bluuebunny/crossref_metadata_2025 huggingface dataset:
Purification of Porous Zircon by Carbochlorination
Authors: Jr. Pavlik Robert S. , Sempolinski Daniel R. , Froberg Robert
Published: March 2010

Porous zircon refractory brick were carbochlorinated to remove tramp impurities. The peak temperature of this process did not exceed 1400°C. Chemical analysis results showed the level of impurities removed. High‐temperature mass spectrometry results as a function of increased temperature showed how the volatilization behavior of zircon changed after carbochlorination. High‐temperature (1400°C) modulus of rupture tests were performed, and no degradation in average strength to failure was observed. Little or no change in bulk density, porosity, or zircon microstructure was observed. Carbochlorinated zircon refractories were used to build production‐sized glassmaking furnaces for manufacturing high‐optical‐quality glass.
Preparation of YBCO Films on CeO2‐Buffered (001) YSZ Substrates by a Non‐Fluorine MOD Method
Authors: Xu Y. , Goyal A. , Lian J. , Rutter N. A. , Shi D. , Sathyamurthy S. , Paranthaman M. , Wang L. , Martin P. M. , Kroeger D. M.
Published: March 2010

YBa2Cu3O7−δ(YBCO) films were fabricated via a fluorine‐free metal organic deposition (MOD) method followed by high‐temperature, low oxygen partial pressure annealing. Trimethyl acetate salts of copper, yttrium, and barium hydroxide were used as the precursors, which were dissolved in proponic acid‐ and amine‐based solvents. After spin‐coating and burnout, samples were annealed at 740°C in 180 ppm oxygen partial pressure and exposed to humid atmosphere for different times. A critical transition temperature,Tc(R=0) of 90.2 K and a transport critical current density (Jc) of 0.55 MA/cm2(77 K and self‐field) were obtained for 0.2 μm YBCO films on CeO2‐buffered yttria‐stabilized zirconia (YSZ) substrates. X‐ray studies shows that the YBCO films have sharp in‐plane and out‐of‐plane texture for all samples; however, the porosity of the YBCO film varies with the time of exposure to the humid atmosphere. A reaction between YBCO and CeO2during the high‐temperature anneals and formation of the reaction product BaCeO3was confirmed by X‐ray diffraction (XRD) studies. The XRD and transmission electron microscopy analysis indicated that the epitaxial relations in the film were YBCO (00l)//CeO2(00l)//YSZ (00l) and YBCO [100]//CeO2[110]//YSZ [110].
Crack Interactions in Laminar Ceramics That Exhibit a Threshold Strength
Authors: Moon Haksung , Pontin Michael G. , Lange Fred F.
Published: March 2010

Laminar ceramic composites have been fabricated with thin compressive layers, containing a mixture of alumina and mullite, sandwiched between thicker alumina layers. It has previously been shown that a single crack that extends within a thicker alumina layer can be arrested by the compressive layers to produce a threshold strength, i.e., a strength below which the probability of failure is zero. The behavior of multiple cracks within the laminate has been investigated, to observe the mechanisms of crack interaction and measure their influence on the threshold strength. It was found that when the cracks in adjacent thick layers were offset by a distance less than the thickness of two thick layers, the cracks would interact and decrease the threshold strength. The number of interacting cracks, their orientation, and location can also have an effect on the threshold strength.
Phase Relations and Microstructural Development of Aluminum Nitride–Aluminum Nitride Polytypoid Composites in the Aluminum Nitride–Alumina–Yttria System
Authors: Tangen Inger‐Lise , Yu Yingda , Grande Tor , Høier Ragnvald , Einarsrud Mari‐Ann
Published: March 2010

AlN–AlN polytypoid composite materials were preparedin situusing pressureless sintering of AlN–Al2O3mixtures (3.7–16.6 mol% Al2O3) using Y2O3(1.4–1.5 wt%) as a sintering additive. Materials fired at 1950°C consisted of elongated grains of AlN polytypoids embedded in equiaxed AlN grains. The Al2O3content in the polytypoids varied systematically with the overall Al2O3content, but equilibrium phase composition was not established because of slow nucleation rate and rapid grain growth of the polytypoid grains. The polytypoids, 24Hand 39R, previously not reported, were identified using HRTEM. Solid solution of Y2O3in the polytypoids was demonstrated, and Y2O3was shown to influence the stability of the AlN polytypoids. The present phase observations were summarized in a phase diagram for a binary section in the ternary system AlN–Al2O3–Y2O3parallel to the AlN–Al2O3join. Fracture toughness estimated from indentation measurements gave no evidence for a strengthening mechanism due to the elongated polytypoids.
Effect of External Electric Field on the Grain‐Growth Behavior of Barium Titanate
Authors: Jin Hong‐Ri , Yoon Seok‐Hyun , Lee Jong‐Heun , Lee Je‐Hun , Hwang Nong M. , Kim Doh‐Yeon , Han Joo‐Hwan
Published: March 2010

The effect of an external electric field on the grain‐growth behavior of acceptor Mg‐doped, undoped, and donor Nb‐doped BaTiO3 ceramics was investigated. The acceptor‐doped and undoped specimens showed enhanced grain growth at the positive‐biased region. On the other hand, for the highly donor‐doped specimens, grain growth was enhanced in the negative‐biased region. The results have been explained in terms of defect polarization and the consequent change in the boundary potential. It has been suggested that liquid penetration into grain boundaries is critically dependent on the boundary potential.
Low‐Temperature Synthesis of Nanocrystalline Zinc Titanate Materials with High Specific Surface Area
Authors: Hosono Eiji , Fujihara Shinobu , Onuki Megumi , Kimura Toshio
Published: March 2010

Nanocrystalline zinc titanate (ZnTiO3) was synthesized at low temperatures through the combination of a sol–gel processing and a polymer binder method. ZnTiO3 powders of ∼5 nm in size were obtained by heating pastes, which were composed of a Zn‐Ti methanolic solution containing acetylacetone and an organic polymer binder, at 500°C in air. Thermal decomposition behavior of the pastes was analyzed by thermogravimetry‐differential thermal analysis. Crystallinity of ZnTiO3 was examined by transmission electron microscopy. The BET measurement revealed that the powders had a relatively high specific surface area of 106 m2/g.
Electrical Conduction Behavior of La1+xSr1−xGa3O7–δ Melilite‐Type Ceramics
Authors: Rozumek Michael , Majewski Peter , Schluckwerder Heike , Aldinger Fritz , Künstler Klaus , Tomandl Gerhard
Published: March 2010

Ceramics of the melilite‐type compound La1+xSr1−xGa3O7−δ were prepared by conventional ceramic processing. Samples prepared represented the entire homogeneity region of the phase (i.e., x=−0.15 to 0.60). Electrochemical characterization under variable temperature and atmospheric conditions in the vicinity of air entailed four‐point direct‐current conductivity measurements and electromotive force measurements. La1+xSr1−xGa3O7−δ samples exhibited a p‐type behavior with generally increased conductivity with increased substitution of lanthanum for strontium, which reached a saturation value of ∼10−1 S·cm−1 at 950°C.
New Method to Prepare Nitrogen‐Doped Titanium Dioxide and Its Photocatalytic Activities Irradiated by Visible Light
Authors: Yang Songwang , Gao Lian
Published: March 2010

A Ti‐based metal organic compound is taken as the precursor to be decomposed in NH3 flow at a certain temperature to prepare modified TiO2 with high photocatalytic activity under visible‐light irradiation. The processes of doping and crystallization of TiO2 are conducted at the same time during the treatment in the NH3 flow. This approach could efficiently dope N into anatase TiO2 lattice. The prepared TiO2 also has well‐defined mesoporosity with a BET area of 217 m2/g.
The Tokyo Subway Sarin Attack: Disaster Management, Part 1: Community Emergency Response*
Authors: Okumura Tetsu , Suzuki Kouichiro , Fukuda Atsuhiro , Kohama Akitsugu , Takasu Nobukatsu , Ishimatsu Shinichi , Hinohara Shigeaki
Published: March 2010

Abstract. The Tokyo subway sarin attack was the second documented incident of nerve gas poisoning in Japan. Prior to the Tokyo subway sarin attack, there had never been such a large‐scale disaster caused by nerve gas in peacetime history. This article provides details related to how the community emergency medical services (EMS) system responded from the viewpoint of disaster management, the problems encountered, and how they were addressed. The authors' assessment was that if EMTs, under Japanese law, had been allowed to maintain an airway with an endotracheal tube or use a laryngeal mask airway without physician oversight, more patients might have been saved during this chemical exposure disaster. Given current legal restrictions, advanced airway control at the scene will require that doctors become more actively involved in out‐of‐hospital treatment. Other recommendations are: 1) that integration and cooperation of concerned organizations be established through disaster drills; 2) that poison information centers act as regional mediators of all tox‐icologic information; 3) that a real‐time, multidirectional communication system be established; 4) that multiple channels of communication be available for disaster care; 5) that public organizations have access to mobile decontamination facilities; and 6) that respiratory protection and chemical‐resistant suits with gloves and boots be available for out‐of‐hospital providers during chemical disasters.
Intracranial Hemorrhage Associated with Tangential Gunshot Wounds to the Head
Authors: Anglin Deirdre , Hutson H. Range , Luftman Joseph , Qualls Stephanie , Moradzadeh Doris
Published: March 2010

Abstract. Tangential gunshot wounds (TGSWs) to the head are gunshot wounds in which the bullet or bullet fragments do not penetrate the inner table of the skull. Objectives: To determine the occurrence of intracranial hemorrhage (ICH) associated with TGSW to the head and to assess the ability of selected clinical criteria to predict ICH in this patient population. Methods: A retrospective chart review of patients diagnosed as having TGSWs to the head presenting to the ED of Los Angeles County + University of Southern California Medical Center from October 1, 1993, to May 31, 1996. Results: Four hundred twenty patients with gunshot wounds to the head presented to the ED. CT confirmed the diagnosis of TGSWs in 154 patients (36.7%). Head CT of patients with TGSWs revealed 25 (16.2%) skull fractures and 37 (24.0%) ICHs. Fourteen (56.0%) skull fractures were depressed. Of patients with a CT‐doc‐umented TGSW to the head, 23 (16.1%) had a history of a loss of consciousness (LOC), 129 (84.3%) had a normal neurologic examination in the ED, 17 (11.1%) had a Glasgow Coma Scale score (GCS) < 15, and 75 (48.7%) had retained extracranial bullets or bullet fragments. Of all patients with TGSWs to the head, 113 had a GCS of 15 with no LOC and a normal neurologic examination, with 17 of these 113 patients (15.0%) having ICH. One patient died while hospitalized. Fifty‐six (36.6%) patients were released home directly from the ED. Five clinical criteria (history of LOC, GCS < 15 on ED presentation, skull fracture, location of TGSW on the skull, and presence of extra‐cranial bullet fragments) were examined to determine their ability to predict ICH. None of these criteria either alone or in combination were adequately predictive of ICH. Conclusion: In this series, 1 in 4 patients with a TGSW to the head had an ICH. All patients with TGSWs to the head should undergo head CT to rule out depressed skull fractures and ICH.
Pediatric Pedestrian Injuries: A Community Assessment Using a Hospital Surveillance System
Authors: Calhoun Alice D. , Jr. Gerald McGwin , King William D. , Rousculp Matthew D.
Published: March 2010

Abstract. Objective: To provide a descriptive demographic and environmental account of pedestrian injuries among children aged ≤15 years in Jefferson County, Alabama. Methods: This was a retrospective study with a case definition for inclusion of individuals, aged ≤15 years, who suffered a pedestrian injury and sought care at The Children's Hospital of Alabama between 1989 and 1991. Demographic and injury‐related information was obtained from the medical record and analyses were performed using t‐test and a simple correlation. Results: The majority of the cases were nonwhite, and nearly half had Med‐icaid or were uninsured. The most common injuries were fractures and closed head trauma. The geographic locations of injury events were not uniformly distributed: a comparison of areas wherein an injury occurred with those that were injury‐free revealed a number of significant differences with regard to specific demographic, socioeconomic, and ecological factors. Conclusions: Some of the possible manageable environmental risk factors identified in this study were relatively high posted speed limits; sidewalks that were narrow, absent, or in a state of disrepair; vehicular parking on both sides of the street; and the absence of a divided highway. In this community, the most cost‐effective educational intervention may best be targeted to elementary‐aged schoolchildren living in areas with low‐income families and that have a high density of children.
Time Series Analysis Using Autoregressive Integrated Moving Average (ARIMA) Models
Authors: Nelson Brian K.
Published: March 2010

Abstract. Most methods of defining a statistical relationship between variables require that errors in prediction not be correlated. That is, knowledge of the error in one instance should not give information about the likely error in the next measurement. Real data frequently fail this requirement. If a Durbin‐Watson statistic reveals that there is autocorrelation of sequential data points, analysis of variance and regression results will be invalid and possibly misleading. Such data sets may be analyzed by time series methodologies such as autoregressive integrated moving average (ARIMA) modeling. This method is demonstrated by an example from a public policy intervention.
The Prognostic Significance of Troponin I and Troponin T
Authors: Green Gary B. , Li Dai J. , Bessman Edward S. , Cox Jennifer L. , Kelen Gabor D. , Chan Daniel W.
Published: March 2010

Abstract. Objectives: To determine and compare the prognostic abilities of early, single‐sample measurements of cardiac troponin I (cTn‐I), cardiac troponin T (cTn‐T), creatine kinase‐MB (CK‐MB) among ED patients with possible myocardial ischemia. Methods: Prospective collection of clinical and serologic data using an identity‐unlinked technique from patients with possible myocardial ischemia at 2 urban EDs. Outcome data concerning the occurrence of adverse events (AEs) during the 14 days after enrollment were used to calculate and compare the relative risks (RRs) and predictive values (with 95% confidence intervals) of the 3 markers for predicting AEs. Results: Among the 401 study patients, 105 AEs occurred in 67 patients. cTn‐I, cTn‐T, and CK‐MB were all significantly predictive of AEs, with RRs of 3.87 (2.39, 6.26), 3.03 (1.92, 4.79), and 6.45 (4.74, 8.77), respectively. For prediction of AEs, sensitivity for each of the 3 markers was low (cTn‐I = 15.38, cTn‐T = 24.62, CK‐MB = 15.38), while specificity was high (cTn‐I = 97.62, cTn‐T = 93.15, CK‐MB = 99.70). No significant difference in predictive ability was found between cTn‐I and cTn‐T. However, a positive CK‐MB result was a stronger predictor of AEs than either cTn‐I (p = 0.01) or cTn‐T (p = 0.001). Conclusions: No significant difference in predictive abilities was found between cTn‐I and cTn‐T. However, routine testing for both CK‐MB and either of the troponins may optimize early identification of high‐risk patients so they may be targeted for a higher level of care and consideration of more aggressive therapies.
Assessment of Chest Pain Onset and Out‐of‐hospital Delay Using Standardized Interview Questions: The REACT Pilot Study
Authors: Hedges Jerris R. , Mann N. Clay , Meischke Hendrika , Robbins Mark , Goldberg Robert , Zapka Jane
Published: March 2010

Abstract. Objective: To determine the consistency of responses to a standardized 2‐part “key” question (Key‐Q) about acute symptom onset in patients presenting with chest pain when measured using alternative questions (Qs) about symptom perception and decisions to seek treatment. Methods: A structured patient interview was performed at 3 university teaching hospitals and 1 community hospital. Convenience samples of adult patients presenting to these EDs with chest pain were asked specific questions related to their symptoms and recognition of illness. Information obtained included the 2‐part Key‐Q: “What are the symptoms that brought you here today?” and “When did those symptoms start?” The alternative Qs (in order of use) were as follows: Ql =“When did your very first symptom or sensation begin?”; Q2 =“When did your symptoms lead you to think something was wrong or that you were ill?”; Q3 =“When did your symptoms become serious enough for you to seek medical care?”; and Q4 =“When did you actually call 9‐1‐1/emergency medical services (EMS) or go to the hospital?” The documented ED arrival time, demographic variables, and whether the patient arrived by ambulance were obtained from the medical record. Patients also were queried regarding potential barriers to seeking medical care and their cardiac risk factors. Results: Of the 135 patients surveyed, 9 were unsure of the date and time of symptom onset. For the 126 patients with analyzable data, the mean (±SD) patient age was 62 ± 16 years, and 59% were male. The general sequence of events reported from acute symptom onset until hospital care was Q1/ Key‐Q ← Q2 ← Q3 ← Q4 ← ED arrival. The median differences and interquartile ranges (IQRs) in minutes between Q times and the Key‐Q response were: Q1 = 0 (0‐0); Q2 = 30 (0–210); Q3 = 140 (30–720); Q4 = 265 (90‐1,215); and ED arrival = 340 (120‐1,230). The interval from the Key‐Q response until calling 9‐1‐1/EMS or going to the hospital was shorter for those who used an ambulance and for those who did not consult a physician first. The interval from the Key‐Q response until considering symptoms to be serious was shorter for those with a family history of heart disease, but longer for non‐white patients. Conclusion: The Key‐Q elicited a response recalled near the time of first symptoms and generally before the patient had concluded something was “wrong or that he or she was ill.” Measurement of the out‐of‐hospital delay in chest pain patients using the Key‐Q appears promising.
Do Patients Refusing Transport Remember Descriptions of Risks after Initial Advanced Life Support Assessment?
Authors: Schmidt Terri A. , Mann N. Clay , Federiuk Carol S. , Atcheson Regina R. , Fuller David , Christie Michael J.
Published: March 2010

Abstract. Objective: To determine patient recall and understanding of instructions given to patients who refuse transport after initial paramedic assessment and medical treatment. Methods: Following patient consent, a phone interview was completed for consecutive persons living in a large urban area for whom 9‐1‐1 was contacted but who subsequently refused transport after advanced life support (ALS) assessment. Subjects were asked about their recall of explained risks and benefits of transport, their understanding of those risks at the time of assessment, and subsequent use of medical care, including hospitalization. Results: From October 1, 1996, to February 23, 1997, 324 people refused transport after ALS arrival. Sixty‐eight people could not be contacted, providing a response rate of 79% (256/324). Six percent were subsequently admitted to the hospital for the same problem and an additional 59% sought care from a health care provider (66 ED visits, 63 personal physician, 16 urgent care, 5 other). There were no unexpected deaths. Ninety (35%) respondents were still experiencing symptoms at the time of phone contact. Despite the routine practice of providing a verbal explanation of risks and written instructions, only 141 (55%) recalled receiving written instructions and 56 (22%) recalled an explanation of risks. Twenty‐six percent believed they did not fully understand their conditions or circumstances surrounding the 9‐1‐1 call when they refused transport and 18% would now take an ambulance if the same incident were to recur. Conclusion: A substantial proportion of patients refusing transport do not recall receiving verbal or ritten instructions and would reconsider their transport decision, raising doubts about people's ability to make informed decisions at a time of great vulnerability. The majority of patients accessed health care after refusing transport and 6% were hospitalized.
Transvaginal Ultrasonography by Emergency Physicians Decreases Patient Time in the Emergency Department
Authors: Burgher Stephen W. , Tandy Thomas K. , Dawdy Michael R.
Published: March 2010

Abstract. Objectives: An important argument for emergency physician use of ultrasonography is that it results in more rapid patient disposition, but there are few articles to support this position. This study sought to demonstrate a significant decrease in the time spent in the ED when emergency physicians performed transvaginal ultrasonography (TVUS), as compared with when TVUS was performed by consultants, in the evaluation of first‐trimester pelvic pain or vaginal bleeding. Methods: A retrospective analysis was conducted of the time spent in the ED (time placed in gynecologic examination room to time released from ED) by patients with first‐trimester pelvic pain or vaginal bleeding necessitating further evaluation with TVUS. TVUS was performed in the ED by obstetrics/gynecology (ob/gyn) residents who were consulted to the ED from January 11, 1996, to March 31, 1996, and by emergency physicians from April 17, 1996, to July 7, 1996. Results: Emergency physicians evaluated 46 patients by TVUS, with a mean time of 164.70 minutes (SEM ± 13.29). Ob/gyn consultants evaluated 38 patients by TVUS, with a mean time of 234.79 minutes (SEM ± 12.74). This was a significant difference at the level of p < 0.0003 (Student's t‐test). There were no known missed ectopic pregnancies as ascertained by 100% patient follow‐up. There was no significant difference between the groups in the percentage of ectopic pregnancies (Fisher's exact test). The number of patients in the emergency physician group requiring subsequent consultation was reduced by 85%. Conclusions: This study demonstrates a more rapid ED transit time when TVUS was performed at the bedside by emergency physicians as compared with when pelvic ultrasonography required consultation. Additionally, fewer calls to consultants were required.
Effects of Ethanol in an Experimental Model of Combined Traumatic Brain Injury and Hemorrhagic Shock
Authors: Zink Brian J. , Stern Susan A. , Wang Xu , Chudnofsky Carl C.
Published: March 2010

Objectives: Given that clinical and laboratory studies suggest that ethanol and hemorrhagic shock (HS) potentiate traumatic brain injury (TBI), the authors studied the effects of ethanol in a model of combined TBI and HS.

Methods: A controlled porcine model of combined TBI and HS was evaluated for the effect of ethanol on survival time, hemodynamic function, and cerebral tissue perfusion. Anesthetized swine (17–24 kg) were instrumented, splenectomized, and subjected to fluid percussion TBI with concurrent 25‐mL/kg graded hemorrhage over 30 minutes. Two groups were studied: control (n= 11) and ethanol (n= 11). Ethanol, 3.5 g/kg intragastric, was given 100 minutes prior to TBI/HS. Systemic and cerebral physiologic and metabolic parameters were monitored for 2 hours without resuscitation. Regional cerebral blood flow (rCBF) and renal blood flow were measured with dye‐labeled microspheres. Data were analyzed with 2‐sample t‐test and repeated‐measures ANOVA.

Results: Ethanol levels at the time of injury were 162 ± 68 mg/dL. Average TBI was 2.65 ± 0.35 atm. Survival time was significantly shorter in the ethanol group (60 ± 27 min vs 94 ± 28 min, p = 0.011). The ethanol group had significantly lower mean arterial pressure, cerebral perfusion pressure, and cerebral venous

O2 saturation in the postinjury period. Cerebral O2 extraction ratios and cerebral venous lactate levels were significantly higher in the ethanol group. A trend toward lower postinjury rCBF in all brain regions was observed in the ethanol group.

Conclusion: In this TBI/HS model, ethanol administration decreased survival time, impaired the hemodynamic response, and worsened measures of cerebral tissue perfusion.
The Electrocardiographic Diagnosis of Acute Myocardial Infarction in Patients with Ventricular Paced Rhythms
Authors: Kozlowski Frederick H. , Brady William J. , Aufderheide Tom P. , Buckley Ralph S.
Published: March 2010

Use of the ECG for diagnosis of ischemic heart disease is more difficult in the setting of ventricular paced rhythms (VPRs). ST‐segment/T‐wave configurations are changed by the altered intraventricular conduction associated with ventricular pacing. The anticipated, or expected, morphology in patients with VPRs is one of QRS‐complex‐ST‐segment to T‐wave discordance. Several strategies are available to the physician to assist in the correct interpretation of the 12‐lead ECG in patients with permanent ventricular pacemakers, including: a knowledge of the anticipated ST‐segment‐T‐wave changes of VPRs and consequently the ability to recognize acute, ischemic morphologies; the performance of serial ECGs or ST‐segment trend monitoring demonstrating dynamic changes encountered in acutely ischemic patients; a comparison with previous ECGs; and, if appropriate, an analysis of the native, underlying rhythm. The first strategy, an awareness of the anticipated ST‐segment morphologies of VPRs, is the most important and not dependent on additional diagnostic testing, past medical records, or additional expertise in pacemaker function. Two cases are reported in which an analysis of the ECG in the setting of VPR assisted the treating physicians in establishing the correct diagnosis of acute myocardial infarction.
Evaluation of an Instructional Model for Emergency Ultrasonography
Authors: Lanoix Richard , Baker William E. , Mele Joanne M. , Dharmarajan Lekshmi
Published: March 2010

Objective: To evaluate a 4‐hour ultrasonography course in the setting of an emergency medicine (EM) training program.

Methods: EM residents and faculty at a large urban center were provided a 4‐hour emergency ultrasonography course. Then, during an 18‐month period, a nonconsecutive sample of ultrasonographic examinations were videotaped and later reviewed. The interpretations of the emergency physician examinations were compared with the following reference standards: 1) an official ultrasound performed and interpreted by the departments of radiology or cardiology; 2) an operative report; 3) A CT scan or IV pyelogram (IVP); or 4) a cardiologist's or a radiologist's interpretation of the videotaped examinations.

Results: Of 258 examinations reviewed, 28 (11%) of these were excluded because the cardiologist or radiologist reviewing the videotape determined them to be “technically limited” studies. Of the remaining 230 examinations, there were: 127 gallbladder studies [disease prevalence = 0.58; sensitivity = 0.89; specificity = 0.80; kappa (κ) = 0.69; 95% CI: 56–82%]; 39 echocardiograms to rule out pericardial effusions [disease prevalence = 0.15; sensitivity = 0.83; specificity = 0.97; κ= 0.80; 95% CI: 54–100%]; 25 abdominal ultrasounds to rule out free peritoneal fluid [disease prevalence = 0.32; sensitivity = 0.88; specificity = 0.94; κ= 0.81; 95% CI: 26–95%]; 16 renal ultrasounds to rule out hydronephrosis [disease prevalence = 0.25; sensitivity = 1.0; specificity = 0.92; κ= 0.84; 95% CI: 56–100%]; 12 pelvic ultrasounds to rule in an intrauterine pregnancy [disease prevalence = 0.67; sensitivity = 1.0; specificity = 0.75; κ= 0.80; 95% CI: 43–100%]; and 11 abdominal ultrasounds to rule out abdominal aortic aneurysms [disease prevalence = 0.09; sensitivity = 1.0; 95% CI: 2.5–91%; specificity = 1.0; 95% CI: 68–100%].

Conclusion: This 4‐hour ultrasonography course has potential to serve as a foundation for an instructional model for ultrasonography training in the setting of an EM residency program.
The Effect of Order on Pain of Local Anesthetic Infiltration
Authors: Bartfield Joel M. , Pauze Denis , Raccio‐Robak Nancy
Published: March 2010

Objective: To define the relationship between order of injection and pain of infiltration of buffered lidocaine.

Methods: Volunteers ≥18 years of age were enrolled in a prospective, double‐blind experimental protocol.

Subjects received a 0.5‐mL intradermal injection of anesthetic in each forearm. All injections were given by the same individual in the same manner. Immediately following each injection, the subjects rated the pain of infiltration on a standardized 100‐mm visual analog pain scale. Both the subjects and the individual giving the injections were blinded to the anesthetic being administered. They were told that the injections could be either plain or buffered lidocaine. They were further informed that any individual subject could receive 2 of the same anesthetics or 1 of each in either order. In reality, all injections were buffered lidocaine for all subjects. Pain scores were converted to a numerical score by making measurements to the nearest millimeter and analyzed by a Wilcoxon signed‐rank test with p < 0.05 considered significant.

Results: Fifty subjects were enrolled. The first injection had a median pain score of 13.5 mm, compared with 23.5 mm for the second (p = 0.007).

Conclusion: The second injection of buffered lidocaine was found to be statistically more painful than the first in this protocol that controlled for all variables except for order of injection. Future studies involving paired comparisons should take this information into account.
Does the Use of Topical Lidocaine, Epinephrine, and Tetracaine Solution Provide Sufficient Anesthesia for Laceration Repair?
Authors: Adler Adam J. , Dubinisky Isser , Eisen Jeff
Published: March 2010

Objective: To determine: 1) the effectiveness of lidocaine, epinephrine, and tetracaine (LET) solution in eliminating or reducing the pain experienced in suturing superficial lacerations in adult patients; and 2) the effectiveness of LET in reducing the pain of local anesthetic injection.

Methods: A prospective, randomized, double‐blind study in which 60 adult patients with superficial lacerations were entered was conducted in the ED of a community‐based teaching hospital affiliated with the University of Toronto. Following application of the LET or placebo (sterile water) solution to the laceration, a visual analog pain scale was recorded by the patient upon needle probing of the wound margin. If probing was painless, the laceration was repaired using LET alone. If injection of local anesthetic was required, an additional pain scale was elicited to quantify the attenuation of the pain of injection by the prior application of LET.

Results: Pain scale values on needle probing were significantly reduced in the LET group vs the placebo group (medians of 4.0 vs 5.0 cm, respectively; p < 0.05). Only 13 of the 30 patients in the LET group required additional anesthetic, while all 30 patients in the placebo group requested local anesthetic. Pain scale values on injection of local anesthetic were not significantly different between the LET and placebo groups (medians of 3.5 vs 5.0 cm, respectively; p = 0.09), although there was a trend for lower pain scale values for those patients who received LET. No adverse effects were noted after the application of either LET or placebo solution. Follow‐up was achieved for 54 of 60 patients with only 1 complication (a wound infection) reported in the LET group.

Conclusions: Significantly fewer patients require an injectable anesthetic when LET is applied. Those who do require an injection may experience less discomfort. These advantages should be balanced against the 20 to 30 minutes necessary for the LET to take effect.
No Relationship between Emergency Department Activity and Triage Categorization
Authors: Richardson Drew
Published: March 2010

Objective: To examine the consistency of Australasian National Triage Scale (NTS) categorization in a large hospital ED, especially in relation to daily activity.

Methods: This was a prospective, observational study of the relationship between NTS category, presenting features, and disposition in a large Australian adult ED. The “admission rate” was defined as the percentage of presentations whose dispositions were recorded as admitted to hospital, transferred to another hospital for admission, or died in the ED. A “busy” weekday was defined as one during which >140 presentations were recorded in the 24 hours from midnight. For a “busy” weekend day, a figure of 100 presentations in 24 hours was used. “Nonbusy” days were defined as those during which presentation numbers were less than or equal to these thresholds.

Results: Data describing triage and disposition were available for 94,681 presentations in the 2‐year period, representing 100% of ED presentations. “Busy” weekday admission rates in the 5 triage categories were 93.2%, 67.6%, 43.6%, 15.4%, and 1.6%, respectively. “Nonbusy” weekday admission rates were 91.4%, 68.3%, 43.7%, 15.6%, and 2.0%. Weekend days had a higher admission rate in NTS category 4 and 5 patients, but none of the differences between “busy” and “nonbusy” days reached statistical significance at the 0.05 level. Admission rates varied according to the time of day of presentation and increased with age, but did not change significantly over the 2 years of the study.

Conclusions: In this ED, triage categorization according to the Australasian NTS does not vary with daily activity and has been consistent over time. Further study in other settings is required, particularly to identify variation dependent on the presenting population.
Data Elements for Emergency Department Systems, Release 1.0 (DEEDS): A Summary Report
Authors:   DEEDS Writing Committee
Published: March 2010

Variations in the way that data are entered in ED record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control is coordinating a public‐private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product, Data Elements for Emergency Department Systems, Release 1.0 {DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems—such as data incompatibility and high costs of collecting, linking, and using data—can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0, sets a precedent for future review and revision of the initial recommendations.
Unusual Presentation of Postdural Puncture Discomfort
Authors: Goldman Mitchell J.
Published: March 2010

Raymond M. Wright, MD
Randomized, Controlled Trial of Inhaled Budesonide as an Adjunct to Oral Prednisone in Acute Asthma
Authors: Sung Lillian , Osmond Martin H. , Klassen Terry P.
Published: March 2010

Objective: To compare the clinical effect of nebulized budesonide with placebo in acute pediatric asthma.

Methods: A randomized, controlled, double‐blind trial with parallel design was used in the ED of a tertiary care children's hospital. Children aged 6 months to 18 years with a moderate to severe exacerbation of asthma [Pulmonary Index Score (PIS) ≥5 or ≤11 after a salbutamol nebulization of 0.15 mg/kg] were eligible. All patients received prednisone 1 mg/kg orally and nebulized salbutamol (0.15 mg/kg) every 30 minutes for 3 doses and then every hour for 4 hours. The intervention was 2 mg (4 mL) of nebulized budesonide or 4 mL of nebulized normal saline.

Results: Baseline characteristics were comparable in the budesonide group (n= 24) and in the placebo group (n ‐ 20). There were no significant differences in the primary outcome measure (PIS) between the 2 groups. However, the PIS at 1 hour had a tendency to be lower in the budesonide group (median = 5) as compared with the placebo group (median = 6; p = 0.07). Survival analysis of release/discharge from the ED/hospital showed a more rapid rate in the budesonide group as compared with the placebo group (p = 0.02). No adverse effects were seen.

Conclusion: Although these preliminary results suggest that nebulized budesonide may be an effective adjunct to oral prednisone in the management of moderate to severe asthma exacerbations, a larger trial will be required before the widespread use of inhaled budesonide in acute asthma can be advocated.
Cutaneous Tape Stripping to Accelerate the Anesthetic Effects of EMLA Cream: A Randomized, Controlled Trial
Authors: Singer Adam J. , Shallat John , Valentine Sharon M. , Doyle Linda , Sayage Valerie , Thode Henry C.
Published: March 2010

Abstract. Most medications are not absorbed topically due to the stratum corneum barrier. While effective as a topical anesthetic, EMLA cream is absorbed slowly, delaying its effects for up to one hour, thereby limiting its usefulness.

Objective: To determine whether removal of the cornified layer of the skin by tape stripping (TS) would allow more rapid onset of anesthesia after topical application of EMLA cream prior to IV catheterization (IVC).

Methods: This was a prospective, randomized, controlled trial comparing the levels of pain of IVC 15 minutes after topical application of EMLA cream in patients who had TS vs patients who did not. The setting was a suburban university‐affiliated ED. A convenience sample of 68 alert adult patients requiring IVC were enrolled. The primary outcomes measured were pain of IVC and pain of TS using a previously validated 100‐mm visual analog scale as well as the IVC success rate.

Results: The pain of IVC was less for TS vs control patients [29.7 mm (95% CI = 20.4 to 39.0 mm) vs 15.9 mm (95% CI = 9.1 to 22.6 mm), p = 0.017]. The mean pain of TS was 4.8 ± 7.4 mm. The IVC success rate for TS vs control patients was 91% vs 74% (p = 0.056). There were no adverse events after TS.

Conclusions: Removal of the cornified layer of the skin resulted in a more rapid anesthetic effect of EMLA cream as evidenced by lower IVC pain scores after TS. The effectiveness of TS for enhanced absorption of other medications should be investigated.
Academic Departments of Emergency Medicine: The Effects of Managed Care
Authors: Counselman Francis L. , Schafermeyer Robert W. , Perina Debra G.
Published: March 2010

Abstract. Objective: To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice.

Methods: A 38‐question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994–1995 and 1995–1996.

Results: Forty‐seven ADEMs (90.3%) responded. When comparing the 1995–1996 and 1994–1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two‐thirds of ADEMs used mid‐level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast‐track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety‐eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty‐eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9‐1‐1 services and 16% reporting HMOs provided 9‐1‐1 services to take patients only to participating hospital EDs.

Conclusion: ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.
Emergency Medicine in Undergraduate Education
Authors: Burdick William P. , Jouriles Nicholas J. , D'Onofrio Gail , Kass Lawrence E. , Mahoney John F. , Restifo Karen M. ,   For the SAEM Education Committee, Undergraduate Subcommittee
Published: March 2010

Abstract. Society has a right to expect that all physicians possess basic knowledge of emergency care and the skills to manage acute problems. Competency in the care of acutely ill and injured patients is one of the fundamental exit goals of most medical schools as mandated by the Liaison Committee on Medical Education. Several groups have called for strengthening the general components of undergraduate medical education, and surveys during the early years of the development of the field of emergency medicine (EM) showed that only a small percentage of schools required significant education in EM. This paper defines the goals and objectives of undergraduate EM education in order to help guide the development of curricular offerings as the role of EM in undergraduate medical school education increases. This paper was developed by the SAEM Education Committee and presents this committee's beliefs on what all graduating medical students should know about assessment and treatment of acutely sick and injured patients. It also suggests methods by which acquisition of this information can occur in medical school education.
Use of Emergency Departments by Elder Patients: A Five ‐year Follow‐up Study
Authors: Strange Gary R. , Chen Edwin H.
Published: March 2010

Abstract. Objective: Tb compare the use of emergency medical care by elders in the United States in 1995 with that previously described for 1990.

Methods: A computerized billing database of 88 EDs in 21 states was retrospectively reviewed for 1995, comparing elder and nonelder patients, estimating national use of emergency medical services by elders, and comparing the 1995 data with previously published results for 1990.

Results: From 1990 to 1995, the number of ED visits in the United States increased from 92 million to 100 million. The number of visits made by patients aged 65 years or older increased from 13,639,400 (15%) to 15,666,300 (15.7%), but this increase did not reach statistical significance (p = 0.17). The admission rate for elder ED patients increased from 32% to 46% over the five‐year interval (p < 0.01). This represents more than 7 million hospital admissions for elder patients in 1995. The rate of intensive care unit (ICU) admission for elders decreased from 7% to 6% over the five‐year interval (p = 0.56), compared with 1.3% for nonelder patients for both years. Thirty percent of elder ED patients arrived by ambulance in 1990, compared with 33% in 1995 (p = 0.02). Based on 1995 data, elders comprised 39% of patients arriving by ambulance [odds ratio (OR) 4.75, 95% confidence interval (CI) = 4.71 to 4.79], 43% of all admissions (OR 6.59, 95% CI = 6.54 to 6.64), and 47% of ICU admissions (OR 5.00, 95% CI = 4.91 to 5.09). The comparable ORs in 1990 were 4.4, 5.6, and 5.5, respectively.

Conclusions: From 1990 to 1995, the overall number of ED visits increased. The rate of increase was somewhat greater for elder patients. The use of ambulance services also disproportionately grew among elder patients, as did the rate of hospital admission. The overall rate of ICU admission was stable, but actually fell modestly for elder patients. Of these changes, only the increase in the rate of hospital admission for elders reached statistical significance.
1995–1996 SAEM Emergency Medicine Faculty Salary/Benefits Survey
Authors: Kristal Steve L. , Thompson Bruce M. , Marx John A.
Published: March 2010

Abstract. Objective: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefit survey for all 1995 Residency Review Committee in Emergency Medicine (RRC‐EM)‐accredited programs using the SAEM third‐generation survey instrument. Responses were collected by SAEM and blinded from the investigators.

Population: Seventy‐six of 112 (68%) accredited programs responded, yielding data for 1,032 full‐time faculty among the four Association of American Medical Colleges (AAMC) regions.

Methods: Blinded program and individual faculty data were entered into a customized version of Filemaker Pro, a relational database program with a built‐in statistical package. Salary data were sorted by 115 separate criteria such as program regions, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to AAMC. Demographic data from 132 categories were analyzed and included number of staff and residents per shift, number of intensive care unit (ICU) beds, obstacles to hiring new staff, and specific type and value of fringe benefits offered. Data were compared with those from the 1990 and 1992 SAEM and the 1995‐96 AAMC studies.

Results: Mean salaries were reported as follows: all faculty, $158,100; first‐year faculty, $131,074; programs reporting data to AAMC, $152,198; programs not reporting data to AAMC, $169,251. Mean salaries as reported by AAMC region: northeast, $155,909; south, $155,403; midwest, $172,260; west, $139,930. Mean salaries as reported by program financial source: community, $175,599; university, $152,878; municipal, $141,566.

Conclusions: Reported salaries for full‐time EM residency faculty continue to rise. Salaries in programs reporting data to the AAMC are considerably lower than those not reporting. The gap between ABEM‐certified and non‐ABEM‐certified faculty continues to widen. Residency‐trained faculty are now shown to earn more than non‐residency‐trained faculty. Significant regional differences in salaries have been present in all three SAEM surveys.
Patients with Alcohol Problems in the Emergency Department, Part 2: Intervention and Referral
Authors: D'Onofrio Gail , Bernstein Edward , Bernstein Judith , Woolard Robert H. , Brewer Phillip A. , Craig Sandra A. , Zink Brian J. ,   for the SAEM Substance Abuse Task Force
Published: March 2010

Abstract. Early intervention and appropriate referral of patients with alcohol problems have the potential to reduce alcohol‐related morbidity and mortality. Part 1 of this series introduced screening tools that can be applied in the ED to allow early detection of at‐risk drinkers. This article was developed by members of the SAEM Substance Abuse Task Force and describes assessment and intervention techniques once the at‐risk or dependent drinkers has been identified. Appropriate aftercare and referral of patients found to have alcohol problems are also discussed.