bluuebunny/crossref_metadata_2025_split huggingface dataset:
Randomized, Prospective Trial of Fenoldopam vs Sodium Nitroprusside in the Treatment of Acute Severe Hypertension
Authors: Patmcek Edward A. , Bednarczyk Edward M. , Dunbar Lala M. , Foulke Garrett E. , Holeslaw Terry L. ,   for the Fenoldopam Study Group
Published: September 2008

ABSTRACTObjective:To compare the safeties and efficacies of IV fenoldopam (FNP) vs sodium nitroprusside (NTP) in severe acute hypertension.Methods:A prospective. randomized, open‐label, multimember international trial, at 24 academic medical centers, was conducted. The participants were adult patients (21–80 years of age) who had supine diastolic blood pressures (DBPs) ≥ 120 mm Hg, were capable of written informed consent, and did not have selected exclusion criteria. The subjects were randomized to either FNP or NTP therapy; DBP was titrated to 95–110 mm Hg. or a maximum reduction of 40 mm Hg for very high pressures. Infusions were maintained for at least six hours, then the patients were weaned off the IV therapy and oral medication was started. Measurements included BP, heart rate, and duration of study drug infusion and frequency of side effects or complications.Results:A total of IS3 patients (90 FNP, 93 NTP) were enrolled. Fifteen patients from each arm were excluded from efficacy analysis due to protocol violation. There was no significant difference in baseline characteristics. The two antihypertensive agents were equivalent in controlling and maintaining DBP. Systolic blood pressure (SBP) was reduced to a slightly greater degree for the NTP‐treated patients during the initial (0.5–1‐hr) study period, and both SBP and DBP were reduced more for the FNP‐treated patients in the subset receiving infusions during the 12–24‐hour period. The adverse effect profiles of the drugs were similar, as were the times to achieve target pressure, with no clinically relevant difference.Conclusions:For patients who had acute severe hypertension, FNP and NTP were equivalent in terms of efficacy and acute adverse events. Because of a unique mechanism of action, FNP may have advantages in selected subsets of patients. Further studies may be indicated in patient populations with pure “hypertensive emergencies.”
Use of Radiography in Acute Knee Injuries: Need for Clinical Decision Rules
Authors: Stiell Ian G. , Wells George A. , McDowell Ian , Greenberg Gary H. , McKnight R. Douglas , Cwinn A. Adam , Quinn James V. , Yeats Ashley 
Published: September 2008

ABSTRACTObjectives: To study: 1) the efficiency of the current use of radiography in acute knee injuries, 2) the judgments and attitudes of experienced clinicians in their use of knee radiography, and 3) the potential for decision rules to improve efficiency.Methods: This two‐stage study of adults with acute knee injuries involved: 1) a retrospective review of all 1,967 patients seen over a 12‐month period in the EDs of one community and two teaching hospitals, and 2) a prospective survey of another 1,040 patients seen by attending emergency physicians. The prospective survey assessed each clinician's estimate of the probability of a knee or patella fracture; 120 patients were independently assessed by two physicians.Results: Of the 1,967 patients seen in the first stage, 74.1% underwent radiography but only 5.2% were found to have fractures. Of the 1,727 knee and patella radiographic series ordered. 92.4% were negative for fracture. In the second stage. experienced physicians predicted the probability of fracture to be 0 or 0.1 for 75.6% of the patients. The kappa value for this response was 0.51 (95% CI 0.34 to 0.68). The physicians also indicated that they would have been Comfortable or very comfortable in not ordering radiography for 55.5% of the patients. The area under the receiver operating characteristic curve for the physicians' prediction of fracture was 0.87 (95% CI 0.82 to 0.91). reflecting good discrimination between fracture and nonfracture cases. Likelihood ratios for the physicians' prediction ranged from 0.09 at the 0 level to 42.9 at the 0.9–1.0 level.Conclusions: Emergency physicians order radiography for most patients with acute knee injuries, even though they can accurately discriminate between fracture and nonfracture cases and expect most of the radiographs to be normal. These findings suggest great potential for more efficient use of knee radiography, possibly through the use of a clinical decision rule.
Bedside Fluoroscopy for the Detection of Foreign Bodies
Authors: Wyn Tod , Jones Jeffrey , McNinch Dale , Heacox Robert 
Published: September 2008

ABSTRACTObjective: To determine the sensitivity and specificity of portable fluoroscopy for foreign‐body detection using an exvivo experimental model.Methods: A prospective, randomized masked investigation was performed to characterize foreign‐body detection in cubes of beef. Three emergency physicians (EPs) independently used a portable fluoroscope to determine the presence or absence of various foreign bodies in ten cubes of beef (approximately 6 cm on each side). Six different groups of foreign bodies were examined: glass, wood, graphite (pencil lead), metal (needle), plastic, and gravel. An independent observer placed the six objects randomly into each set of ten beef cubes. One hundred observations were made by each physician using sets of ten beef cubes at a time.Results: Fluoroscopy detected 117 of 180 foreign bodies (sensitivity 65%; 95% CI 58–72%), including all cubes of beef embedded with gravel, metal, and glass. Graphite was detected 27 of 30 times (sensitivity 90%; 95% C1 74–9896). None of the plastic or wooden foreign bodies was identified despite magnification techniques and real‐time imaging (sensitivity 0%; 95% C10–17%. each). Of the 120 cubes of meat with no foreign body. two false‐positives were recorded (specificity 98%; 9.5% C1 94–100%). The overall positive predictive value and negative predictive value of fluoroscopy were 98% and 6570, with 95% CIs of 94–10070 and 58–7270, respectively. Interobserver agreement between the three EPs was considered excellent (kappa = 0.75).Conclusion: Bedside fluoroscopy lacks sufficient sensitivity to rule out many foreign bodies in the ED. Its use should be limited to suspected gravel, glass, pencil lead, and metallic objects, which are known to be radiopaque.
Poor Correlation of Short‐ and Long‐term Cosmetic Appearance of Repaired Lacerations
Authors: Hollander Judd E. , Blasko Barbara , Singer Adam J. , Valentine Sharon , Thode Henry C. , Henry Mark C. 
Published: September 2008

ABSTRACTObjective: To describe the consistency of a cosmetic scale for repaired lacerations and to determine whether the appearance of lacerations at the time of suture removal correlates with the appearance six to nine months later.Methods: A convenience sample of patients who had lacerations repaired in a university teaching hospital were evaluated at the time of suture removal and sin to nine months following repair. All lacerations were assigned 0 or 1 point each for the presence or absence of a step‐off of borders, contour irregularities, margin separation, edge inversion, excessive distortion. and overall appearance. A total cosmetic score (0–6) was calculated by adding the scores for the categories above. The consistency of the cosmetic scale was assessed by comparison of scores given by two different practitioners evaluating each patient at suture removal and long‐term follow‐up. The 38 evaluating practitioners were assigned based on availability and did not necessarily perform serial evaluations of the same patient.Results: The 41 participating patients had a median age of 19 years (range. 2–82 years). Wounds were located predominantly on the head (73%) and upper extremity (22%). Long‐term follow‐up was performed at a median of 219 days (range, 155–280 days) after suture removal. Interpractitioner concordance regarding optimal appearance (score of 6 vs ≤5) was moderate (kappa = 0.52) at the time of suture removal and substantial at the time of long‐term follow‐up (kappa = 0.68). However, the correlation of actual scores at the time of suture removal vs at long‐term follow‐up was poor (r = 0.17. p = 0.29).Conclusion: For our clinicians, the six‐item categorical scale appears consistent as a tool for the assessment of the cosmetic appearance of wounds. However. correlation between laceration appearance at the time of suture removal and six to nine months later is poor.
Relating Patient Satisfaction to Waiting Time Perceptions and Expectations: The Disconfirmation Paradigm
Authors: Thompson David A. , Yarnold Paul R. 
Published: September 2008

ABSTRACTObjective: To determine the association of patient satisfaction with waiting time perceptions and expectations.Methods: A random sample of patients seen at one community hospital ED during a one‐year period was surveyed by telephone within two to four weeks of evaluation to determine perceived satisfaction and waiting time perceptions and expectations.Results: In response to 3, 641 attempted phone surveys, 1, 574 patients had usable interviews. Consistent with a hypothesis derived using the disconfirmation paradigm (i.e., that satisfaction is a function of the magnitude and direction of the difference between perceived service and expected service), the patients were least satisfied when waiting times were longer than expected, were relatively satisfied when waiting times were perceived as equal to expectations, and were highly satisfied when waiting times were shorter than expected (p < 0.0001). Overall. the measure of effect strength (values from 0 to 1) of perceived waiting time vs expectation on the patient satisfaction score was 0.32. indicating moderate association.Conclusions: The current study supports the validity of the disconfirmation paradigm in relating patient satisfaction to waiting time perceptions and expectations. Furthermore, it emphasizes that achieving satisfaction in a service encounter necessitates that perceived performance meet or exceed patient expectations.
Ectopic Pregnancy—Part II: Diagnostic Procedures and Imaging
Authors: Brennan Daniel F. 
Published: September 2008

SUMMARYEctopic pregnancy is an increasingly common and potentially catastrophic condition in which the patient often presents to the ED with abdominal pain or vaginal bleeding. Recent developments in the laboratory (sensitive PhCG assays, progesterone assays), in ultrasonogra‐phy (transvaginal probes, Doppler ultrasonography), and in the combination of modalities (discriminatory zone of PhCG for ultrasono‐graphic evidence of IUP) have allowed the earlier diagnosis of ectopic pregnancy, with the potential for a reduction in maternal mortality and morbidity.Understanding the strengths and limitations of the variety of diagnostic modalities available will allow the clinician to formulate a rational strategy for the early diagnosis of ectopic pregnancy. Numerous algorithms have been developed. All begin wiht high clinical suspicion for women of reproductive age with abdominal/ pelvic pain or vaginal bleeding. Pregnancy testing with a sensitive PhCG qualitative test is next. For stable patients found to be pregnant, zoography generally follows (often first Tran abdominally then transvaginally). Unstable patients require immediate resuscitation and gynecology consultation; invasive diagnostic methods may supplant laboratory studies and sonography. Unclear cases may necessitate the use of quantitative PhCG (discriminatory zone), other pregnancy hormones (progesterone), invasive procedures (laparoscopy, culdocentesis, D&C), or observation (serial ßhCGs). A suggested algorithm incorporating these elements is shown (Fig. 1).
The Quantity of Cause‐of‐injury Information Documented on the Medical Record: An Appeal for Injury Prevention
Authors: Schwartz Robert J. , Boisoneau David , Jacobs Lenworth M. 
Published: September 2008

ABSTRACTObjective: To determine how much information about the cause of injury (available at the time of ED treatment) is documented on the medical record. This information is used by medical records coders to assign e‐codes.Methods: Quantitative “stages of information” were defined: stage 1 = the maximum amount of information available from the patient, as collected by a trained research assistant; stage 2 = the amount of information obtained by the care provider during the patient interview; and stage 3 = the amount of information the care provider documented in the medical record. Comparisons were made between the three stages; subgroup analyses compared amounts of information loss between the stages for levels of care provider and cause‐of‐injury information categories.Results: Information was obtained from 109 patients. Only 46% of the cause‐of‐injury information available during the ED visit was recorded on the medical record. Incomplete history taking (obtaining 68% of the available information) and failure to document (writing 67% of the information obtained during the patient interview) contributed equally to the loss of information. The most information was obtained about who had received the injury (72%) and the least amount of information was in the category of where the injury had occurred (14%). Attending physicians collected the most information (74%) but documented significantly less (65%) than did physician assistants (70%) or medical students (81%). Medical students collected the least (65%) but documented the most, resulting in the students' medical records' being the most complete (52%) for cause‐of‐injury information.Conclusions: Emergency providers obtain significantly less cause‐of‐injury information than is available from the patient. Also, these providers' handwritten medical records contain significantly less cause‐of‐injury information than was obtained during the patient interview.
Weapon Carriage among Major Trauma Victims in the Emergency Department
Authors: Ordog Gary J. , Wasserberger Jonathan , Ordog Cindy , Ackroyd Greg , Atluri Syama 
Published: September 2008

ABSTRACTObjective: To determine the occurrence of weapon carriage by major trauma patients at a university/county hospital ED.Methods: Retrospective observational study of major trauma patients seen in the ED of a major urban trauma center in Los Angeles from 1979 to 1993. All major trauma patients were searched routinely for weapons by the security police. Cases of violence in the ED caused by these weapons were reviewed.Results: Over the 14‐year period, 26.7% of the victims of major trauma presenting to ED were armed with lethal weapons. The occurrence of automatic weapon seizure increased significantly from an annual rate of only 0.2 in the first five years to an average of 17 over the last five years (p < 0.001). A total of 115 “incidents” of violence involving weapons in the ED were recorded during this period; 1.7% of the weapons brought to the ED led to violence and injury. There were four fatalities of armed and dangerous patients, but only six minor injuries to the staff. No other (unarmed) patient in the ED at the time of these incidents was injured.Conclusions: ED major trauma patients at one urban trauma center in Los Angeles frequently carry weapons, including automatic military weapons. In addition to violence prevention measures such as weapon confiscation, plans must be made and practiced for the management of violence within the “sacrosanct” hospital doors to protect both patients and ED personnel.
Resident Service Hours in Emergency Medicine
Authors: Wols Matthew , Kramer David , Strange Gary R. ,   for the SAEM Education Committee
Published: September 2008

ABSTRACTObjective: The number of hours worked by residents in all specialties has become a controversial issue. Residents often are expected to competently conduct patient care activities and to take educational advantage of clinical experiences in spite of frequent fatigue and sleep deprivation. This survey of residency directors was designed to assess the scheduled clinical time for emergency medicine (EM) residents.Methods: A 13‐question survey dealing with time commitments of EM residents was sent to the residency directors of all accredited EM residency programs in the United States in the fall of 1991. Residency directors were asked to indicate the number of shifts, hours, and days off per week; and the number of night shifts and weekend days off per month for each postgraduate year of residency training (PGY1‐PGY4). Directors also were asked whether shifts were scheduled randomly or predictably with progression from days to nights with time off after nights.Results: Seventy of 71 (98.6% response rate) residency directors responded. Residents were scheduled for an average of 49.1 hours per week. Scheduled hours decreased from an average of 51.9 at the PGY1 level to an average of 44.5 at the PGY4 level. A similar progression with year of training was noted for scheduled night shifts/ month, days off/week, and weekend days off/month. A PGY1 trainee averaged 7.0 night shifts/month, 1.9 days off/week, and 3.0 weekend days off/month; while a PGY4 trainee averaged 5.3, 2.4, and 3.2, respectively. Only 40% of the directors reported predictable scheduling progressing from days to nights.Conclusion: Emergency medicine resident schedules, as reported by residency directors, fall well within current specialty‐specific requirements and compare favorably with the reported numbers for other specialties. However, because large ranges in scheduling parameters were reported, the data may be of value to residency directors, residents, and prospective residents. Most programs did not report a predictable schedule progression of shifts.
Abdominal Wall Hematoma in an Elderly Man
Authors: Lindbeck George H. 
Published: September 2008

ABSTRACTThis report describes an abdominal wall hematoma that occurred in an unusual location and resulted in significant hemorrhage in a generally healthy individual. Angiography‐directed therapeutic embolization was halted due to an embolic complication. Evidence of continued hemorrhage led to surgical intervention. After a right flank incision was made, fresh blood as well as approximately 1 L of clotted blood were evacuated from the abdominal wall. After resection of a portion of the twelfth rib, the twelfth intercostal artery was noted to be actively bleeding and was ligated. This operative procedure controlled the patient's blood loss. The etiologies, presenting findings, diagnostic studies, and modes of therapy reported for abdominal wall hematomas are reviewed.
Cocaine‐associated Chest Pain: One‐year Follow‐up
Authors: Hollander Judd E. , Hoffman Robert S. , Gennis Paul , Fairweather Phillip , Feldman James A. , Fish Susan S. , DiSano Michael J. , Schumb David A. , Dyer Sophia 
Published: September 2008

ABSTRACTObjective: To determine the one‐year mortality and incidence of myocardial infarction (MI) post‐hospital discharge or ED release for patients with cocaine‐associated chest pain.Methods: A prospective, observational study of an inception cohort of consecutive patients who presented to one of four municipal hospital EDs with cocaine‐associated chest pain. Patients were followed for one year from the end of the enrollment period. Main outcome parameters were the one‐year actuarial survival and the frequency of nonfatal MI.Results: Mortality data were available for all 203 patients at a mean of 408 days. Additional clinical information was available for 185 patients (91%). There were six deaths (one‐year actuarial survival 98%; 95% CI, 95–100%); none from MI. Nonfatal MI occurred in two patients (1%; 95% CI, 0–2%). Continued cocaine use was common (60%; 95% CI, 52–68%) and was associated with recurrent chest pain (75% vs 31%, p < 0.0001). No MI or death was reported for patients who claimed to have ceased cocaine use.Conclusions: Patients who presented with cocaine‐associated chest pain commonly continued to use cocaine after discharge. Urgent evaluation of coronary anatomy or cardiac stress tests may not be necessary for patients for whom MI is ruled out and who do not have recurrent potentially ischemic pain. The subsequent risk for MI and death in this group appears to be low. Intervention strategies should emphasize cessation of cocaine use.
The Effects of Warming and Buffering on Pain of Infiltration of Lidocaine
Authors: Bartfield Joel M. , Crisafulli Kathleen M. , Raccio‐Robak Nancy , Salluzzo Richard F. 
Published: September 2008

ABSTRACTObjectives: To investigate the effects of warming vs buffering, and warming with buffering, on the pain of lidocaine infiltration.Methods: A randomized, double‐blind clinical trial was conducted using volunteers aged 18 years or more and without an allergy to lidocaine. The study consisted of two parts, each comparing two solutions. The solutions for Part I were warm (38.9°C; 102°F) plain lidocaine and room‐temperature buffered lidocaine. Warm buffered lidocaine and room‐temperature buffered lidocaine were used for Part II. The subjects received two standardized 0.5‐mL intradermal injections, one study solution in each forearm. Immediately after each injection, pain was assessed using a 100‐mm visual analog pain scale. Pain scores were analyzed by the sign test, with significance defined as p < 0.05.Results: Part I (n = 10): Nine subjects reported room‐temperature buffered lidocaine to be less painful than warm plain lidocaine. Mean pain scores were 28 mm lower for room‐temperature buffered lidocaine than they were for warm plain lidocaine (p < 0.01). Part II (n = 24): Eleven subjects found warm buffered lidocaine to be the least painful, 11 reported room‐temperature buffered lidocaine to be the least painful, and two reported no difference. A mean pain score difference of 2.1 mm favoring warm buffered lidocaine was not statistically significant. Part II had a power of 80% to detect a 10‐mm difference between the two solutions at a = 0.05.Conclusion: To reduce the pain of lidocane infiltration, buffering is more effective than warming. Warming does not enhance buffering.
Association of Drug Therapy with Survival in Cardiac Arrest: Limited Role of Advanced Cardiac Life Support Drugs
Authors: Stiell Ian G. , Wells George A. , Hebert Paul C. , Laupacis Andreas , Weitzman Brian N. 
Published: September 2008

ABSTRACTObjective: To generate hypotheses regarding the association of standard Advanced Cardiac Life Support (ACLS) drugs with human cardiac arrest survival.Methods: This observational cohort study was conducted over a two‐year period in the wards, intensive care units, and EDs of two tertiary care hospitals. Included were adult patients who suffered cardiac arrest either inside or outside the hospital and who required epinephrine according to standard ACLS guidelines. Six standard ACLS drugs (given while CPR was in progress) were assessed for association with survival from resuscitation to one hour and to hospital discharge by univariate and multivariate logistic regression analyses.Results: In the 529 patients studied, initial cardiac rhythm had no impact on the association between drug administration and survival. The time of drug administration (quartile of ACLS period) was associated with resuscitation for atropine (p < 0.05) and lidocaine (p < 0.01). The odds ratios (95% CIs) for successful resuscitation, after multivariate adjustment for potential confounders, were: a respiratory initiating cause, 3.7 (2.1–6.4); each 5‐minute increase in CPR‐ACLS interval, 0.5 (0.4–0.7); each 5‐minute duration of ACLS, 0.9 (0.8–1.0); atropine, 1.2 (1.0–1.3); bretylium, 0.4 (0.1–1.1); calcium, 0.8 (0.2–2.4); lidocaine, 0.9 (0.7–1.1); procainamide, 21.0 (5.2–84.0); and sodium bicarbonate 1.2 (1.0–1.6). All other potential confounding variables entered into the model were not significantly associated with resuscitation.Conclusion: Initiating cause of arrest, time to ACLS, and duration of ACLS were important correlates of survival. Other than procainamide, standard ACLS drugs had relatively little association with survival, but timing of administration may be an important factor. Further research using definitive large randomized controlled trials is warranted to assess the role of drug therapy in improving cardiac arrest survival.