bluuebunny/crossref_metadata_2025_split huggingface dataset:
Emergency Department Triage of Patients Infected with HIV
Authors: Haukoos Jason S. , Witt Mallory D. , Zeumer Christel M. , Lee Thomas J. , Halamka John D. , Lewis Roger J. 
Published: September 2002

Abstract Objective: The emergency department (ED) and HIV specialty clinics are primary sources of care for persons infected with HIV. HIV disease may be complicated by vague and complex symptomatology, and determining the degree of illness at triage is often difficult. The goals of this project were to characterize the ED presentation of HIV‐related conditions, to develop a clinical decision rule to triage HIV‐infected patients, and to validate the rule in clinical practice. Methods: The study population consisted of ambulatory patients with self‐reported HIV infection who presented for care to the ED of a 553‐bed public hospital that serves a medically indigent, minority population. An Illness Severity Instrument was developed by an expert panel to serve as the criterion standard for defining medical urgency for HIV‐infected patients presenting to the ED for care. Two phases of the study were conducted. Data from the first phase, a noninterventional cohort study, were used to develop a clinical decision rule for the ED triage of HIV‐infected patients. The second phase was a prospective validation of the clinical decision rule. Results: During phase I, data from 542 patient visits were collected. Data from 441 (81%) patient visits were used in a classification and regression tree (CART) analysis to produce a decision rule, the Clinical Triage Instrument. During phase II, the prospective validation of the Clinical Triage Instrument, 156 patient visits occurred. Of these, 88 (56%) patient visits were triaged using the Clinical Triage Instrument and could be scored using the Illness Severity Instrument. The Clinical Triage Instrument accurately triaged 45 [51%; 95% confidence interval (95% CI) = 40% to 62%] patient visits, undertriaged 11 (13%; 95% CI = 6% to 21%) patient visits, and overtriaged 32 (36%; 95% CI = 26% to 47%) patient visits. Sensitivities and specificities for determining emergent, urgent, and nonurgent medical conditions by the Clinical Triage Instrument were 56% (95% CI = 31% to 75%) and 84% (95% CI = 74% to 92%), 71% (95% CI = 55% to 84%) and 39% (95% CI = 25% to 55%), and 18% (95% CI = 6% to 37%) and 93% (95% CI = 84% to 98%), respectively. The positive and negative predictive values for determining an emergent medical condition using the Clinical Triage Instrument were 48% (95% CI = 26% to 70%) and 88% (95% CI = 78% to 95%), respectively. The positive and negative predictive values for determining a nonurgent medical condition using the Clinical Triage Instrument were 56% (95% CI = 21% to 86%) and 71% (95% CI = 60% to 81%), respectively. Conclusions: The Clinical Triage Instrument was not sufficiently accurate for clinical use. Until accurate and reliable triage methods are developed, all patients infected with HIV who present to the ED for care should receive timely evaluation and care.
Predictive Validity of the Global Assessment Form Used in a Final‐year Undergraduate Rotation in Emergency Medicine
Authors: Bandiera Glen W. , Morrison Laurie J. , Regehr Glenn 
Published: September 2002

AbstractObjectives:To determine whether the predictive validity of Global Assessment Form (GAF) knowledge subdomain marks exceeds that of the overall GAF marks with respect to written examination marks for an undergraduate rotation in emergency medicine, and to determine the interdependence between subdomain marks on the GAF.Methods:Final‐year clinical clerks completing a four‐week rotation through the emergency departments of a university teaching center were evaluated using both a ten‐subdomain GAF for clinical performance and an independent written examination. The GAF and examination marks were prospectively obtained for clinical clerks over a two‐year period. Pearson correlations were calculated between examination marks and both the GAF knowledge subdomain and the GAF overall mark. Olkin's Z score was calculated to determine the significance of the difference between correlations. Interdependencies between subdomains of the GAF were calculated using an alpha coefficient and inter‐item correlations.Results:Data sets were reviewed for 347 clinical clerks. Nine sets of data were excluded (incomplete evaluations); 338 sets were analyzed. Means for overall clinical mark and examination mark were 80.11% (SD = 4.375) and 81 (SD = 7.66). Among subdomains, knowledge had the highest correlation with the examination mark (0.19). Overall clinical marks had lower correlation with the examination marks (0.169); the difference was not significant (Olkin's Z = 0.40). The correlation of the examination marks with the average marks of all subdomains excluding knowledge was even lower (0.12). The tenitem alpha for the GAF was 0.92.Conclusions:Clinical GAF assessments of knowledge, as measured by written examination, do not appear to be any more predictive than overall clinical impression. There is substantial consistency between subdomain scores, suggesting that assessors are not effectively discriminating between them when assigning marks.
Adverse Cardiac Events in Emergency Department Patients with Chest Pain Six Months after a Negative Inpatient Evaluation for Acute Coronary Syndrome
Authors: Manini Alex F. , Gisondi Michael A. , Van Der Vlugt Theresa M. , Schreiber Donald H. 
Published: September 2002

Abstract Objective: To evaluate the impact of the diagnostic test setting—inpatient versus outpatient—on adverse cardiac events (ACEs) after six months in emergency department (ED) patients with chest pain who were admitted to the hospital and subsequently had a negative evaluation for acute coronary syndrome (ACS). Methods: The authors retrospectively studied a consecutive sample of ED patients with chest pain over a nine‐month period. All patients were admitted to the hospital and underwent negative evaluations for ACS, defined as the absence of diagnostic changes on serial electrocardiograms or cardiac markers (creatine kinase—MB and troponin T), and a negative diagnostic cardiac study. Subjects were classified according to cardiac diagnostic study setting—either inpatient or outpatient. Diagnostic testing included exercise treadmill, angiography, stress echocardiography, or stress thallium scans. Acute cardiac events at six months were defined as cardiac death, myocardial infarction, unstable angina, cardiac arrest, or emergent revascularization. Results: The six‐month rate of ACEs among 157 subjects was 14%, with 2% cardiac mortality. The outpatient group had higher ACE risk when compared with the inpatient group using multivariate logistic regression, both for the entire cohort (OR 3.5, p < 0.03) and for a subgroup excluding patients with prior coronary artery disease (OR 6.7, p < 0.05). The outpatient group included 19 of 52 (37%) noncompliant subjects who did not receive a diagnostic study. Conclusions: Long‐term cardiac morbidity of patients after a negative ACS evaluation may be higher than previously thought. Risk of ACE is significantly higher in subjects scheduled for outpatient diagnostic tests. Inpatient diagnostic testing is justified for subjects at risk for poor compliance.
Congestive Heart Failure Patients with Chest Pain: Incidence and Predictors of Acute Coronary Syndrome
Authors: Lettman Nadine A. , Sites Frank D. , Shofer Frances S. , Hollander Judd E. 
Published: September 2002

Abstract Objective: New diagnostic and treatment options for emergency department (ED) patients with congestive heart failure (CHF) may facilitate the ED discharge of some patients. However, some patients require admission to exclude concurrent acute coronary syndrome (ACS) as the precipitant of CHF. The objective of this study was to identify the incidence, clinical characteristics, and hospital course of CHF patients who present to the ED with and without concurrent ACS. Methods: This was a prospective cohort study of consecutive patients >23 years of age who presented to the ED with chest pain, received an electrocardiogram (ECG), and either had a known history of CHF or presented with new‐onset CHF, between July 1999 and April 2001. The hospital course of each patient was followed daily, and telephone follow‐up occurred at 30 days. The main outcomes were the incidence of ACS and comparisons of lengths of hospital stay (LOSs), rates of admission to the intensive care unit (ICU), intubations, and death rates among patients with and without ACS. Results: Two hundred ninety‐eight CHF patients presented 380 times. The incidence of ACS in the 380 patient visits was 32% (95% CI = 27% to 36%). Compared with patients who did not have ACS, patients who had concurrent ACS were more likely to have known coronary artery disease (CAD) (67% vs. 42%; p < 0.0001) and hypercholesterolemia (36% vs. 18%; p = 0.0002). Patients with concurrent ACS were also more likely to be admitted to the hospital (97% vs 82%; p < 0.0001), had a longer LOS (5.2 [3.9‐6.5] vs 3.2 [2.6‐3.8] days; p = 0.006), had higher rates of ICU admission (44% vs. 13%; p < 0.0001), were more likely to be intubated (8% vs. 1%, p = 0.002), and were more likely to die (15 vs 7 deaths; p < 0.0001). Conclusions: The incidence of ACS in ED CHF patients with chest pain was 32%. Patients with CHF complicated by ACS had more prolonged hospital stays, required higher levels of care, and had a higher incidence of death than those patients without ACS. Strategies tailored to early identification and management of these patients would be desirable.
Lack of Association between Patient Ethnicity or Race and Fracture Analgesia
Authors: Fuentes Eloisa F. , Kohn Michael A. , Neighbor Martha L. 
Published: September 2002

Abstract Objective: Ethnic and racial differences in the provision of emergency department (ED) analgesia for long‐bone fractures have recently been reported in two large cities. The authors sought to determine, in a third city, whether nonwhite patients with long‐bone fractures were less likely to receive analgesics than white patients with similar injuries. Methods: At an urban Level 1 trauma center and teaching hospital, a retrospective cohort study was conducted of all ED patients aged 18 to 55 years seen from July 1, 1998, through June 30, 1999, with an ED discharge diagnosis of isolated long‐bone fracture identified by ICD‐9 codes 812, 813, 821, and 823. Exclusion criteria included injury more than 12 hours prior to presentation or a Glasgow Coma Scale score of less than 14. The main outcome measure was ED analgesia administration. Results: Three hundred twenty‐three patients met inclusion criteria; 181 were white, 58 African American, 46 Hispanic, 38 Asian. All ethnic/racial groups were equally likely to receive no analgesia or no parenteral analgesia. The overall risk for no analgesia was 20% and for no parenteral analgesia was 31%. Stratification and multiple logistic regression to control for gender, bone fractured, and need for reduction failed to identify any trend toward reduced analgesia administration in any ethnic/racial group. Conclusions: In contrast to two recently reported studies, at this urban trauma center and teaching hospital ED, there was no difference in the administration of analgesics to white and nonwhite patients with long‐bone fractures.
Usual Source of Care and Nonurgent Emergency Department Use
Authors: Sarver Joshua H. , Cydulka Rita K. , Baker David W. 
Published: September 2002

Abstract Objective: To examine whether dissatisfaction with one's usual source of care (USC) and perceived access difficulties to one's USC were associated with nonurgent emergency department (ED) use. Methods: Variables that measured USC satisfaction and access were identified in the 1996 cohort of the Medical Expenditure Panel Survey (MEPS), a nationally representative sample administered by the Agency for Healthcare Research and Quality. The main outcome measured was nonurgent ED use at least once during 1996. Results: A total of 9,146 adults had a USC other than the ED, had at least one contact with the health care system or were unable to get needed care, and had complete data for all the variables in the final model. Dissatisfaction with the USC, dissatisfaction with the USC staff, lack of confidence in the USC's ability, difficulty scheduling an appointment, difficulty reaching the USC by phone, and long waiting times with an appointment were all associated with having a nonurgent ED visit in 1996 (all at p < 0.05). The positive associations between both dissatisfaction and perceived access barriers and nonurgent ED use persisted even in multiple logistic regression that adjusted for age, sex, race, education, health status, employment status, income, insurance, region of residence, and rural vs. urban residence. Conclusions: Patients who are dissatisfied with their USC or perceive access barriers to their USC are more likely to have a nonurgent ED visit.
Crash Scene Photography in Motor Vehicle Crashes without Air Bag Deployment
Authors: Newgard Craig D. , Martens Katherine A. , Lyons Evelyn M. 
Published: September 2002

Abstract Objective: To determine whether vehicle characteristics, measured using crash scene photography, are associated with anatomic patterns of injury and severity of injury sustained in motor vehicle crashes (MVCs) without air bag deployment. Methods: A prospective observational study was conducted over 22 months, using 12 fire departments serving two hospitals. Two vehicle photographs (exterior and interior) were taken at each MVC. Vehicular variables were assigned by grading the photographs with a standardized scoring system, and outcome information on each patient was collected by chart review. Results: Five hundred fifty‐nine patients were entered into the study. Frontal crashes and increasing passenger space intrusion (PSI) were associated with head, facial, and lower‐extremity injuries, while rear crashes were associated with spinal injuries. Restraint use had a protective effect in head, facial, and upper and lower extremity injuries, yet was associated with higher odds of spinal injury. Lack of restraint use, increasing PSI, and steering wheel deformity were associated with an increased hospital length of stay and hospital charges, yet only steering wheel deformity was associated with increasing injury severity when adjusting for other crash variables. Conclusions: Out‐of‐hospital variables, as obtained from crash vehicle photography, are associated with injury site, injury severity, hospital length of stay, and hospital charges in patients involved in MVCs without air bag deployment.
Bench to Bedside: Brain Edema and Cerebral Resuscitation: The Present and Future
Authors: Xiao Feng 
Published: September 2002

AbstractSudden cardiac arrest (CA) claims approximately 1,200 lives daily in the United States. Cardiopulmonary resuscitation attempts have so far achieved suboptimal results, and even when restoration of spontaneous circulation (ROSC) is achieved, about 30% of survivors suffer permanent brain damage. This illustrates the need for an improved basic scientific understanding of the pathophysiology of global cerebral injury caused by whole‐body ischemia/reperfusion (I/R) injury following CA. Brain edema has been recently documented in experimental CA followed by one hour of ROSC. Brain edema has also been documented in CA and stroke patients by computed tomography or magnetic resonance imaging scanning, and has been shown to predict a poor neurologic outcome. The mechanisms underlying brain edema formation elicited by CA are unclear. New scientific findings of the roles of blood—brain barrier (BBB) permeability, matrix metalloproteinases (MMPs) of a family of proteases, aquaporin 4 (AQP4) of a family of membrane water‐channel proteins, and the N‐methyl‐D‐aspartate (NMDA) receptors in the mechanisms underlying CA‐elicited brain edema were reviewed. By defining the roles of BBB permeability, MMPs, AQP4, and NMDA receptors in CA‐induced brain edema formation, effective new therapeutic strategies to extend cellular and tissue survival, and preserve neurologic function following CA may be feasible.
Emergency Medicine: Competencies for Youth Violence Prevention and Control
Authors: Denninghoff Kurt R. , Knox Lyndee , Cunningham Rebecca , Partain Sandi 
Published: September 2002

AbstractBy any standard one wishes to apply, the impact of violence on the health and safety of the public is significant. The expression of violence among children in the United States has increased significantly during the modern era. Homicide and suicide are the second and third leading causes of death in youths 15‐24 years of age. The emergency department (ED) is a common site for the care of these victims, and because victims often become assailants, the emergency care provider needs to know the epidemiology, treatment, and methods for prevention of youth violence in order to curtail the cycle. A multidisciplinary task force was convened by the Centers for Disease Control and Prevention (CDC)‐funded Southern California Center of Academic Excellence on Youth Violence Prevention and the Keck School of Medicine at the University of Southern California to define competencies for health professionals in youth violence prevention and control. Three levels of competence were identified: the generalist level, which should be obtained by all health professionals; the specialist level, which should be obtained by health professionals such as emergency medicine providers, who frequently work with populations affected by violence; and a third, or scholar level, to be acquired by health professionals who wish to become experts not only in the care, but also in research and advocacy. This article reports the details of this group's efforts and applies them to emergency care provider education. These competencies should shape the development of curricula for the span of emergency medical training from emergency medical services scholastic training to postgraduate continuous medical education.
A Comparison of the Antemortem Clinical Diagnosis and Autopsy Findings for Patients Who Die in the Emergency Department
Authors: O'Connor Alan E. , Parry Jeremy T. , Richardson Drew B. , Jain Sanjiv , Herdson Peter B. 
Published: September 2002

Abstract Objectives: In spite of advances in medical technology, there remains a high discrepancy rate between the antemortem clinical diagnosis and postmortem examination diagnosis for patients who die in hospitals. The aim of this study was to compare the clinical and postmortem examination diagnoses of patients who died in the emergency department (ED) of a tertiary hospital, and to analyze any discrepancy between them. Methods: The study was a retrospective chart review of patients who died in the ED of a tertiary referral teaching hospital and a comparison of the antemortem diagnosis with the autopsy diagnosis. Any missed diagnosis was classified, according to the Goldman criteria, into major and minor missed diagnoses. Results: A total of 59 patients were eligible for inclusion in the study. There was complete agreement between the antemortem diagnosis and the autopsy result in 51% of cases. The incidence of major missed diagnoses—where if the diagnosis had been known before the patient died, treatment may have been altered or survival may have been prolonged—was 7%. Conclusions: There is a significant discrepancy rate between the antemortem diagnosis and the autopsy diagnosis. However, in this study, serious missed diagnoses in which outcome may have been significantly altered are unusual among those who die in the ED of a tertiary referral hospital.
Altered Responsiveness of the Hypothalamus-Pituitary-Adrenal Axis and the Sympathetic Adrenomedullary System to Stress in Patients with Atopic Dermatitis
Authors: Buske-Kirschbaum Angelika , Geiben Andrea , Höllig Heike , Morschhäuser Ellen , Hellhammer Dirk 
Published: September 2002

A growing number of animal data strongly suggest that a hyporeactive hypothalamus-pituitary adrenal (HPA) axis may be pathologically significant by increasing the susceptibility to chronic inflammation. Following this line of evidence, the specific goal of the present study was to investigate the HPA axis in patients with atopic dermatitis (AD), a chronic allergic inflammatory disease. In addition, the sympathetic adrenomedullary (SAM) system as a second potent immunoregulatory and anti-inflammatory stress-response system has been examined.AD patients (n = 36) and nonatopic control subjects (n = 37) were exposed to a standardized laboratory stressor consisting of a free speech and mental arithmetic task in front of an audience. Cortisol, ACTH, and catecholamine concentrations were assessed before and after the stressor. To investigate feedback sensitivity of the HPA axis, a low dose (0.5 mg) dexamethasone suppression test was also performed. AD patients showed significantly attenuated cortisol and ACTH responses to the stressor, whereas catecholamine levels were significantly elevated in atopic patients. No difference between the experimental groups was found in basal cortisol and ACTH concentrations, whereas basal catecholamine levels were significantly elevated. Analysis of cortisol levels after dexamethasone treatment suggested an intact feedback sensitivity in AD sufferers at the pituitary level. The present findings suggest that patients with AD demonstrate a blunted HPA axis responsiveness with a concurrent overreactivity of the SAM system to psychosocial stress. Considering the important immunoregulatory role of the HPA axis and the SAM system, especially under stressful conditions, an aberrant responsiveness of these neuroendocrine systems may increase the susceptibility to (allergic) inflammation and may be one psychobiological mechanism of stress-related aggravation of the disease.