bluuebunny/crossref_metadata_2025_split huggingface dataset:
N‐Acetylcysteine Reduces Methemoglobin in an In‐vitro Model of Glucose‐6‐phosphate Dehydrogenase Deficiency
Authors: Wright Robert O. , Woolf Alan D. , Shannon Michael W. , Magnani Barbarajean 
Published: March 2010

ABSTRACTObjective:To determine whether N‐acetylcysteine (NAC) reduces methemoglobin (MHB) in an in‐vitro model of glucose‐6‐phosphate dehydrogenase (G6PD) deficiency, given that methylene blue is an ineffective MHB antidote in G6PD deficiency.Methods:Five volunteers donated blood, which was divided equally into 2 test tubes, centrifuged, and washed with Tris‐Mopps buffer (pH 7.4, 15 mmol/L glucose). Both tubes were incubated with epiandrosterone (EA) (400 μmol), a specific inhibitor of G6PD. After 75 μL of 0.18 mol hydroxylamine (HA) was added to induce MHB formation, 150 μL of NAC (20 mg/mL) was added to tube 1 and 150 μL of phosphate‐buffered saline (PBS) was added to tube 2 as a volume control. Serial MHB levels are reported as a percentage of total hemoglobin (Hb). G6PD activity was measured at baseline, 15 minutes after EA, and at 5 hours.Results:Mean G6PD activity at baseline was 9.2 ± 2.9 U/g Hb (normal >4.6 U/g Hb); 15 minutes after EA was 3.0 ± 1.0 U/g Hb; and at experiment's end was 2.3 ± 0.7 U/g Hb. The mean (±SD) areas under the concentration‐time curves (AUCs) of NAC‐EA‐HA and PBS‐EA‐HA samples were compared using an unpaired t‐test and were significantly different: PBS‐EA‐HA, 20,400 ± 1,100 % min, vs NAC‐EA‐HA, 10,400 ± 1,000 % min, respectively (p < 0.05).Conclusion:In this in‐vitro model of G6PD deficiency, NAC efficiently reduced MHB.
Predictive Validity of the Emergency Physician and Global Job Satisfaction Instruments
Authors: Lloyd Stephen , Streiner David , Shannon Sue 
Published: March 2010

ABSTRACT Objective: To evaluate the predictive validity of the Emergency Physician Job Satisfaction (EPJS) and Global Job Satisfaction (GJS) instruments. Methods: Prospective mail survey of 223 Canadian emergency physicians (EPs) using a 42‐item questionnaire, including 14 items evaluating their reasons for leaving emergency medicine (EM). Original (1990) EPJS and GJS scores were analyzed using 1‐way ANOVA and Scheffe's test comparing the physicians who left EM with those still in their original jobs, and those who had left their original jobs but who stayed in EM. Mean scores on the 14 “reason for leaving” items were compared with scores from an earlier sample of U.S. physicians using a t‐test for independent means. Criteria for statistical significance were set at a = 0.05 for all analyses. Results: The response rate for the primary study questions was 99.1%. Of the respondents, 29.4% had left their original jobs, and 10.4% had left EM altogether. The GJS scores for the physicians who left EM were significantly different from those for the physicians who stayed (p = 0.004). The EPJS scores for the physicians who left EM were not significantly different from those for the physicians who stayed (p = 0.56). There was no significant difference in scores between the Canadian and U.S. physicians' reasons for leaving EM (all p‐values > 0.05). Shiftwork scored the highest as a reason to leave EM. Conclusions: A low GJS score is associated with physicians' leaving EM, but not with changing jobs. The EPJS instrument was not associated with either outcome. Canadian and U.S. EPs place similar levels of importance on potential reasons for leaving EM.
Declining Rate of Cricothyrotomy in Trauma Patients with an Emergency Medicine Residency: Implications for Skills Training
Authors: Chang Robert S. , Hamilton Richard J. , Carter Wallace A. 
Published: March 2010

ABSTRACT Objective: To report the change in cricothyrotomy rate with emergency medicine (EM) residency development and to address the implications for training in this skill. Methods: A retrospective chart review was used to determine the cricothyrotomy rate at a 1,000‐bed urban Level‐1 trauma center with EM, surgery, and anesthesiology residencies. All adult trauma patient visits to the ED between July 1, 1985, and June 30, 1995, were reviewed. The cricothyrotomy rate was defined as the total number of cricothyrotomies per trauma admissions during a study phase. Results: The study period was divided into 3 phases. Phase 1 (academic years 1985–1989): prior to the inception of the EM residency; phase 2 (academic years 1990–1992): initiation and establishment of the residency; and phase 3 (academic years 1993–1994): full implementation of the EM residency. The cricothyrotomy rate during phase 1 was 1.8% (95% CI: 1.6 to 2.0), vs 1.1% (95% CI: 0.0 to 2.8) and 0.2% (95% CI: 0.0 to 0.2) during phases 2 and 3, respectively. Conclusions: The cricothyrotomy rate decreased with the full implementation of the EM residency. Whether this trend was an effect of the presence of an EM faculty and residency training program, a parallel approach to airway management nationwide, or another unidentified factor will require further investigation. Nonetheless, given the increasing rarity of this procedure, it is likely that many EM, surgical, and anesthesiology residents will not acquire clinical experience with this technique during training.
Statistical Methodology: IV. Analysis of Variance, Analysis of Co variance, and Multivariate Analysis of Variance
Authors: Gaddis Monica L. 
Published: March 2010

ABSTRACTMedical research frequently involves the statistical comparison of >2 groups, often using data obtained through the application of complex experimental designs. Fortunately, inferential statistical methodologies exist to address these situations. Analysis of variance (ANOVA) in its many forms is used to simultaneously test the equality of all groups in a study. One‐way (with 1 independent variable), 2‐way (with 2 independent variables), and repeated‐measures (patients serve as their own controls) ANOVAs are forms of this technique. Each form has been developed to analyze data from a specific experimental design. Analysis of covariance (ANCOVA) allows the researcher to control for confounding variables that may influence the response of the dependent variable. Finally, multivariate analysis of variance (MANOVA) evaluates the simultaneous responses of multiple dependent variables to s 1 independent variable. Whereas ANOVA is the correct alternative to statistically inappropriate multiple t‐tests, MANOVA is the correct alternative to statistically inappropriate multiple uni‐variate ANOVA calculations. Use of each of these statistical methods requires an appropriate experimental design and data meeting a number of assumptions. When used properly, each of these methods provides a powerful statistical analysis technique.
Subcutaneous Buffered Lidocaine for Intravenous Cannulation: Is There a Role in Emergency Medicine?
Authors: Burgher Stephen W. , McGuirk Timothy D. 
Published: March 2010

Abstract. Objective: To prospectively evaluate whether subcutaneous buffered lidocaine (SQBL) significantly reduces the pain or adversely affects the success rate of IV cannulation (IVC) in adult ED patients. Methods: A convenience sample of patients a 18 years old requiring IVC in a regional military ED were prospectively randomized to receive SQBL, SQ normal saline with 0.9% benzyl alcohol (SQNS), or no pretreatment (NPTx), prior to IVC with an 18‐gauge angiocatheter. SQ infiltration was accomplished using a 27‐gauge insulin syringe. Investigators and patients were blinded to SQBL and SQNS in the pretreatment groups. The number of attempts at IVC was recorded for each patient. A 100‐mm visual analog pain scale (VAPS) was used to record pain scores for both SQ infiltration and IVC. Comparisons of the mean numbers of attempts to achieve IVC and of the VAPS scores were accomplished by analysis of variance followed by Duncan's multiple range test if significance was found. Results: A total of 103 patients (SQBL‐34, SQNS‐30, and NPTx‐39) were enrolled between November 15, 1996, and June 13, 1997. There were no significant differences among the groups in either the mean number of attempts (SQBL = 1.35, 95% CI ± 0.260; SQNS = 1.13, 95% CI ± 0.124; and NPTx = 1.28, 95% CI ± 0.203) (p = 0.367) or the success rate on the first attempt (SQBL = 79.4%, SQNS = 86.7%, NPTx = 79.5%) (p = 0.533). The median VAPS score of rVC without pretreatment (21 mm, 95% CI ± 7.97) was greater than that for SQBL infiltration alone (10 mm, 95% CI ± 9.11), SQNS infiltration alone (9 mm, 95% CI ± 7.37), and IVC after SQBL (6 mm, 95% CI ± 9.18) (p < 0.009 for each group). SQNS infiltration had no significant effect on the VAPS score of subsequent rVC (20 mm, 95% CI ± 10.5) compared with IVC without pretreatment (21 mm). Conclusions: SQBL significantly reduced the pain, while not adversely affecting the success rate, of IVC in adult patients in the ED.
Wound Irrigation with Tap Water
Authors: Moscati Ronald M. , Reardon Robert F. , Lerner E. Brooke , Mayrose James 
Published: March 2010

Abstract. Objective: The study hypothesis was that irrigation with tap water is as efficacious as irrigation with sterile saline in removing bacteria from simple lacerations in preparation for wound closure. Methods: The study was conducted in a laboratory rat model previously described in the literature for evaluating wound irrigation techniques. The study used a randomized, blinded crossover design using 10 animals. Two full‐thickness skin lacerations were made on each animal and each wound was inoculated with standardized concentrations of a Staphylococcus aureus broth. Wounds were irrigated for 4 minutes with normal saline from a syringe or 4 minutes with tap water from a faucet. Tissue specimens were sampled from each laceration prior to and following irrigation. Bacterial counts per gram of tissue were determined for each specimen and compared pre‐ and postirrigation. Results: Preirrigation bacterial counts were not significantly different for saline vs tap water specimens. The wounds irrigated with saline had a mean reduction in bacterial count of 54.7% (SD =±28%), while the wounds irrigated with tap water had a mean reduction in bacterial count of 80.6% (SD =±20%) (p < 0.05, 2‐tailed, paired t‐test). Conclusions: In this animal model, bacterial decontamination of simple lacerations was not compromised, and was actually improved using tap water irrigation. This is most likely due to the mechanical differences in the types of irrigation. In certain instances, such as with upper‐extremity lacerations, tap water irrigation would likely be cheaper and less labor‐intensive than irrigation with normal saline from a syringe.
Testicular Infarction in a Patient with Epididymitis
Authors: Sue Sean R. , Pelucio Maria , Gibbs Michael 
Published: March 2010

SummaryTo the authors' knowledge, this case is unique to the emergency medicine literature. Although testicular infarction from epididymitis is rare, it should be considered as a complication of severe or unresolving epididymitis. These patients should be Dlaced on broad spectrum antibiotcs, i.e., quinolones; color flow Dopp‐er of the testes should be obtained; md urologic consultation should be onsidered for possible admission ind surgical exploration.
Abdominal Pain in Geriatric Emergency Patients: Variables Associated with Adverse Outcomes
Authors: Marco Catherine A. , Schoenfeld Charles N. , Keyl Penelope M. , Menkes Edana D. , Doehring Marla C. 
Published: March 2010

Abstract. Objective: To determine the diagnoses and outcomes of geriatric patients with abdominal pain, and to identify variables associated with adverse outcomes. Methods: Geriatric emergency patients (aged 65 years and older) with a complaint of abdominal pain were participants in this longitudinal case series. Eligible patients were followed by telephone contact and chart review, to determine outcomes and final diagnoses. Results: Of 380 eligible patients, follow‐up information was available for 375 (97%), for the two months following the ED visit. Final diagnoses included infection (19.2%), mechanical‐obstructive disorders (15.7%), ulcers/hypersecre‐tory states (7.7%), urinary tract disease (7.7%), malignancy (7.2%), and others. Although 5.3% of the patients died (related to presenting condition), most (61.3%) patients ultimately recovered. Surgical intervention was required for 22.1% of the patients. Variables associated with adverse outcomes (death, and need for surgical intervention) included hypotension, abnormalities on abdominal radiography, leukocytosis, abnormal bowel sounds, and advanced age. Most physical examination findings were not helpful in identifying patients with adverse outcomes. This study demonstrated a higher incidence of malignancy (7.2%) and a lower incidence of disease necessitating surgical intervention (22.1%) than previously reported. Conclusions: The majority of geriatric emergency patients with abdominal pain have significant disease necessitating hospital admission. Morbidity and mortality among these patients are high, and specific variables are strongly associated with death and the need for surgical intervention. Absence of these variables does not preclude significant disease. Physical examination findings cannot reliably predict or exclude significant disease. These patients should be strongly considered for hospital admission, particularly when fever, hypotension, leukocytosis, or abnormal bowel sounds are present.
Severe Sepsis in the Emergency Department and Its Association with a Complicated Clinical Course
Authors: Smith Stephen W. , Pheley Alfred , Collier Robert , Rahmatullah Amin , Johnson Lori , Peterson Phillip K. 
Published: March 2010

Abstract. Objective Infection severity as determined by clinical criteria has been recently classified and studied in hospitalized inpatients. The objective of the study was to use modified criteria to determine the clinical course associated with three levels of infection severity in infected patients admitted from the ED. Methods: This was a retrospective cohort study involving all patients 18 years of age and older admitted through the ED of an urban teaching hospital during a four‐month period whose primary reason for requiring hospitalization was an infection that was recognized in the ED. ED records were reviewed for criteria used to classify patients by three levels of infection severity: no systemic inflammatory response syndrome, sepsis, and severe sepsis (SS). The relationships between these classifications as well as certain clinical characteristics and any complicated clinical course as measured by death and/or admission to an intensive care unit (ICU), and/or prolonged hospitalization, were analyzed. Results: Of 408 patients entered into the study, 138 (33.8%) fulfilled the criteria of SS in the ED. Patients with SS in the ED had a mortality of only 4.3%, though with an increased risk of dying compared with that of the other groups combined [relative risk (RR) = 11.64, 95% confidence interval (CI) = 1.43 to 96.53], an increased risk of ICU stay (RR = 7.65, 95% CI = 4.08 to 14.36), and an increased risk of prolonged hospitalization (RR = 1.99, 95% CI = 1.38 to 2.88). Although age over 60 years and several comorbid conditions also were identified by univariate analysis as risk factors, multivariate analysis revealed that only SS and diabetes mellitus (DM) were independent predictors of a complicated course. In the authors' institution, the positive predictive value (PPV) of SS for complicated clinical course was 0.48 and the negative predictive value (NPV) of no SS for no complicated course was 0.77. The PPV of [SS + DM] was 0.83, and the NPV of [SS, DM, or both] was also 0.83. Conclusion: Although the strongest correlate of a complicated clinical course identified in the ED is SS as defined by the study criteria, its specificity and PPV are low. The mortality of ED patients with SS is much lower than the mortality rates reported for inpatients with SS. SS as defined by the study criteria is too sensitive and therefore lacks utility in the ED setting.
Intravenous vs Subcutaneous Naloxone for Out‐of‐hospital Management of Presumed Opioid Overdose
Authors: Wanger Karen , Brough Laura , Macmillan Ian , Goulding Jim , MacPhail Iain , Christenson James M. 
Published: March 2010

ABSTRACTObjective: To determine whether naloxone administered IV to out‐of‐hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (SQ).Methods: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out‐of‐hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate ≥10 breaths/min, and durations of bag‐valve‐mask ventilation. Subjects received either naloxone 0.4 mg IV (n= 74) or naloxone 0.8 mg SQ (n= 122), for respiratory depression of <10 breaths/min.Results: Mean interval from crew arrival to respiratory rate ≥ 10 breaths/min was 9.3 ± 4.2 min for the IV group vs 9.6 ± 4.58 min for the SQ group (95% CI of the difference ‐1.55, 1.00). Mean duration of bag‐valve‐mask ventilation was 8.1 ± 6.0 min for the IV group vs 9.1 ± 4.8 min for the SQ group. Cost of materials for administering naloxone 0.4 mg IV was $12.30/patient, compared with $10.70/patient for naloxone 0.8 mg SQ.Conclusion: There was no clinical difference in the time interval to respiratory rate ≥10 breaths/min between naloxone 0.8 mg SQ and naloxone 0.4 mg IV for the out‐of‐hospital management of patients with suspected opioid overdose. The slower rate of absorption via the SQ route was offset by the delay in establishing an IV.
Serum Creatine Kinase Is an Unreliable Predictor of Ectopic Pregnancy
Authors: Plewa Michael C. , Ledrick David , Buderer Nancy Fenn , King Randall W. 
Published: March 2010

ABSTRACT Objective: To compare serum creatine kinase (CK) values in patients with ectopic pregnancy vs patients with threatened miscarriage or normal pregnancy. Methods: An observational case‐control study was performed at an urban teaching hospital. Pregnant women with a quantitative β‐hCG obtained for suspicion of ectopic pregnancy were evaluated. Excluded were cases with recent trauma, IM injections, surgery, or history of heart, liver, or muscle disease. The serum β‐hCG and CK values were recorded and compared between groups with 1‐way ANOVA and Tukey's multiple comparison procedure at the overall 0.05 level. Results: The 15 ectopic, 28 threatened miscarriage, and 21 normal pregnancy cases were of similar gestational ages (p = 0.2), ranging from 3 to 12 weeks. Although the CK values for ectopic pregnancy (88.8 ± 33.6 IU/L) exceeded those for threatened miscarriage (65.9 ± 59.0 IU/L) and normal pregnancy (56.0 ± 38.1 U/L) (p = 0.02), there was significant overlap between groups. CK values were at or above a cutoff of 74 IU/L in 80% (95% confidence interval: 52–96%) of ectopic pregnancies, 25% (11–45%) of threatened miscarriages, and 14% (3–36%) of normal pregnancies. Conclusions: Although the ectopic pregnancy population is characterized by a higher mean CK than are patients with threatened miscarriage or a normal pregnancy, a significant overlap in CK values makes use of this serum marker unreliable for detecting ectopic pregnancy.
University and Community Hospital Medical Student Emergency Medicine Clerkship Experiences
Authors: DeLahunta Elizabeth A. , Bazarian Jeffrey 
Published: March 2010

ABSTRACT Objective: To determine whether there is a significant difference between educational opportunities for fourth‐year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship. Methods: A self‐reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six‐hour shifts. They rated the EM attending clinical teaching by site using a 5‐point scale at the end of the clerkship. Results: Most (95%) of the 87 students in the 7 clerkship blocks of the 1996–97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 ± 0.10 vs 2.8 ± 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 ± 0.04 vs 0.56 ± 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs. Conclusions: The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.
Effect of Skin Pigmentation on Pulse Oximetry Accuracy in the Emergency Department
Authors: Adler Jonathan N. , Hughes Lori A. , Vtvilecchia Robert , Jr. Carlos A. Camargo 
Published: March 2010

Abstract. Objective:To determine whether pulse oximeter (PO) accuracy and signal quality are affected by level of skin pigmentation.Methods:Observational study in a community hospital ED. Consecutive adult patients undergoing arterial blood gas determination were enrolled into the study. Skin pigmentation was determined by comparison with standardized color swatches under controlled lighting; assigned values were used to stratify patients into 3 groups (light, intermediate, and dark) using predetermined criteria. Simultaneous with arterial blood sampling, staff recorded PO reading of O2 saturation using the Nellcor D‐25 oximeter. PO values were compared with criterion standard values measured using a 4‐wavelength spectrophotometer or cooximeter. PO signal quality also was recorded. Bias (the mean difference between PO and co‐oximeter‐measured values of hemoglobin saturation) and precision (the standard deviation of the bias) were calculated. Groups were compared using one‐way ANOVA, Bart‐lett's test for variances, and x2 test.Results:O2 saturation data were obtained for 284 patients. Bias values did not differ between the 3 skin pigment groups (p = 0.79). Precision was of borderline significance (p = 0.05), but there was no dose‐response relation between skin pigmentation and precision. Study personnel reported suboptimal PO function most often among patients in the dark group (p = 0.003), but this finding was of no clinical significance. PO signal failure was rare (<1% of all patients).Conclusions:Although several prior studies suggest the contrary, this study found that skin pigmentation does not affect the bias or precision of pulse oximetry. Furthermore, skin pigmentation has no clinically significant effect on PO signal quality.
A Comparison of Demand‐valve and Bag‐Valve Ventilations in a Swine Pneumothorax Model
Authors: Jr. Hervy B. Kornegay , Carroll Robert G. , Brown Lawrence H. , Whitehurst Marvin E. 
Published: March 2010

Abstract. Objective:Two means of delivering artificial ventilation readily available to out‐of‐hospita] personnel are the bag‐valve (BV) and the empowered demand‐valve (OPDV). However, use of the OPDV has been limited because of concerns that it may worsen an underlying pneumothorax. This study compared the changes in size of pneumothorax in swine ventilated with the 2 devices.Methods:Three swine were anesthetized, intubated, and instrumented with a femoral arterial line and a pediatric Swan‐Ganz catheter. A chest tube was placed, the chest was opened, and the lung parenchyma was visualized. The lung was disrupted by a single stab with a #10 scalpel; the chest was then sealed; and a pneumothorax was created by injecting 30 mL of air through the chest tube. The animals were ventilated by 12 emergency medical technicians using either BV or OPDV. After 10 minutes of ventilation, the pneumothorax volume was measured.Results:When comparing final pneumothorax volumes after 10 minutes of ventilation with the 2 devices, there was no significant difference (mean ± SD = 40.8 ± 28.2 mL vs 52.3 ± 23.1 mL, p = 0.286).Conclusion:There is no difference in final pneumothorax volumes after OPDV or BV ventilation.