authors: Kvist Martin , Kanje Martin , Ekberg Henrik , Corbascio Matthias , Dahlin Lars B.
Published: September 2008

Abstract  Costimulation blockade can prevent rejection of nerve allografts in short‐term studies. We tested if costimulation blockade also prevented rejection of nerve allografts in long‐term experiments, thereby improving functional recovery. A 7‐mm sciatic nerve defect in C57/BL6 mice was bridged either by nerve allografts from Balb/C mice or by isogenic nerve grafts (isografts) from C57/BL6 mice. Costimulation blockade in the form of a triple treatment with anti‐LFA‐1, anti‐CD40L, and CTLA4Ig was given at post‐operative days 0, 2, 4, and 6 (intraperitoneal). Control mice (placebo; allografts) with nerve grafts were treated with isotype antibodies during the same time period. After 49 days, tetanic muscle force, wet weight of gastrocnemius muscle, histology, and morphometry in the tibial nerve were evaluated. Costimulation blockade diminished rejection of the nerve allografts. Axons bridged the graft. Treatment increased wet weight of the gastrocnemius muscle and resulted in a higher mean myelin area/nerve fiber in the tibial nerve distal to the nerve grafts. Tetanic muscle force and number of axons in tibial nerve showed no differences between groups. We conclude that rejection is suppressed by costimulation blockade. Treatment improves recovery of target muscle and myelination after nerve allografting.
The Utah Early Neuropathy Scale: a sensitive clinical scale for early sensory predominant neuropathy
Authors: Singleton J. Robinson , Bixby Billie , Russell James W. , Feldman Eva L. , Peltier Amanda , Goldstein Jonathan , Howard James , Smith A. Gordon
Published: September 2008

Abstract  Early neuropathy is often sensory predominant and prominently involves small‐diameter nerve fibers. Established neuropathy examination scales such as the Michigan Diabetic Neuropathy Scale (MDNS) and the Neuropathy Impairment Score–Lower Leg (NIS‐LL) focus primarily on large‐fiber sensory and motor function. Here, we validate the Utah Early Neuropathy Scale (UENS), a physical examination scale specific to early sensory predominant polyneuropathy. Compared with other scales, the UENS emphasizes severity and spatial distribution of pin (sharp) sensation loss in the foot and leg and focuses less on motor weakness. UENS, MDNS, and NIS‐LL were compared in 215 diabetic or prediabetic subjects, with (129) or without neuropathy (86), and repeated in 114 neuropathy subjects after 1 year of follow‐up. Neuropathy severity was also evaluated with nerve conduction studies, quantitative sensory testing, quantitative sudomotor axonal reflex testing, and intraepidermal nerve fiber density determination. The UENS had a high degree of interrater reliability (interclass correlation of 94%). UENS correlated significantly to MDNS and NIS‐LL (p < 0.01), and more significantly than MDNS or NIS‐LL to confirmatory tests. In this cohort, UENS had a superior profile to receiver operating characteristic analysis across a range of scores, with a sensitivity (92%) higher than MDNS (67%) or NIS‐LL (81%), without sacrificing specificity. UENS more closely correlated with change in ancillary and small‐fiber neuropathy measures over 1 year follow‐up than did MDNS or NIS‐LL. UENS is a sensitive and reproducible clinical measure of sensory and small‐fiber nerve injury and may be useful in trials of early neuropathy.
C5 inhibitor rEV576 protects against neural injury in an in vitro mouse model of Miller Fisher syndrome
Authors: Halstead Susan K. , Humphreys Peter D. , Zitman Femke M.P. , Hamer John , Plomp Jaap J. , Willison Hugh J.
Published: September 2008

Abstract  Guillain‐Barré syndrome and its clinical variants, including the anti‐GQ1b ganglioside–mediated Miller Fisher syndrome (MFS), comprise the world’s leading cause of acute neuromuscular paralysis. Presently, no specific drug therapies exist. The complement cascade, which is activated in these patients, forms an attractive drug target. In this study, we tested whether the complement C5–inhibiting recombinant protein, rEV576, was able to prevent neural injury in a previously developed in vitro mouse model for MFS. Mouse hemidiaphragm preparations were treated with anti‐GQ1b antibody and normal human serum as a source of complement with added rEV576 or control protein. Immunohistology in control tissue showed deposition of C3c and membrane attack complex at neuromuscular junctions (NMJs), along with terminal motor axonal neurofilament degradation as well as ethidium homodimer‐2 staining showing perisynaptic Schwann cell (pSC) injury. Electrophysiological and functional analyses showed block of synaptic transmission at the NMJ after an initial period of a dramatically high level of asynchronous acetylcholine release. In tissue treated with rEV576, all these indicators of motor neuronal damage were absent, except for the presence of C3c, indicating effective inhibition of C5. These results demonstrate that rEV576 effectively prevents development of neuronal and pSC damage in experimental murine neuropathy.
The Politics of Foreign Direct Investment into Developing Countries: Increasing FDI through International Trade Agreements?
Authors: Büthe Tim , Milner Helen V.
Published: September 2008

The flow of foreign direct investment into developing countries varies greatly across countries and over time. The political factors that affect these flows are not well understood. Focusing on the relationship between trade and investment, we argue that international trade agreements—GATT/WTO and preferential trade agreements (PTAs)—provide mechanisms for making commitments to foreign investors about the treatment of their assets, thus reassuring investors and increasing investment. These international commitments are more credible than domestic policy choices, because reneging on them is more costly. Statistical analyses for 122 developing countries from 1970 to 2000 support this argument. Developing countries that belong to the WTO and participate in more PTAs experience greater FDI inflows than otherwise, controlling for many factors including domestic policy preferences and taking into account possible endogeneity. Joining international trade agreements allows developing countries to attract more FDI and thus increase economic growth.
Substitution Is in the Variance: Resources and Foreign Policy Choice
Authors: Clark David H. , Nordstrom Timothy , Reed William
Published: September 2008

This article argues that foreign policy substitution arises as a result of the costs of foreign policies relative to state resources. States with few resources are constrained in foreign policy choice compared to states with an abundance of resources. As a result, states with few resources will, on average, select, lower‐cost policies than will resource‐rich states. Resource‐rich states, by virtue of their abundant resources, have greater discretion over policy choice and thus behave less uniformly than do resource‐poor states. Our empirical results provide evidence of this and support the argument that substitution is in the variance.
Power Politics and Wars without States
Authors: Lemke Douglas
Published: September 2008

In order to evaluate the applicability of power politics theories of war and international stability to interactions among nonstate actors, I test hypotheses from power transition theory and from neorealist arguments about systemic polarity against the behavior of 20 state and nonstate actors in nineteenth‐century South America. I find considerable support for two of the three hypotheses tested and conclude that existing IR theory has more explanatory power within the empirical domain of nonstate relations than critics of such theory claim.
The Externalities of Civil Strife: Refugees as a Source of International Conflict
Authors: Salehyan Idean
Published: September 2008

Domestic strife and civil war frequently produce large population dislocations and refugee flows across national boundaries. Mass refugee flows often entail negative consequences for receiving states, particularly in developing countries. Moreover, civil violence frequently extends across national boundaries as “internal” conflicts are not constrained by borders. This article argues that refugee flows between states significantly increase the likelihood of militarized interstate disputes (MIDs) in that dyad. Refugee‐receiving states are more likely to initiate MIDs as they intervene to prevent further externalities, and refugee‐sending states initiate MIDs as they violate borders in pursuit of dissidents. Moreover, this research challenges conventional theories of international conflict that focus exclusively on distributional bargains between states. These propositions are tested in a quantitative analysis of the relationship between refugees and MID initiation, 1955–2000. Results confirm that refugees significantly increase the probability of international conflict.
Public Regulation and Private Lawsuits in the American Separation of Powers System
Authors: Farhang Sean
Published: September 2008

This article investigates causes of the legislative choice to mobilize private litigants to enforce statutes. It specifies the statutory mechanism, grounded in economic incentives, that Congress uses to do so, and presents a theoretical framework for understanding how certain characteristics of separation of powers structures, particularly conflict between Congress and the president over control of the bureaucracy, drive legislative production of this mechanism. Using new and original historical data, the article presents the first empirical model of the legislative choice to mobilize private litigants, covering the years 1887 to 2004. The findings provide robust support for the proposition that interbranch conflict between Congress and the president is a powerful cause of congressional enactment of incentives to mobilize private litigants. Higher risk of electoral losses by the majority party, Democratic control of Congress, and demand by issue‐oriented interest groups are also significant predictors of congressional enactment of such incentives.
Dealing in Discipline: Party Switching and Legislative Voting in the Italian Chamber of Deputies, 1988–2000
Authors: Heller William B. , Mershon Carol
Published: September 2008

Compared to U.S. political parties, parties in Italy (and Europe generally) are quite cohesive. Rarely do members of parliament vote against their copartisans in legislative divisions. Yet in Italy in recent years, legislators switch parties with seeming abandon. Between 1996 and spring 2000, one out of four deputies in the Chamber of Deputies switched parties at least once, compared to only 20 switches in the U.S. Congress from 1947 to 1997 (Nokken 2000). We examine the relationship between switching and observed party unity in Italy by focusing on individual legislators' switching decisions and voting behavior. Overall, switchers move out of highly disciplined parties, suggesting that they switch partly in order to escape strong discipline.
On Latent‐Variable Model Misspecification in Structural Measurement Error Models for Binary Response
Authors: Huang Xianzheng , Tebbs Joshua M.
Published: September 2008

Summary We consider structural measurement error models for a binary response. We show that likelihood‐based estimators obtained from fitting structural measurement error models with pooled binary responses can be far more robust to covariate measurement error in the presence of latent‐variable model misspecification than the corresponding estimators from individual responses. Furthermore, despite the loss in information, pooling can provide improved parameter estimators in terms of mean‐squared error. Based on these and other findings, we create a new diagnostic method to detect latent‐variable model misspecification in structural measurement error models with individual binary response. We use simulation and data from the Framingham Heart Study to illustrate our methods.
Teaching Spanish to Emergency Medicine Residents
Authors: Prince Diana , Nelson Marc
Published: September 2008

Objective: To determine the effects of teaching medical Spanish to eight PGY1 emergency medicine residents on their subsequent interactions with Spanish‐speaking patients.

Methods: Eight PGY1 residents completed a 45‐hour medical Spanish course administered during their first residency month. Thirty‐four subsequent physician‐patient interactions by these residents were audiotaped over a six‐month period at a suburban teaching ED. The tapes were transcribed and analyzed for errors by a professional medical Spanish interpreter and a native Spanish speaker.

Results: Minor errors (e.g., technically incorrect grammar or vocabulary with generally appropriate patient understanding) were found in more than half of the interactions and major errors (e.g., misunderstanding duration of symptoms, misunderstanding of vocabulary) were found in 14% of the interactions. In addition, although the course was designed to supplement, not replace, professional interpreters, the residents called for an interpreter only 46% of the time.

Conclusion: Although medical language courses may be a useful adjunct to interpreters, they are not designed to replace them. Significant errors may occur when participants in such courses assume their knowledge is sufficient to obtain a good history, give patient release instructions, and provide medical care in general without an interpreter present.
Position of Epicardial Patch Electrodes for Implantable Defibrillation Significantly Affects Shock Strength Requirements
Authors: Knight Bruce H. Ken , Heil John E. , Hahn Stephen J. , Lang Douglas J.
Published: September 2008

Objective: To assess the impact of epicardial patch electrode position on internal defibrillation efficacy.

Methods: Two mesh patch electrodes (13 cm2) were positioned on the epicardium of acute, isoflurane‐ anesthetized pigs (n = 7, 40–47 kg). Defibrillation efficacy was determined for three different patch positions: P1 = anterior‐basal right ventricle (RV) and lateral‐apical left ventricle (LV); P2 = lateral RV and lateral LV; and P3 = anterior‐basal septal region and posterior‐apical septal region. To quantify defibrillation efficacy, single capacitor discharge, fixed‐tilt (68%) biphasic waveforms were delivered to the heart 10 seconds after initiation of ventricular fibrillation. Initial shock intensities were selected using an up/down protocol. Conversion data were used to construct sigmoidal curves relating probability of defibrillation to energy delivered, peak voltage, and peak current in each animal.

Results: Mean peak voltage and current at 50% defibrillation probability were 40% higher for P2 than they were for either P1 or P3 (p < 0.05). Similarly, mean energy delivered was 75% higher for P2. In this pig model, position of epicardial patch electrodes affects defibrillation efficacy.

Conclusion: Apical‐to‐basal shock vectors (P1 and P3) yielded significantly lower defibrillation shock strength requirements than did a lateral‐wall‐to‐lateral‐wall vector (P2), which was perpendicular to the intraventricular septum. These data may help explain the disparity in defibrillation thresholds observed in the human population of patients undergoing implantable cardioverter defibrillator testing with epicardial patch electrodes.
Countershock Strength‐Duration Relationship for Myocardial Refractory Period Extension
Authors: Sweeney Robert J. , Gill Robert M. , Reid Philip R.
Published: September 2008

Objectives: To determine the strength‐duration relationship for refractory period extension (RPE) in order to understand better the influence of shock waveform on RPE.

Methods: In six open‐chest pentobarbital‐anesthetized dogs, the RPE was measured by rectangular transcardiac shocks that produced 2– to 32‐V/cm local voltage gradients at the measurement site. At each intensity, measurements were made for shocks with 2– to 32‐msec durations delivered 30 msec before the end of the tissue refractory period.

Results: These shocks produced up to 40% RPE. The RPE varied strongly with shock intensity and duration, with more RPE for stronger or longer shocks. At 32 V/cm, early portions of the shock waveform contributed most to RPE. At 8 and 16 V/cm, later portions made relatively larger contributions that were still smaller than those of the early portions. At 4 V/cm, the contributions to total RPE were spread over the entire waveform. At 2 V/cm, shocks failed to produce significant RPE.

Conclusions: For rectangular shock waveforms, the relationship between RPE and duration is approximately linear at low intensity, but at higher intensity greater RPE is produced by earlier, rather than later, portions of the waveform. This may be because RPE by early portions of the waveform changes the effective timing in the refractory period for later portions of the same waveform. These results' provide new insight into the possible role of waveform on defibrillation efficacy.
Esophageal Countershock: Anthropometric Determinants of Impedance
Authors: McKeown Pascal P. , Croal Simon , Allen J. Desmond , Anderson John , Khan Mazhar M. , Adgey A. A. Jennifer
Published: September 2008

Objective: To examine the use of a novel esophageal electrode system for countershock of atrial and ventricular tachyarrhythmias, with particular regard to the measurement of transesophageal and transthoracic impedances and their association with anthropometric variables.

Methods: Transesophageal cardioversion was attempted during 131 episodes of arrhythmia in 105 patients (including 109 episodes of atrial fibrillation). The esophageal system also was used in 29 patients undergoing electrophysiologic studies for investigation of ventricular tachyarrhythmias. Transesophageal and transthoracic impedances were estimated during passage of a high‐frequency, low‐amplitude current between the respective electrodes. Impedance estimates were associated with anthropometric measurements using linear regression (least‐squares method).

Results: In the group of patients undergoing attempted transesophageal cardioversion, the mean estimated transesophageal impedance of 52.6 ± 11.7 Ω was significantly lower than the mean estimated transthoracic impedance of 63.1 ± 16.4 Ω(n = 104, p < 0.01). For all the patients, transesophageal impedance was associated with weight, body mass index, and chest circumference (all r 0.65, p < 0.01). Transthoracic impedance was associated with the same factors (all r 0.55, p < 0.01).

Conclusion: This esophageal electrode system results in lower impedance values for countershock between the esophagus and the cutaneous cardiac apex in comparison with standard transthoracic cutaneous electrode placement. Both techniques are dependent on anthropometric factors.
Association of Out‐of‐hospital Criteria with Need for Hospital Admission
Authors: Burstein Jonathan L. , Hollander Judd E. , Henry Mark C. , Delagi Robert , Thode Henry C.
Published: September 2008

Objective: To validate high‐risk historical and physiologic out‐of‐hospital criteria as predictors of the need for hospitalization following ED evaluation.

Methods: Consecutive patients entered into the Suffolk County advanced life support system were enrolled. Previously proposed historical and physiologic “high‐risk” criteria for hospitalization were prospectively collected. Criteria were associated with the need for hospital admission following ED evaluation.

Results: 1,238 patients were enrolled; 391 were released from an ED after transport. Most patients (843/1,238; 68%) were admitted to a hospital; and four died in the ED. Factors associated with an increased likelihood of admission or death among the transported patients were: bradycardia (90% admitted, p < 0.02); hypotension (80%, p < 0.03); hypertension (89%, p < 0.03); and age > 55 years (81%, p < 0.0001). Unresponsiveness and other abnormal vital signs were not associated with admission on univariate analysis. Logistic regression analysis identified two other factors associated with admission or death: tachycardia (72%, admitted, p < 0.01) and head injury (78% admitted. p < 0.001).

Conclusions: Abnormal pulse or blood pressure, head injury, and age > 55 years are associated with patients' requiring hospital admission after accessing the emergency medical services system. These criteria may aid the design of out‐of‐hospital refusal‐of‐care policies.
Ultrasonographic Examination by Emergency Physicians of Patients at Risk for Ectopic Pregnancy
Authors: Mateer James R. , Aiman E. James , Brown Michael H. , Olson David W.
Published: September 2008

Objective: To evaluate a diagnostic protocol that includes the early use of endovaginal sonography (EVS) by emergency physicians of patients at risk for ectopic pregnancy.

Methods: During this prospective study. pregnant patients ≥ 18 years old and at risk for ectopic pregnancy were assessed. Emergency physicians who had completed a training program performed EVS on a convenience sample of eligible women. Clinical disposition was based on predetermined clinical, laboratory, and ultrasonographic criteria. The EVS examinations were reviewed on video by a gynecologist whose interpretation was correlated with the emergency physician EVS readings and with the final clinical diagnoses. Quantitative serum P‐human chorionic gonadotropin (βhCG) levels were determined for patients who had no definite intrauterine pregnancy (IUP) on EVS.

Results: Of 157 patients studied during a 12‐month period. four were lost to follow‐up. Emergency physician ultrasonographic diagnoses included: definite IUP, 87/146 (59%): probable abnormal IUP. 17/148 (11%); definite ectopic pregnancy. 31148 (2%); and no definite IUP. 41/148 (28%). The gynecologist agreed with 93% of the initial interpretations. Twelve of 16 patients who had the final diagnosis of ectopic pregnancy were admitted from the ED with this diagnosis. The ultrasonographic diagnosis of the other four was no definite IUP. and no mass or free fluid. For the latter four patients, the presenting serum βhCG level was < 2,000 mlU/mL (First International Reference Preparation). They were diagnosed as having ectopic pregnancy after serial outpatient EVS and βhCG measurements.

Conclusions: The application of EVS to emergency practice appears promising. Emergency physicians trained in its use and who apply this diagnostic tool in conjunction with a defined protocol can stratify the risk of patients who have the potential for ectopic pregnancy.
Continuous Noninvasive Determination of Pulsus Paradoxus: A Pilot Study
Authors: Steele Dale W. , Wright Robert O. , Lee Calvin M. , Jay Gregory D.
Published: September 2008

Objective: To evaluate two methods of continuous, noninvasive monitoring of pulsus paradoxus (PP).

Methods: A single‐subject, nonblind assessment was conducted of the ability of noninvasive monitoring techniques to measure experimentally induced PP. Variable degrees of PP were induced in a healthy adult breathing through a oneway valve to which a series of external airway resistances were added. Intra‐arterial pressure (IAP), finger arterial blood pressure (FINAP), pulse oximeter pulse waveform, and chest wall motion were continuously recorded. For each resistance, PP was calculated from the IAP (PPIAP) and the FINAP (PPFINAP) recordings. PP was measured manually (PPmanual) in the opposite arm. The percentage pulse waveform decrease on inspiration (%PWDpleth) was derived from the oximeter pulse waveform. These measurements were compared with the PPIAP. Bias was assessed as the mean difference between PP measures.

Results: PPFINAP, was highly correlated with PPIAP (r = 0.96; 95% CI 0.93 to 0.98; p < 0.0001). There was a weak correlation between PPmanual and PPIAP (r = 0.27; 95% CI ‐0.05 to 0.55; p = 0.0963). The %PWDpleth correlated with PPIAP (r = 0.59, 95% CI 0.32 to 0.78; p = 0.0002). Bias was ‐1.515 ± 5.6 mm Hg between PPIAP and PPFINAP; and ‐4.508 ± 23.4 mm Hg between PPIAP and PPmanual.

Conclusion: An accurate and continuous PP can be measured noninvasively using a FINAP monitor. This method has much better agreement with IAP measurements than do manual measurements. The qualitative information provided by the oximeter pulse waveform is less accurate than that provided by the FINAP monitor, but is a potentially useful screening tool for detection of significant PP.
Evaluation of Capnography in Nonintubated Emergency Department Patients with Respiratory Distress
Authors: Plewa Michael C. , Sikora Steven , Engoren Milo , Tome Daniel , Thomas James , Deuster Anthony
Published: September 2008

Objective: To evaluate the ability of noninvasive capnographic measurement of end‐tidal CO2 tension (Petco2) to predict artenal CO2 tension (Paco2) in nonintubated ED patients with respiratory distress

Methods: A prospective, nonblind study was performed in a level I trauma centerkommunity teaching hospital ED. Participants included all nonintubated adult patients with respiratory distress requiring measurement of arterial blood gases (ABGs): 29 patients were enrolled Petcoz was measured with a capnography monitor. using both baseline tidal volumes and forced expiratory volumes. The bias between Petco? values and simultaneous measurements of Paco2 by ABG was assessed

Results: Petco, measured with forced expiration, and Pace? agreed well, with bias (i.e, average difference) = 044 ± 0.52 kPa (33 ± 3.9 torr). Petco2 measured with the tidal volume breath produced an unacceptably high bias of 0.82 ± 0.70 kPa (6.1 ± 5.2 torr). Levels of agreement between Paco2 and Petco2 were similar for smokers and nonsmokers and for men and women. The arterial‐end‐tidal CO2 tension (Pa‐etco2) difference was not related to Paco2 Pa‐etco2 correlated with age (r = 0.473; p = 0.01), and was significantly higher in patients with pulmonary disease (132 ± 0S6 kPa; 99 ± 42 torr) than it was in those without pulmonary disease (0.46 ± 055 kPa, 3.5 ± 4.1 torr, p < 0.001).

Conclusions: Noninvasive Petcoz monitoring may adequately predict Paco2 in nonintubated ED patients with respiratory distress who, are able to produce a forced expiration. Petco2 is less accurate for Paco2 with tidal volume breathing and in patients with pulmonary disease
Observation of Emergency Medicine Residents at the Bedside: How Often Does It Happen?
Authors: Burdick William P. , Schoffstall John
Published: September 2008

Objective: To determine how often trainees in emergency medicine (EM) are observed while performing a history, a physical examination, or specific procedures.

Methods: The 26 members of the National Consensus Group on Clinical Skills in Emergency Medicine affiliated with an EM residency program were asked to circulate a survey to their residents during February and March 1994. Twenty‐one programs participated. surveying a total of 514 residents. The residents were asked how many times they had been observed by an attending physician while they performed a history, a physical examination. endotracheal intubation. or central vein catheterization during training. The residents also were asked about observation of specific components of the physical examination. such as the heart. lung, and genitourinary systems.

Results: Three hundred nineteen residents (62%) responded to the survey. Thirteen percent of the residents reported that they had never been observed taking a history during training. During their PGYI training, 19% of the residents reported that they had never been observed taking a history, 42% had been observed one to three times, 255% had been observed four to 12 times. and 13% had been observed >12 times. Six percent of the residents reported that they had never been observed doing a physical examination during training. During their PGYI training, 10% of the residents had never been observed performing a physical examination, 38% had been observed one to three times. 34% had been observed four to 12 times, and 18% had been observed >12 times.

Conclusions: Many residents report that they are infrequently observed performing histories and physical examinations during their EM training. with a significant number of residents reporting that they were never observed performing basic bedside clinical skills. More direct observation with trained faculty observers may provide an opportunity for better evaluation and remediation of bedside clinical skills.
Effective Treatment for Acute Alkali Injury to the Esophagus Using Weak‐acid Neutralization Therapy: An Ex‐vivo Study
Authors: Honiun Clark S. , Mairra Subir R. , Lane Bernard P. , Thode Henry C. , Finkelshteyn Jonathan , Davidson Lev
Published: September 2008

Objective: 1) To evaluate whether neutralization therapy with weak acid is effective in reducing observed histopathologic esophageal tissue injury secondary to liquid alkali. 2) to quantify the temperature change of the neutralizing agent. and 3) to determine the effect of interval to therapy on injury severity.

Methods: Harvested Sprague‐Dawley rat esophagi were catheterized and placed in an oxygenated saline bath (37°C) for 60 minutes and then fixed in 10% formalin. Nine groups (ti = 10) were perfused with 50% sodium hydroxide (NaOH). Six of the groups were treated hy neutralization with cooled orange juice (OJ) or cola that was maintained between 2°C and 4°C. This was performed at 0, 5. or 30 minutes after injury. In addition, two positive control groups were exposed to OJ or cola at time 0 and were not exposed to strong alkali. A third control group was exposed to strong alkali hut was not administered any subsequent treatment. The temperature of the neutralizing agent was recorded prior to instillation and after exiting the esophagus. Blinded pathologic scoring of 0 (no injury) to 3 (severe) was performed for six histopathologic categories: epithelial cell viability, cornified epithelial cell differentiation, granular cell differentiation. epithelial cell nuclei, muscle cells, and muscle cell nuclei. Comparisons were made among treatment times using the Kruskal‐Wallis test and linear trend analysis.

Results: For each histopathologic category and each treatment mode, the Kruskal‐Wallis test showed significant differences between the groups (p < 0.003) over time. Trend analyses showed more severe injury with delayed ncutralization therapy (p < 0.05) for each treatment mode and histopathologic category.

Conclusion: Early neutralization therapy with OJ or cola reduces acute esophageal alkali injury. Additional in‐vivo study is needed before neutralization therapy is adopted for clinical use.
Lack of a Hyperkalemic Response in Emergency Department Patients Receiving Succinylcholine
Authors: Zink Brian J. , Snyder Howard S. , Raccio‐Robak Nancy
Published: September 2008

Objective: To determine whether serum potassium (K) levels increase significantly following succinylcholine (SCh)‐assisted intubation in ED patients.

Methods: A prospective. noncontrolled, consecutive case series design was used to evaluate the change in serum K levels in ED patients who received SCh for emergency intubation. The study was performed at an academic medical center staffed by board‐certified emergency physicians. The subjects were 100 consecutive prescreened ED patients with various diagnoses who received SCh for intubation. The eligible subjects had serum K levels determined prior to and 5 minutes after administration of a 1.0–1.5‐mg/kg IV dose of SCh. Serum K levels were measured by the ionselective electrode assay method.

Results: The mean change in serum K levels was ‐0.04 mmol/L (95% CI ‐0.14 to 0.06). The maximum increase was 1.10 mmol/L. The serum K level rose in 46 cases, decreased in 46 cases, and was unchanged in eight cases. No instance of SCh‐induced cardiac arrest was identified.

Conclusion: Changes in serum K levels following SCh administration in prescreened ED patients were minimal. A hyperkalemic response is uncommon in ED patients who undergo SCh‐assisted intubation.
Ethics of Emergency Department Triage: SAEM Position Statement
Authors:   SAEM Ethics Committee
Published: September 2008

Emergency department overcrowding, the growth of managed care, and the high cost of emergency care are creating pressures to triage patients away from US. EDs. Paradoxically. this pressure to limit patient access to EDs has increased in spite of federal laws that restrict patient triage and transfer The latter regulations view EDs as the safety net for the US health care system. The SAEM Ethics Committee evaluated the ethical implications of policies that triage patients nut of the ED prior to complete evaluation and treatment. The committee used these implications to develop practical guidelines, which are reported.