bluuebunny/crossref_metadata_2025_split huggingface dataset:
Thermal Characteristics of Neutralization Therapy and Water Dilution for Strong Acid Ingestion: An In‐vivo Canine Model
Authors: Homan Clark S. , Singer Adam J. , Thomajan Craig , Henry Mark C. , Thode Henry C. 
Published: March 2010

ABSTRACT Objective: To determine whether in‐vivo neutralization therapy for acid ingestions will superimpose a thermal injury upon tissue already damaged by acid. Methods: An in‐vivo canine model was used with repeated measures of tissue and luminal temperatures. All dogs were placed under halothane general anesthesia. The stomach was exteriorized and temperature probes were placed in the lumen and mucosa. 25 mL of 0.5 N HC1 (25°C) was placed in the gastric lumen followed 5 minutes later by 75 mL of either 8% NaHCO, neutralization (25°C. n = 10) or water dilution (25°C, n = 10). Temperature measurements were recorded at specified intervals for 5 minutes post HCl acid exposure and for 30 minutes post treatment. Temperature profiles were analyzed by repeated‐measures ANOVA. Post treatment changes were evaluated using signed‐rank tests. Results: In both treatment groups, treatment resulted in significant decreases in initial mucosa and intraluminal temperatures. Both the mucosa and intraluminal temperatures decreased immediately after treatment with HCO, by an average of 1.6°C (p = 0.05). In the water dilution treatment group, both temperatures decreased by 1.1°C (p = 0.05). Ensuing post‐treatment temperatures increased but did not reach baseline temperatures at any time up to 30 minutes post treatment. Conclusions: In the in‐vivo setting, there is no evidence of hazardous temperature elevation when a weak alkali or dilution therapy is used to neutralize strong acid‐induced injury. Contraindication of this form of emergency treatment should not be based on the preconceived idea that a resultant exothermic reaction will cause a superimposed thermal injury. Further clinical study is needed to determine the clinical utility of this emergency therapeutic modality.
Serum Progesterone and Endovaginal Sonography by Emergency Physicians in the Evaluation of Ectopic Pregnancy
Authors: Valley Verena T. , Mateer James R. , Aiman E. James , Tkoma Margaret E. , Phelan Mary Beth 
Published: March 2010

ABSTRACT Objective: To determine a discriminatory level for serum progesterone (SP) in pregnant patients with no definite intrauterine pregnancy (IUP) on endovaginal ultrasonography (US) in the differentiation of ectopic pregnancy from normal IUPs. Methods: A prospective observational study in a convenience sample of women at risk for ectopic pregnancy was performed at an urban teaching hospital from May 1991 until May 1994. Women aged ≥18 years presenting to the ED with a positive pregnancy test in combination with pelvic or abdominal pain, vaginal bleeding, orthostasis, adnexal mass or tenderness, or any historical risk factor for ectopic pregnancy were eligible. Hypotensive or unstable patients were excluded. Endovaginal US was performed and patients with no definite IUP had a serum 3‐hCG and SP measured. Results: 314 patients were enrolled, with 14 excluded for lack of follow‐up or incomplete SP data, yielding 300 patients. The initial endovaginal US diagnoses included 169 definite IUP, 31 abnormal IUP, 5 definite ectopic pregnancy, and 95 no definite IUP. 68/95 had SP measured, with values of 22.8 ± 13.4 ng/mL (mean ± SD) for IUP; 4.9 ± 6.5 for spontaneous abortion, and 7.5 ± 7.2 for ectopic pregnancy. The mean values were significantly different (2‐tailed t‐test) for ectopic pregnancy vs IUP and for spontaneous abortion vs IUP. An SP of ≥11 ng/mL (sensitivity 91%; specificity 84%) was post hoc the best cutoff value for suggesting an IUP when the endovaginal US was not definite for IUP. Conclusions: SP cannot reliably discriminate ectopic pregnancy vs spontaneous abortion in pregnant patients with no definite IUP on endovaginal US; however, a low SP (<11 ng/mL) in this sonographic category suggests an abnormal pregnancy.
Subclassification of Indeterminate Pelvic Ultrasonograms: Stratifying the Risk of Ectopic Pregnancy
Authors: Dart Robert , Howard Kristin 
Published: March 2010

ABSTRACT Objective: To determine whether the subclassification of indeterminate ultrasound readings can identify patients who are at high, intermediate, or low risk for ectopic pregnancy. Methods: A retrospective review was made of consecutive ED patients presenting to an urban teaching hospital from August 1991 to December 1994 with abdominal pain and/or vaginal bleeding and a positive β‐hCG. Patients who had transvaginal ultrasonograms obtained during the ED visit that were read as indeterminate (no extrauterine findings of ectopic pregnancy and no intrauterine fetal pole or yolk sac) were eligible. Ultrasonograms were subclassified into 5 groups (empty uterus, nonspecific intrauterine fluid, echo‐genic debris within endometrial cavity, abnormal sac, normal sac) based on predetermined criteria. Patients were excluded if the final diagnosis could not be definitively determined. Results: 248 patients were identified. 20 patients were excluded because a final diagnosis could not be determined. Patients with an empty uterus [25/94 = 27% (95% CI 18–36%)] had the highest frequency of ectopic pregnancy. Patients with nonspecific intrauterine fluid collections [4/30 = 13% (95% CI 4–31%)] had the next highest frequency of ectopic pregnancy. Patients with intrauterine echogenic debris [2/39 = 5% (95% CI 1–11%)], abnormal sacs [1/36 = 3% (95% CI 1–9%)], or normal‐appearing sacs [0/29 = 0% (95% CI 0 ‐8%)] had low frequencies of ectopic pregnancy. Conclusion: Subclassification of indeterminate ultrasound readings identifies patients at high, intermediate, or low risk for ectopic pregnancy and should improve the diagnostic accuracy of ultrasonography in patients at risk for ectopic pregnancy. Key words: ectopic pregnancy; tubal pregnancy; intrauterine pregnancy; ultrasound; diagnosis.
Gas Exchange and Lung Mechanics during Percutaneous Transtracheal Ventilation in an Unparalyzed Canine Model
Authors: Tran T. Paul , Rhee Kenneth J. , Schultz Harold D. , Carl Michael L. 
Published: March 2010

ABSTRACT Objective: To compare the efficacy of percutaneous transtracheal ventilation (PTV) in the unparalyzed state with that in the paralyzed state using a sedated nonobstructed canine model. Methods: Eight mongrel dogs (16.8–32 kg) were anesthetized, instrumented, and placed in a volume ple‐thysmograph. Anesthesia was achieved with pentobarbital sodium (up to 30 mg/kg). The spontaneous respiratory drive was kept intact. PTV was performed using a 13‐ga transtracheal catheter and compressed air at 45 psi at an I:E ratio of 1:3 (15 breaths/min). Each dog was sequentially ventilated in both the paralyzed and unparalyzed states. The paralyzed/unparalyzed sequence was alternated among the animals to avoid sequence bias. Paralysis was achieved with succinylcholine (0.1 mg/kg bolus and 0.01 mg/kg/min drip). Reversal of paralysis was achieved by discontinuing the succinylcholine infusion. Key variables, including arterial blood gas, tidal volume, and pulmonary mechanics, were measured and compared for the paralyzed and unparalyzed states. Results: Gas exchanges and lung mechanics were similar between the unparalyzed and paralyzed states. There was no significant difference in mean pH, pCO2, pO2, tidal volume, or peak inspiratory transpulmonary pressure. There was also no significant difference in pulmonary resistance or pulmonary compliance. Conclusion: In a sedated nonobstructed canine model, PTV is as efficacious in the unparalyzed state as it is in the paralyzed state. The lung mechanics are also similar in the 2 states. These data suggest that it may be unnecessary to induce paralysis when using PTV for emergency ventilation in the heavily sedated state.
Physicians in Rural West Virginia Emergency Departments: Residency Training and Board Certification Status
Authors: McGirr Joseph , Williams Janet M. , Prescott John E. 
Published: March 2010

ABSTRACT Objective: To describe the training and certification of physicians who staff small EDs in rural West Virginia. Methods: A survey of rural hospital‐based EDs was performed. The authors chose to study all hospitals in counties with populations of <30,000 and in which the hospital was the only one in the county. Interviews were conducted with the medical director of the ED or the hospital administrator, depending on who was available at the time of interview. Data collected describing the emergency physicians (EPs) employed at each facility included: medical school and residency training, specialty board certification, and certification in a variety of life support courses. General information about each ED, such as census and hospital resources, was also obtained. Interview data were collected on a survey form and subsequently entered into a database. Descriptive analyses were performed. Results: 20 hospitals met rural criteria for inclusion in the study and all were included. The median number of full‐time physicians per ED was 2 (IQR 2–4). 98 part‐time doctors were identified; 28 (29%) of these were residents in training. 13/40 (33%) of full‐time and 37/98 (38%) of part‐time physicians were foreign medical graduates. Only 3/40 (7.5%) of full‐time EPs completed residency training in emergency medicine (EM). Only 4/98 (4%) of part‐time EPs were residency‐trained in EM. 50% of full‐time EPs were board‐certified in a primary care specialty. Only 5/42 (12%) of full‐time EPs were board‐certified in EM. One third of full‐time and the majority of part‐time EPs were not board‐certified in any specialty whatsoever. The majority of EPs had been certified in Advanced Cardiac Life Support, but fewer had been certified in Advanced Trauma Life Support and/or Pediatric Advanced Life Support/Advanced Pediatric Life Support. Conclusions: The majority of physicians staffing small rural EDs in West Virginia are neither residency‐trained nor board‐certified in EM. Further studies are warranted to determine the most efficient and effective way to maximize the skills and availability of emergency care providers in rural settings.
The False‐positive Rate of Thoracic Outlet Syndrome Shoulder Maneuvers in Healthy Subjects
Authors: Plewa Michael C. , Delinger Mark 
Published: March 2010

ABSTRACT Objective: To estimate the incidence of false‐positive findings of thoracic outlet syndrome (TOS) shoulder maneuvers, Adson's test (AT), costoclavicular maneuver (CCM), elevated arm stress test (EAST), and supra‐clavicular pressure (SCP) in healthy subjects. Methods: A cross‐sectional, observational study was performed in a medical school and affiliated emergency medicine residency program setting. Participants included healthy adult volunteers without symptoms of TOS. The shoulder maneuvers AT, CCM, EAST, and SCP were performed in randomized order for 30 sec, 30 sec, 3 min, and 30 sec, respectively. Pulse quality and the presence and timing of pain or paresthesias were assessed. Results: 53 subjects were enrolled, including 27 women, aged 29.7 ± 6.4 years (range 21–58 years). AT, CCM, EAST, and SCP resulted in an altered pulse in 11%, 11%, 62%, and 21%; pain in 0%, 0%, 21%, and 2%; and paresthesias in 11%, 15%, 36%, and 15% of cases, respectively. The following outcomes had reasonable false‐positive rates (upper 95% confidence limit): pain with the AT (7%), CCM (7%), SCP (10%), or any 2 TOS shoulder maneuvers (10%); discontinuing the EAST because of symptoms (16%); or any symptom with 3 (13%) or 4 (7%) TOS shoulder maneuvers. Conclusions: In a study of TOS shoulder maneuvers in healthy subjects, the outcomes of pulse alteration or paresthesias were unreliable in general. However, TOS shoulder maneuvers have reasonably low false‐positive rates when a positive outcome is defined as pain after AT, CCM, or SCP; discontinuation of the EAST secondary to pain; pain in the same arm with ≥2 maneuvers; or any symptom in the same arm with ≥3 maneuvers.
Apoptosis: Only the Good Die Young?
Authors: Cairns Charles B. 
Published: March 2010

SummaryDespite its deadly nature, apoptosis has rapidly become a fashionable area of research in a number of areas ranging from oncology to immunology to cardilogy. The challenge for EM researchers is to convert recent developments in the field of apoptosis as outlined in the accompanying review into mechanistic insights, diagnostic modalities, and novel therapies.
Derivation of a Clinical Prediction Model for the Emergency Department Diagnosis of Ectopic Pregnancy
Authors: Buckley Robert G. , King Kerry J. , Disney Jeffrey D. , Ambroz Pamela K. , Gorman John D. , Klausen Jack H. 
Published: March 2010

Abstract. Objective:To derive a clinical prediction model for estimating the pretest probability of ectopic pregnancy in ED patients with first‐trimester abdominal pain or vaginal bleeding.Methods:All hemody‐namically stable first‐trimester patients presenting to the ED of a tertiary care military teaching hospital over a 14‐month period with a chief complaint of abdominal pain and/or vaginal bleeding had clinical data coded prior to determining outcome. They were then followed longitudinally until a criterion standard pregnancy outcome was established.Results:Of the 486 patients enrolled, 280 (58%) had viable intrauterine pregnancies, 167 (34%) had nonviable intrauterine pregnancies, and 39 (8%) had ectopic pregnancies. Using a recursive partitioning model, a high‐risk group was derived (that was separated from intermediate and low‐risk groups), consisting of patients with abdominal peritoneal signs or definite cervical motion tenderness, with a sensitivity of 31% (95% CI: 17–48%), a specificity of 93% (95% CI: 90–95%), a positive likelihood ratio of 4.3, and a negative likelihood ratio of 0.74. A low‐risk group, consisting of patients with either fetal heart tones or tissue at the cervical os, or the absence of pain other than midline menstrual‐like cramping and lacking any pelvic tenderness, was differentiated from an intermediate‐risk group, with a sensitivity of 96% (95% CI: 81–100%), a specificity of 22% (95% CI: 18–26%), a positive likelihood ratio of 1.2, and a negative likelihood ratio of 0.17.Conclusion:A clinical prediction model for estimating the probability of ectopic pregnancy in ED patients has been derived. It may prove to have practical clinical application for estimating pretest probability of ectopic pregnancy as well as assisting in medical decision making when laboratory and ultrasonographic findings are nondiagnostic. Clinical application should await prospective validation in an independent sample.
Effect of Magnesium Hydroxide on Iron Absorption Following Simulated Mild Iron Overdose in Human Subjects
Authors: Wallace Kevin L. , Curry Steven C. , LoVecchio Frank , Raschke Robert A. 
Published: March 2010

Abstract. Objective:To determine the effect of oral magnesium hydroxide [Mg(OH)2] on iron absorption after simulated iron overdose in human subjects.Methods:A randomized, controlled crossover study was conducted in healthy adult male human volunteers taking no medications. Subjects received an average of 5.0 mg/kg elemental iron orally followed 1 hour later by either oral administration of 4.5 g of Mg(OH)2 per g ingested elemental iron or no treatment. Serial serum specimens were obtained over the 12 hours following iron ingestion and stored at ‐60oC until standard serum iron assay was performed. After a 2‐week washout period, the subjects were enrolled in the alternative trial arm. Individual baseline diurnal variation in serum iron levels was determined over a 12‐hour period on the day prior to each trial. Area under time‐concentration curves (AUCs) were calculated, and the AUC due to experimental iron ingestion (ΔAUC) was determined by subtracting the baseline diurnal AUC from the experimental AUC for each subject.Results:Thirteen healthy adult male subjects were enrolled. Mean ± SEM for ΔAUC due to experimental iron ingestion followed by treatment with Mg(OH)2, 78 ± 23 |xmol(hr)/L, was significantly less than that followed by no treatment, 144 ± 33 p.mol(hr)/L (p = 0.03 by signed rank test).Conclusions:Magnesium hydroxide, administered 1 hour post‐iron ingestion at an oral dose of 4.5 g per g elemental iron ingested, significantly reduced iron absorption during a 12‐hour period following simulated mild iron overdose in healthy adult human volunteers.
Intravenous Ketamine for Pediatric Sedation in the Emergency Department: Safety Profile with 156 Cases
Authors: Green Steven M. , Rothrock Steven G. , Harris Troy , Hopkins G. Alan , Garrett Wayne , Sherwin Thomas 
Published: March 2010

Abstract. Objectives:To determine the safety of IV ketamine when administered by emergency physicians (EPs) for pediatric procedures, and to contrast the sedation characteristics of the IV and IM routes.Methods:The study was a retrospective consecutive case series of children aged ≤15 years given IV ketamine in the EDs of a university medical center and an affiliated county hospital over a 9‐year period. A protocol for ketamine was used by treating physicians. Records were reviewed for adverse effects, indication, dosing, adjunctive drugs, inadequate sedation, and time to release. Results were contrasted with previously reported data for the IM route.Results:During the study period IV ketamine was administered 156 times, primarily for laceration repair and fracture reduction. Transient apnea and respiratory depression occurred in one patient each; both were quickly identified and were without sequelae. Laryngospasm or aspiration was not noted in any children. There were 6 children with emesis and 2 with mild agitation during recovery. The median time from initial dose to ED release was 103 minutes (25th to 75th percentiles 76 to 146 minutes). The IV and IM routes were comparable in terms of adverse effects, inadequate sedation, and time to release.Conclusion:IV ketamine can be administered safely by EPs to facilitate pediatric procedures when used in a defined protocol. The sedation characteristics of the IV and IM routes appear comparable.
Spinal Cord Emergencies: False Reassurance from Reflexes
Authors: Glick Thomas H. , Workman TOM P. , Gaufberg Slava V. 
Published: March 2010

SummaryEmergency physicians need to understand the potential for false reassurance in the interpretation of reflex examination data. Neurologic consultation should be sought when classic signs are lacking, but other evidence causes suspicion. Changes in teaching emphasis and acute practice are needed, since the stakes may be high and time is of the essence. We have responded to the insights gained from this study by augmenting in‐service and continuing medical education teaching and by implementing guidelines to assist EPs. We have emphasized the importance of spotlighting high‐risk patients, as exemplified above, and of taking advantage of neurologic or neurosurgical consultation. Where in‐person consultation is less available, the use of guidelines and remote consultation should be able to help direct further examination, diagnostic formulation, and the need for imaging decisions. Given the potential for severe negative outcome if spinal emergencies are not optimally managed, we must give the teaching of these issues high priority.
Screening for Geriatric Problems in the Emergency Department: Reliability and Validity
Authors: McCusker Jane , Bellavance François , Cardin Sylvie , Trepanier Sylvain ,   Identification of Seniors at Risk (ISAR) Steering Committee
Published: March 2010

Abstract. Objective: lb determine the test‐retest reliability and concurrent criterion validity of a self‐report ED screening questionnaire for adverse outcomes in elders.Methods: A cohort of 1,885 patients aged ≤ 65 years were recruited from the EDs of 4 Montreal hospitals. Patients were excluded if they could not be interviewed because of their clinical status or cognitive impairment and no informant was available. The screening questionnaire, administered in the ED, contained 27 items on social, physical, and mental risk factors, medical history, and use of hospital services, medications, and alcohol. A random sample of 404 patients were invited to participate in a clinical assessment 1–3 weeks after the ED visit, that included re‐administration of the screening questionnaire, and standardized instruments to assess disability, social resources, depression, alcohol use and abuse, and current medications.Results: Study data were collected from 221 patients (54.7%), of whom 193 were included in the test‐retest reliability analyses and 213 in the analyses of concurrent validity. The concordance correlation coefficient for test‐retest reliability of the risk factor score was 0.78 (95% confidence interval: 0.71, 0.83; n= 193). Several screening questions showed moderately good agreement with the appropriate criterion standard, particularly those on visual and hearing impairment, depression, and use of medications. The best subset of 9 screening questions explained approximately half of the variance in the total disability score.Conclusions: The screening questionnaire score has good test‐retest reliability, but individual screening questions have, at best, modest concurrent validity. The final set of screening questions should be selected based on their predictive validity.
Statistical Methodology: VI. Mathematical Modeling of the Electrocardiogram Using Factor Analysis
Authors: Schreck David M. , Tricarico Victor J. , Frank Joseph D. , Thielen Lawrence E. , Chhibber Parag , Brotea Cristian , Leber Ian B. 
Published: March 2010

Abstract. The ECG is a 12‐lead‐vector system and is known to contain redundant information. Factor analysis (PA) is a statistical technique that improves measured data and eliminates redundancy by identifying a minimum number of factors accounting for variance in the data set. Objective: To identify the minimum number of lead‐vectors required to predict the 12‐lead ECG.Methods: A total of 104 ECGs were obtained from 24 normal men, 22 normal women, and 28 men and 30 women with variable pathologies. Each ECG lead was simultaneously acquired and digitized, resulting in a voltage‐time data array stored for mathematical analysis. Each array was factor‐analyzed to identify the minimum number of lead‐vectors spanning the ECG data space. The 12‐lead ECG was then predicted from this minimum lead‐vector set. ANOVA was used to test for statistical significance between normal and pathologic data groups.Results: FA revealed that 3 lead‐vectors accounted for 99.12%± 0.92% (95% CI ± 0.18%) of the variance contained in the 12‐lead ECG voltage‐time data for all 104 cases. There were no statistically significant differences between men and women (99.25%± 0.66% vs 98.98 ± 1.11%; p = 0.139). Statistically significant differences were noted between normal and acute myocardial infarction ECGs (99.5%± 0.27% vs 98.66 ± 1.25%; p = 0.00003). The measured and predicted leads were almost identical. A 3‐dimensional spatial ECG derived from the 3‐lead‐vector set resulted in variable curved surfaces that differed by pathology.Conclusions: The 12‐lead ECG can be derived from only 3 measured leads and graphed as a 3‐D spatial ECG. This type of data processing may lead to instantaneous acquisition and may enhance the diagnostic capability of the ECG from routine bedside telemetry equipment.