bluuebunny/crossref_metadata_2025_split huggingface dataset:
Bilious Vomiting in a 9‐month‐old Infant
Authors: Brennan Daniel F. 
Published: September 2008

ABSTRACTA case of bilious vomiting in a 9‐month‐old male is reported. The differential diagnosis of infantile bilious vomiting is reviewed, and appropriate diagnostic studies are discussed. The child was found to have intussusception. The common manifestation of this pediatric surgical emergency may vary considerably from classic descriptions. Bilious emesis in infants must be considered a surgical emergency until proven otherwise; intussusception may manifest as bilious vomiting only.
Structured Emergency Medicine Board Review and Resident In‐service Examination Scores
Authors: Gillen James P. 
Published: September 2008

ABSTRACTObjective: To determine whether the institution of a structured board review program is associated with improved in‐service examination scores by residents at an emergency medicine (EM) residency program. Methods: A retrospective, historical control analysis of the association of a board review program and in‐service examination scores at one EM residency program was performed. A structured board review consisting of monthly reading assignments in “classic” EM textbooks followed by a graded multiple‐choice written examination was instituted in 1987. Percentile scores on the American Board of Emergency Medicine (ABEM) in‐service examination before (1985 — 1986) and after (1987–1994) initiation of the board review process were compared by resident level (EM‐1, 2, or 3).Results: The EM‐1 mean percentile score before board review was 50.7 and rose to 68.9 after the institution of the board review program (p = 0.039). Mean EM‐2 scores (66.8 vs 65.4) and EM‐3 scores (74.4 vs 67.4) decreased slightly; these decreases were not statistically significant. Due to the large increase in EM‐1 scores, the mean scores for the total program increased slightly (63.4 vs 67.4; p = NS).Conclusion: In this study, EM‐1 in‐service scores improved in association with the institution of a structured board review program. This formalized didactic program may increase the knowledge base and test performance of EM‐1 residents. A favorable effect on EM‐2 and EM‐3 resident scores was not seen.
Workforce Projections for Emergency Medicine: How Many Emergency Physicians Does the United States Need?
Authors: Holliman C. James , Wuerz Richard C. , Chapman Dane M. , Hirshberg Alan J. 
Published: September 2008

ABSTRACTObjective: To mathematically model the supply of and demand for emergency physicians (EPs) under different workforce conditions.Methods: A computer spreadsheet model was used to project annual EP workforce supply and demand through the year 2035. The mathematical equations used were: supply = number of EPs at the beginning of the year plus annual residency graduates minus annual attrition; demand = 5 full‐time equivalent positions/ED X the number of hospital EDs. The demand was empirically varied to account for ED census variation, administrative and teaching responsibilities, and the availability of physician extenders. A variety of possible scenarios were tested. These projections make the assumption that emergency medicine (EM) residency graduates will preferentially fill clinical positions currently filled by EPs without EM board certification.Results: Under most of the scenarios tested, there will be a large deficit of EM board‐certified EPs well into the next century. Even in scenarios involving a decreasing “demand” for EPs (e.g., in the setting of hospital closures or the training of physician extenders), a significant deficit will remain for at least several decades. Conclusions: The number of EM residency positions should not be decreased during any restructuring of the U.S. health care system. EM is likely to remain a specialty in which the supply of board‐certified EPs will not meet the demand, even at present levels of EM residency output, for the next several decades.
Derivation and Validation of a Methodology for Tracking Academic Stature of Medical Schools
Authors: Gallagher E. John , Henneman Philip L. , Schropp Mary Ann , Force For the Task 
Published: September 2008

ABSTRACTObjective: To derive and validate a methodology for academic ranking of allopathic medical schools in order to track the development of emergency medicine (EM) at academic medical centers.Methods: A methodology for institutional ranking according to NIH research grant funding was derived by using a well‐known multiaxial ordinal ranking of all Liaison Committee on Medical Education (LCME)‐accredited allopathic schools in 1990–91 as the criterion standard. This methodology was validated against the same annually updated criterion standard in 1995–96. Both ranking schemes were first stratified by quartile, then aggregated pairwise by contiguous quartiles to develop a 3 × 3 concordance matrix.Results: Ranking by NIH grant funding produced concordance between all 126 schools in the derivation set and 123/124 schools in the validation set.Conclusion: NIH research grant funding may be used as a valid methodology for broad categorization of allopathic medical school academic rank. This strategy should therefore serve as a suitable means of following the development of academic EM over time.This project was supported by a grant from SAEM.
Changing Status of Academic Emergency Medicine (1991–1996)
Authors: Gallagher E. John , Schropp Mary Ann , Henneman Philip L. , Force For The Task 
Published: September 2008

ABSTRACTObjective: An SAEM national task force previously concluded that academic departments and residencies in emergency medicine (EM) had preferentially developed outside of the academic mainstream. This study was designed to determine whether EM has made significant inroads into academic medical centers over the past 5 years. Methods: The baseline data set (7/1/91) contained all 126 Liaison Committee on Medical Education (LCME)‐accredited schools, and all 87 Residency Review Committee (RRC)‐accredited EM residencies. The comparison data set (7/1/96) contained all 124 LCME‐accredited schools, and all 114 RRC‐accredited EM residencies. The 1991–96 increment in academic departments and university‐hospital residencies was examined in the aggregate, then stratified by medical schools grouped into quartiles and contiguous quartiles, according to academic ranking. A‐priori and post‐hoc comparisons were expressed with 95% and 99% confidence intervals (CIs), respectively.Results: Over the past 5 years, the proportion of academic departments of EM increased by 23%, from 18% to 41% of all LCME‐accredited schools (95% CI 12% to 34%). The largest increase (58%; 99% CI 40% to 77%) occurred among those schools academically ranked above the median. The proportion of EM residencies at university hospitals increased by 17%, from 40% to 57% (95% CI 5% to 30%). Again, the largest increase (25%; 99% CI 3% to 47%) occurred at university hospitals affiliated with schools academically ranked above the median.Conclusion: EM has made substantial inroads into academic medical centers over the past 5 years. This is reflected in quantitatively and statistically significant increases in academic departments and university‐hospital residency programs, both occurring largely within institutions whose academic rankings place them among the upper half of all LCME‐accredited medical schools.
Rural Hospital Transfer Patterns before and after Implementation of a Statewide Trauma System
Authors: Mann N. Clay , Hedges Jerris R. , Mullins Richard J. , Helfand Mark , Worrall William , Zechnich Andrew D. , Group For The OHSU Rural Trauma Research 
Published: September 2008

ABSTRACTObjective: To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system.Methods: A pre‐ vs post‐system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level‐3 and 5 Level‐4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open‐tibia) were reviewed for a 3‐year period before statewide trauma system implementation and 3 years after hospital trauma designation.Results: Of 1,057 patients entered into the database, 532 were evaluated during the pre‐system period and 525 were evaluated during the post‐system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open‐tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in >1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level‐4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level‐4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level‐4 EDs were significantly more likely to be transferred to Level‐2 facilities (66% vs 82%, p = 0.030), while patients at Level‐3 facilities were significantly more likely to be transferred to Level‐1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level‐4 hospitals, while transfers from Level‐3 facilities were dependent on type of injury.Conclusion: Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.
The Urban Epidemiology of Recurrent Injury: Beyond Age, Race, and Gender Stereotypes
Authors: Madden Cynthia , Garrett Joanne M. , Cole Thomas B. , Runge Jeffrey W. , Porter Carol Q. 
Published: September 2008

ABSTRACTObjectives: To profile all patients presenting to an urban ED with any injury, and to determine whether the rate of subsequent injury treated in the ED varied by demographic and E‐code (external mechanism of injury) category. The hypothesis that young black males were disproportionately at risk for re‐injury was addressed.Methods: A cohort of consecutive patients presenting to an urban ED with any injury between January 1, 1991, and November 31, 1992, were followed prospectively for 1 year from their index visit dates. Any repeat ED visits due to injury were sought. The mean number of injury visits per year (the total number of ED injury visits for each patient divided by 1 year) was computed for the overall population and by race, age, gender, and E‐code.Results: The sample consisted of 34,378 patients who made 44,813 visits to the ED for injury. Of these patients, 22% had a repeat injury in 1 year, with a cohort mean of 1.30 injury visits per year. This mean did not vary appreciably by race (black 1.33, white 1.27), age (1–17 yr, 1.21; 18–24 yr, 1.32; 25–64 yr, 1.34; >65 yr, 1.23), gender (males 1.33, females 1.27), or E‐code category. Having a prior injury visit in the preceding year was the best predictor of future injury (mean repeat visit rate = 2.08).Conclusions: When examining patients presenting with any injury to an urban ED, the mean numbers of injury visits are remarkably similar across demographic and E‐code categories. Although there are factors that place patients at risk for recurrent injury, those factors are not demographic—all patients presenting to an ED with injury should be considered at risk for re‐injury.
The Significance of Out‐of‐hospital Hypotension in Blunt Trauma Patients
Authors: Chan Lisa , Bartfield Joel M. , Reilly Kevin M. 
Published: September 2008

ABSTRACTObjective: To determine the significance of a low out‐of‐hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.Methods: A retrospective case‐control study compared admitted blunt trauma patients who were hypotensive (SBP ≤90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra‐abdominal injury, and incidence of pelvic or femur fracture.Results: Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra‐abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).Conclusion: The injured patients who were hypotensive in the out‐of‐hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out‐of‐hospital setting and in the ED. Out‐of‐hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.
The Impact of an Endotracheal Side Port on the Absorption of Lidocaine
Authors: Storrow Alan B. , Walthall John W. , Magoon Michael R. , Pascuzzi Thomas J. , Bifano Sandra L. 
Published: September 2008

ABSTRACTObjective: To compare lidocaine levels after administration through an IV line, a standard endotracheal (ET) tube, and an ET tube side port (ETSP) designed for medication administration.Methods: A double‐blind, prospective, triple crossover canine study was performed. Seventeen anesthetized mongrel dogs were given standard doses of 2% lidocaine via IV (1.5 mg/kg), endotracheally through the main lumen (3 mg/kg diluted in 10 mL normal saline), and endotracheally through the modified side port (3 mg/ kg diluted in 10 mL normal saline). Arterial blood gases (ABGs) and plasma lidocaine levels were measured at time 0, 30 sec, 1 min, 5 min, 10 min, 20 min, 30 min, and 60 min. Mean lidocaine levels across time, comparing the 3 methods of administration, were analyzed with repeated‐measures analysis of variance. The main outcome was the comparison of mean ET and ETSP lidocaine levels at each time point using paired t‐tests. The attainment and duration of lidocaine levels considered therapeutic in cardiac arrest (1.4 μg/mL) were described. ABGs were measured at each point to describe trends in oxygenation.Results: Mean lidocaine levels, comparing the 3 methods of administration, were significantly different at all time points except time 0. The ETSP levels were significantly lower than the ET main‐lumen levels at 30 sec, 1 min, 5 min, and 10 min. IV‐administered lidocaine attained quick therapeutic levels and revealed faster elimination. Lidocaine administered through the ET main lumen reached therapeutic levels more slowly, and maintained such levels longer. Lidocaine administered through the ETSP never reached therapeutic levels. Mean Po2s remained >340 torr throughout each method of administration.Conclusion: This nonarrest canine model suggests that lidocaine levels achieved through an ETSP are lower than levels obtained with the same drug dose via an ET main lumen. Therapeutic lidocaine levels are obtainable by IV or ET main‐lumen routes, but not via this ETSP.
Use of the World Wide Web for Multisite Data Collection
Authors: Subramanian Ashok K. , McAfee Andrew T. , Getzinger Jim P. 
Published: September 2008

ABSTRACTAs access to the Internet becomes increasingly available, research applications in medicine will increase. This paper describes the use of the Internet, and, more specifically, the World Wide Web (WWW), as a channel of communication between EDs throughout the world and investigators who are interested in facilitating the collection of data from multiple sites. Data entered into user‐friendly electronic surveys can be transmitted over the Internet to a database located at the site of the study, rendering geographic separation less of a barrier to the conduction of multisite studies. The electronic format of the data can enable real‐time statistical processing while data are stored using existing database technologies. In theory, automated processing of variables within such a database enables early identification of data trends. Methods of ensuring validity, security, and compliance are discussed.
Use of the Alveolar Dead Space Fraction (Vd/Vt) and Plasma D‐dimers to Exclude Acute Pulmonary Embolism in Ambulatory Patients
Authors: Kline Jefsrey A. , Meek Suzy , Boudrow Dawn , Warner Douglas , Colucciello Stephen 
Published: September 2008

ABSTRACTObjective: To evaluate the utility of a modified calculation of the alveolar dead space fraction (Vd/Vt), combined with plasma D‐dimers, to aid in the exclusion of acute pulmonary embolism (PE). Methods: A prospective comparison of screening modalities was performed in a metropolitan teaching ED. Ambulatory patients evaluated for PE underwent simultaneous end‐tidal CO2 and arterial blood gas determinations, as well as venous latex‐agglutination D‐dimer quantification. The modified Bohr equation was used to calculate Vd/Vt as an index of alveolar dead space. Acute PE was diagnosed or excluded using appropriate combinations of clinical suspicion, ventilation‐perfusion lung scanning, lower‐extremity venous Doppler ul‐trasonography, pulmonary angiography, and comprehensive follow‐up.Results: Of 170 subjects studied, PE was confirmed (PE+) in 26 (15%) and excluded (PE‐) in 144 (85%). In the PE+ group, Vd/Vt was 0.31 ± 0.13 (mean ± SD), and in the PE‐ group, Vd/Vt was 0.06 ± 0.10 (p< 0.05, t‐test). Regarding false‐negative rates, Vd/Vt was normal (i.e., <0.2) in 3/26 PE+ patients and D‐dimer concentrations were normal (<0.5 μg/L) in 4/26 patients in the PE+ group. The combination of a normal Vd/Vt and D‐dimer concentration was 100% sensitive (95% CI = 88–100%) in excluding PE. False‐positive testing (either test positive) occurred in 49/14 subjects (specificity 65%, 95% CI = 52–73%). The age‐adjusted alveolar‐arterial O2 gradient was 33 ± 38 torr in the PE+ group vs 13 ± 37 torr in the PE— group (p = 0.11).Conclusions: In ambulatory patients, the finding of Vd/Vt <0.2 and D‐dimers <0.5 μg/L lowers the probability of acute PE.
Selective Aortic Arch Perfusion Using Serial Infusions of Perflubron Emulsion
Authors: Manning James E. , Batson D. Neil , Gansman Thomas W. , JK Charles A. Murphy 
Published: September 2008

ABSTRACTObjective: To determine whether selective aortic arch perfusion (SAAP) using serial infusions of oxygenated perflubron emulsion combined with aortic epinephrine (AoE) administration is more effective than conventional therapy in treating cardiac arrest.Methods: An experimental cardiac arrest model (10 min ventricular fibrillation and 2 min CPR) was used with 12 mixed‐breed canines, randomized into 2 groups: control (n = 6), CPR and IV epinephrine, 0.01 mgkg, at 12 rnin and then every 3 min; or AoE‐SAAP (n = 6), CPR and aortic epinephrine, 0.01 mgkg, at 12 rnin and then every 3 min, and serial SAAP with oxygenated 60% weightholume (w/v) perflubron emulsion as follows: 300 mL over 30 sec at 12 rnin as continuous SAAP without CPR; 150 mL over 20–30 sec at 15 min and 18 rnin as pulsed diastolic SAAP during CPR.Results: AoE‐SAAP resulted in increased coronary perfusion pressure (CPP) and return of spontaneous circulation (ROSC) compared with control. CPR‐diastolic (release phase) CPP during pulsed diastolic SAAP was similar to or greater in magnitude than the CPP generated during the initial SAAP infusion without CPR. ROSC for control was 0/6 and for AoE‐SAAP was 416 (p < 0.05, Fisher's exact test). Time from initiation of CPR to ROSC with a sustained systolic aortic pressure >60 mm Hg was 8.0 ± 1.2 rnin in the 4 resuscitated AoE‐SAAP animals.Conclusion: The combination of AoE with SAAP infusions of oxygenated perflubron emulsion was more effective than conventional resuscitation therapy. Pulsed diastolic SAAP is a promising method for performing SAAP.
The Clinical Features of Acute Pulmonary Embolism in Ambulatory Patients
Authors: Jr. Otto Susec , Boudrow Dawn , Kline Jeffrey A. 
Published: September 2008

ABSTRACTObjective: To identify clinical findings and predisposing conditions associated with acute pulmonary embolism (PE) in ambulatory patients being evaluated for PE.Methods: A prospective observational study was conducted. A standardized multicomponent data collection form was administered to ambulatory subjects being evaluated for PE. The diagnosis of PE was confirmed or excluded using a combination of scintillation lung scanning, lower‐extremity venous Doppler ultrasonography, and selective use of pulmonary angiography.Results: Data collection was completed for 170 subjects, with 26 (15%) cases of PE. Subjects with PE were significantly older (56 vs 41 years, 99% CI for difference of 15 years [6 to 25 years]), were more likely to report unexplained dyspnea (92% vs 69%. 99% CI for difference of 23% [7% to 40%]), and waited longer after symptom onset to seek medical evaluation (73 vs 36 hours, 99% CI for difference of 37 hours [I1 to 63 hours]). No difference was found for multiple variables commonly associated with PE. Assignment to risk categories was of limited diagnostic utility. For example, low‐risk assignment yielded 85% sensitivity, 20% specificity; high‐risk assignment: 31% sensitivity, 85% specificity, with diagnostic accuracy below 80% in both categories.Conclusions: Among outpatients selected for evaluation for PE, further risk stratification demonstrated poor diagnostic utility. Clinical features alone cannot be used to differentiate presence or absence of PE in at‐risk ambulatory patients. Key words: pulmonary embolism; diagnosis; outpatient; risk; clinical features.
Ethical Issues of Cardiopulmonary Resuscitation: Current Practice among Emergency Physicians
Authors: Marco Catherine A. , Bessman Edward S. , Schoenfeld Charles N. , Kelen Gabor D. 
Published: September 2008

ABSTRACTObjective: To determine current practice and attitudes among emergency physicians (EPs) regarding the initiation and termination of CPR.Methods: An anonymous survey was mailed to randomly selected EPs. Main outcome measures included respondents' answers to questions regarding outcome of resuscitation, and current practice regarding initiation, continuation, and termination of resuscitation for victims of cardiopulmonary arrest.Results: The 1,252 respondents were from all 50 states, a variety of practice settings, and varying board certification. Most (78%) respondents honor legal advance directives regarding resuscitation. Few (7%) follow unofficial documents, or verbal reports of advance directives (6%). Many (62%) make decisions regarding resuscitation because of fear of litigation or criticism. A majority (55%) have recently attempted numerous resuscitations despite expectations that such efforts would be futile. Most respondents indicated that ideally, legal concerns should not influence physician practice regarding resuscitation (78%), but that in the current environment, legal concerns do influence practice (94%).Conclusions: Most EPs attempt to resuscitate patients in cardiopulmonary arrest, regardless of futility, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than their professional judgment of medical benefit or futility. Compliance with patients' wishes regarding resuscitation is low unless a legal advance directive is present. Possible solutions to these problems may include standardized guidelines for the initiation and termination of CPR, tort reform, and additional public education regarding resuscitation and advance directives.