bluuebunny/crossref_metadata_2025_split huggingface dataset:
Tricyclic Antidepressants Directly Depress Human Myocardial Mechanical Function Independent of Effects on the Conduction System
Authors: Heard Kennon , Cain Brian S. , Dart Richard C. , Cairns Charles B. 
Published: January 2008

Abstract Objectives: To measure the effect of tricyclic antidepressant drugs (TCAs) on human myocardial contractility. Methods: Human atrial tissue was obtained during cardiac bypass surgery. The tissue was harvested, suspended in a Tyrode buffer at 37°C, and perfused with a 95%/5% oxygen—carbon dioxide mixture. Developed force was continuously measured using a force transducer and recorded by computer. After an equilibration period, escalating doses of amitriptyline or desipramine were added to the bath. All strips were exposed to the following five concentrations of each drug: 0 (control) 0.4, 4, 40, and 400 μM. The results for each experiment were expressed as the difference between the developed force measured prior to the addition of each concentration of drug and the developed force measured after a 30‐minute exposure to the drug. Results: Desipramine decreased the developed force by 27%, 49%, and 74% at concentrations of 0.4, 40, and 400 μM, respectively. Amitriptyline decreased the developed force by 38% at the 40‐μM concentration and by 89% at the 400‐μM concentration. Untreated strips retained 94% of baseline developed force at 150 minutes. Conclusions: Tricyclic antidepressants depress human myocardial function in a dose‐dependent fashion independent of the effects on the cardiac conduction system. While previous work has demonstrated the effect of therapies for the reversal of impaired cardiac conduction following TCA poisoning, to the best of the authors' knowledge, no reports have documented the effects of therapy on direct myocardial depression. Additional therapies targeted at reversing the direct cardiodepressive effects of TCA may improve outcome following TCA poisoning.
Identification of Prearrest Clinical Factors Associated with Outpatient Fatal Pulmonary Embolism
Authors: Courtney D. Mark , Kline Jeffrey A. 
Published: January 2008

AbstractMassive pulmonary embolism (MPE) is an important cause of outpatient sudden death, and description of these patients is critical for identification and treatment. Objective: To test whether MPE patients can be distinguished from patients suffering sudden death from other causes based on clinical, demographic, and historical data. The hypothesis was that MPE cases would be more likely to manifest components of a clinical triad of 1) overt dyspnea, 2) alteration of mental status or syncope, and 3) shock index (pulse divided by systolic blood pressure) >0.8. Methods: Retrospective case—control study of medical examiner data from 1992 to 1999 including all patients with nontraumatic death, aged 18‐65 years, transported to an emergency department, with autopsy‐determined cause of death. Analysis was done by 95% confidence interval (95% CI) for difference in proportions and multivariate logistic regression for odds ratios. Results: The MPE patients (n = 37) were younger than the control subjects (n = 347) (40.2 vs 46.5 years, unpaired t‐test p < 0.001). At least two of the three components of the triad were present in 56.8% of MPE cases vs 3.5% of controls (95% CI for difference in proportions = 37.3% to 68.0%). Significant variables (and odds ratios) for MPE after multivariate analysis included: dyspnea (13.8), shock index >0.8 (23.6), immobilization or fracture (14.6), seen by a physician within two weeks (5.1), and African American female status (6.4). Conclusions: Patients in this community with fatal MPE were young with risk factors for pulmonary embolism, and commonly manifested components of a triad including: dyspnea, alteration of mental status/syncope, and shock prior to death.
Provider Adherence to a Clinical Practice Guideline for Acute Asthma in a Pediatric Emergency Department
Authors: Scribano Philip V. , Lerer Trudy , Kennedy Dayna , Cloutier Michelle M. 
Published: January 2008

AbstractCritics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time‐consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated. Objectives: To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence. Methods:Prospective, cohort study of children aged 1‐18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parametersResults: Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty‐eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence.Conclusions: Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.
Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments
Authors: Lahn Michael , Friedman Benjamin , Bijur Polly , Haughey Marianne , Gallagher E. J. 
Published: January 2008

Abstract Objective: Ten years have passed since Congress enacted the Patient Self‐Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs). Methods: This was an observational, cross‐sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive patients arriving during 12‐hour data collection shifts. Results: Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40% to 48%] had an AD. Advance directives were significantly more prevalent among white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with ADs, do‐not‐resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful. Conclusions: Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three‐fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care.
Risk Factors for Cardiovascular and Cerebrovascular Death among African Americans and Hispanics in Los Angeles, California
Authors: Henderson Sean O. , Bretsky Philip , Henderson Brian E. , Stram Daniel O. 
Published: January 2008

Abstract Objective: To describe the risk factors associated with cardiovascular mortality in the African American (AA) and Hispanic populations in Los Angeles County in an effort to define causes for the excess mortality seen in AAs. Methods: This was a longitudinal analysis of all‐cause, cardiovascular, and cerebrovascular mortality in a large, prospective multiethnic cohort of individuals aged 45‐74 years. Death rates between AA and Hispanic men and women during the six‐year period from 1993 to 1998 due to hypertension, cardiomyopathy, acute myocardial infarction (AMI), ischemic heart disease, and stroke were compared. Results: There were 1,157 deaths due to cardiovascular disease (CVD) or cerebrovascular disease among the 71,798 eligible members of the cohort included in these analyses. Age‐adjusted mortality rates were two to five times higher in AAs as compared with Hispanics (e.g., 373.15 in AAs for hypertensive disease vs 50.37 in Hispanics). A history of hypertension was the most common significant risk factor for CVD; other risk factors significantly associated with CVD mortality included cigarette smoking and a past history of diabetes and stroke. Adjusting for these factors did not remove the significance of AA ethnicity as a risk factor for CVD mortality in either subjects reporting or subjects not reporting hypertension at baseline. Conclusions: The evidence for both higher relative severity and higher incidence of hypertensive disease among AAs, and the consistency of the effect across gender, suggests that a major determinant of risk may be a gene environment interaction.
Mental Health Aspects of Emergency Medical Services for Children Summary of a Consensus Conference
Authors: Horowitz Lisa , Kassam‐Adams Nancy , Bergstein Jack 
Published: January 2008

Abstract Objective: To address the mental health needs of children involved in emergency medical services (EMS). Methods: A multidisciplinary consensus conference convened to identify mental health needs of children and their families related to pediatric medical emergencies, to examine the impact of psychological aspects of emergencies on recovery and satisfaction with care, and to delineate research questions related to mental health aspects of medical emergencies involving children. Results: The consensus group found that psychological and behavioral factors affect physical as well as emotional recovery after medical emergencies. Children's reactions are critically affected by age and developmental level, characteristics of the emergency medical event, and parent reactions. As frontline health care providers, EMS staff members are in a pivotal position to recognize and effectively manage the mental health needs of patients and their families. Conclusions: Ecological changes in emergency departments, such as linkages to mental health follow‐up services, training of EMS providers and mental health professionals, and focused research that provides an empirical basis for practice, are necessary components for improving current standards of health care.
Ethics Seminars HIV Testing, Consent, and Physician Responsibilities
Authors: Parsa Michael , Walsh Matthew J. 
Published: January 2008

AbstractEmergency physicians constantly have multiple ethical obligations in the emergency department. They must understand these sometimes conflicting obligations and learn to prioritize. A case discussion is presented that exemplifies the conflict between patient privacy and society's right to know. Specific aspects of HIV testing and obtaining patient consent are presented. Teaching physicians are encouraged to use such common cases for “ethics case discussion.”
Are Emergency Department Patients at Risk for Herb—Drug Interactions?
Authors: Rogers Emily A. , Gough John E. , Brewer Kori L. 
Published: January 2008

Abstract Objectives: To determine the prevalence of herbal and/or dietary supplement use and identify patients at risk for herb—drug interactions. Methods: A convenience sample of 944 patients were surveyed to determine the prevalence and types of supplements used. Patients with heart disease, diabetes, psychiatric disorders, and/or hypertension were assessed for potential interactions. Results: One hundred thirty‐five (14.3%) patients reported regular use. Of these, 79.3% were taking supplements concurrently with prescription medications, and 80.0% were administered medication(s) in the emergency department. Cardiac: 19.8% (n? 33) reported regular use, with four potential interactions. Hypertension: 20.3% (n? 54) reported regular use, with two potential interactions. Diabetes: 15.9% (n? 20) reported regular use, with no known interactions. Psychiatric: 15.9% (n? 10) reported regular use, with one potential interaction. Conclusions: Six patients were identified at risk for seven known herb—drug interactions. The prevalence of undisclosed herbal supplement use and lack of research on these supplements suggest that more patients may be at risk.
Is the ACLS Score a Valid Prediction Rule for Survival after Cardiac Arrest?
Authors: Haukoos Jason S. , Lewis Roger J. , Stratton Samuel J. , Niemann James T. 
Published: January 2008

AbstractThe ACLS (advanced cardiac life support) Score was previously developed to predict survival from out‐of‐hospital cardiac arrest. Whether the arrest was witnessed, initial cardiac rhythm, performance of bystander cardiopulmonary resuscitation (CPR), and the response time of the paramedic unit were determined to be predictive of survival. However, the ACLS Score has not been validated in other emergency medical services systems. Objectives: The purpose of this study was to externally validate the ACLS Score in one patient population. Methods: This was a retrospective cohort study performed at an urban county teaching hospital. The study population consisted of consecutive adult patients treated for out‐of‐hospital, nontraumatic cardiac arrest, and transported to the authors' institution between November 1, 1994, and September 30, 2001. Patient records for all cardiac arrests during the study period were reviewed. Study variables included witnessed arrest, initial arrest rhythm, bystander CPR, paramedic response time, and survival to hospital discharge. Predicted probability of survival to hospital discharge was calculated for each patient using the ACLS Score. The overall predicted and observed survival rates were compared using Flora's Z score. The Hosmer‐Lemeshow test was used to evaluate the model's goodness‐of‐fit over a range of survival probabilities. Results: Of 754 cardiac arrest patients enrolled in the study period, 575 (76%) patients had documentation that allowed scoring using the ACLS Score. Twenty‐five (4%) patients survived to hospital discharge. The predicted number of survivors based on the ACLS Score was 104 (18%), yielding a Flora's Z statistic of −4.46 (p < 0.0001). After categorizing predicted survival probabilities into four categories, the resulting Hosmer‐Lemeshow statistic was 210 (p ≪ 10−6). Both goodness‐of‐fit statistics demonstrated extremely poor fit of the model. A receiver operating characteristic (ROC) curve was created, yielding an area under the ROC curve of 0.33 (95% CI = 0.19 to 0.47), signifying extremely poor discrimination. Conclusions: The previously published ACLS Score was not valid when applied to an external cohort of out‐of‐hospital cardiac arrest patients. An externally valid model is needed to predict survival to hospital discharge following out‐of‐hospital cardiac arrest.
Acute Pain Is Underassessed in Out‐of‐hospital Emergencies
Authors: Luger Thomas J. , Lederer Wolfgang , Gassner Michael , Löckinger Alexander , Ulmer Hanno , Lorenz Ingo H. 
Published: January 2008

Abstract Objectives: To evaluate the quality of pain assessment by emergency medical services (EMS) in out‐of‐hospital emergencies. Methods: A prospective study was conducted on a convenience sample of patients during a one‐year observation period. Pain ratings assessed by emergency patients were documented at three different intervals during the emergency call, and compared with concomitant assessments by EMS providers. A visual analog scale (VAS) and a verbal pain scale (VPS) were used for pain assessment. Repeated‐measures ANOVA and Dunnett's t‐test were used for data analysis. Results: Fifty‐one out of 70 eligible patients met inclusion criteria. In most emergency patients the intensity of pain was underestimated by EMS, especially when pain was severe (p = 0.0001). During the course of transport, both pain and pain assessment by EMS improved significantly (p = 0.0001). The VAS and VPS were significantly correlated (p = 0.0001). Conclusions: EMS providers significantly underestimate their patients' pain severity. EMS providers should be more attentive to their patients' complaints and comfort.
Site Management of Health Issues in the 2001 World Trade Center Disaster
Authors: Bradt David A. 
Published: January 2008

AbstractThe terrorist destruction of the World Trade Center led to the greatest loss of life from a criminal incident in the history of the United States. There were 2,801 persons killed or missing at the disaster site, including 147 dead on two hijacked aircraft. Hundreds of buildings sustained direct damage or contamination. Forty different agencies responded with command and control exercised by an incident command system as well as an emergency operations center. Dozens of hazards complicated relief and recovery efforts. Five victims were rescued from the rubble. Up to 1,000 personnel worked daily at the World Trade Center disaster site. These workers collectively made an average of 270 daily presentations to health care providers in the first month post‐disaster. Of presentations for clinical symptoms, leading clinical diagnoses were ocular injuries, headaches, and lung injuries. Mechanical injury accounted for 39% of clinical presentations and appeared preventable by personal protective equipment. Limitations emerged in the site application of emergency triage and clinical care. Notable assets in the site management of health issues include action plans from the incident command system, geographic information system products, wireless application technology, technical consensus among health and safety authorities, and workers' respite care.
Use of helical computed tomography for imaging the pediatric cervical spine
Authors: Adelgais Kathleen M. , Grossman David C. , Langer Steve G. , Mann Fred A. 
Published: January 2008

Abstract Objective: To determine the differences in resource utilization and radiation exposure between conventional radiography (ConvRad) and helical computed tomography (HCT) when used to survey the pediatric cervical spine (CSp). Methods: Patients aged 0–14 years who required CSp radiographic evaluation in addition to cranial CT were prospectively enrolled and assigned to undergo either HCT or ConvRad with adjunctive linear tomography. Outcomes of medication usage, emergency department (ED) length of stay (LOS), cervical spine radiation exposure, and imaging resource use (relative value unit [RVU]) were compared between the two groups. Data were analyzed by regression analysis with adjustment for confounders. Results: Of 136 patients, 64 and 72 patients were assigned to the ConvRad group and HCT group, respectively. At the discretion of the trauma team, 34% of the patients enrolled crossed between the two study arms. Odds ratio (OR), based on original assignment, was 0.8 (95% CI = 0.4 to 1.8) for difference in medication usage between the two groups. Mean LOSs were 259 minutes (95% CI = 124 to 394) and 183 (95% CI = 166 to 200) minutes for HCT and ConvRad, respectively. CSp imaging RVUs were 5.5 (95% CI = 5.1 to 5.8) for HCT and 4.0 (95% CI = 3.3 to 4.6) for ConvRad. Mean CSp radiation doses were 389 mRem (95% CI = 346 to 432) for HCT and 294 mRem (95% CI = 245 to 343) for ConvRad. Adjustment for confounders did not change the direction of the results. Conclusions: As a modality to screen the pediatric CSp for blunt‐force trauma, HCT results in increased radiation exposure and radiology resource use without a reduction in sedation usage or time in the ED.
Emergency Department Management of Acute Pain Episodes in Sickle Cell Disease
Authors: Tanabe Paula , Myers Randall , Zosel Amy , Brice Jane , Ansari Altaf H. , Evans Julia , Martinovich Zoran , Todd Knox H. , Paice Judith A. 
Published: January 2008

ObjectivesTo characterize the initial management of patients with sickle cell disease and an acute pain episode, to compare these practices with the American Pain Society Guideline for the Management of Acute and Chronic Pain in Sickle‐Cell Disease in the emergency department, and to identify factors associated with a delay in receiving an initial analgesic. MethodsThis was a multicenter retrospective design. Consecutive patients with an emergency department visit in 2004 for an acute pain episode related to sickle cell disease were included. Exclusion criteria included age younger than 18 years. A structured medical record review was used to abstract data, including the following outcome variables: analgesic agent and dose, route, and time to administration of initial analgesic. Additional variables included demographics, triage level, intravenous access, and study site. Mann–Whitney U test or Kruskal–Wallis test and multivariate regression were used to identify differences in time to receiving an initial analgesic between groups. ResultsThere were 612 patient visits, with 159 unique patients. Median time to administration of an initial analgesic was 90 minutes (25th to 75th interquartile range, 54–159 minutes). During 87% of visits, patients received the recommended agent (morphine or hydromorphone); 92% received the recommended dose, and 55% received the drug by the recommended route (intravenously or subcutaneously). Longer times to administration occurred in female patients (mean difference, 21 minutes; 95% confidence interval = 7 to 36 minutes; p = 0.003) and patients assigned triage level 3, 4, or 5 versus 1 or 2 (mean difference, 45 minutes; 95% confidence interval = 29 to 61 minutes; p = 0.00). Patients from study sites 1 and 2 also experienced longer delays. ConclusionsPatients with an acute painful episode related to sickle cell disease experienced significant delays to administration of an initial analgesic.
High Rates of Fecal Carriage of Nonenterococcal
vanB
in both Children and Adults
Authors: Graham M. , Ballard S. A. , Grabsch E. A. , Johnson P. D. R. , Grayson M. L. 
Published: January 2008

ABSTRACT

We examined the rate of fecal carriage of
vanB
in the absence of cultivable vancomycin-resistant enterococci in three distinct populations (children, community adults, and hemodialysis patients). Nonenterococcal
vanB
carriage was similarly high in hemodialysis patients (45%) and community adults (63%;
P
= 0.066) and significantly more common among community adults than children (27%;
P
= 0.001).