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Background/Objectives: Pregnant women have limited information on the impact of prenatal cannabis exposure (PCE) alone. Our aim was to determine if PCE, without alcohol, tobacco, or illicit drug use, is associated with altered birth outcome measures in obstetrically low-risk women. Methods: In this observational cohort study, pregnant women were recruited between 2019 and 2022 from communities in Washington and Oregon, USA, and enrolled following their first trimester. PCE eligibility required a minimum of three days/week of cannabis use during the first trimester with no required minimum use thereafter. For all participants, illicit drug, nicotine, or alcohol use was exclusionary throughout pregnancy and monitored via urine toxicology at multiple time points. Cannabis use was quantified into delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) mg/day using product weight and potency. Outcome measures included gestational age, weight, length, head circumference, and Apgar scores. Results: Study participants included 37 people in the PCE cohort and 35 controls. Average cannabis use for the PCE cohort was 198.0 mg of THC (SD = 221.2 mg)/day and 3.5 mg of CBD (SD = 4.3)/day. PCE newborns weighed less (38th vs. 52nd percentile, p = 0.04) and were shorter (40th vs. 55th percentile, p = 0.03) for their gestational age than controls. Female PCE newborns had smaller head circumference for gestational age (28th percentile; SD = 23), compared to male PCE newborns (55th percentile; SD = 32; p = 0.02). Conclusions: PCE is associated with reduced birth weight and shorter length for gestational age. The effect of PCE on brain growth may be sexually dimorphic. Future PCE studies should include sex as a biological variable and longitudinally evaluate long-term developmental and physiological outcomes.

Racial microaggressions often occur in U.S. higher education. However, less is known about how White American students reason about their evaluations of racial microaggressions. The current study investigated how 213 White college students (54.46% cisgender women) attending a PWI in the Southeast U.S. in the Fall of 2019 justified their evaluations of the acceptability of racial microaggressions presented in vignettes. Following Social Domain Theory, to assess participants' social reasoning, we conducted quantitative content analysis of participants' open-ended justifications for their evaluations. Multiple regression analyses revealed that participants were less likely to evaluate racial microaggressions as negative the more they employed justifications focused on 1) assuming that the behaviors in the situation followed conventions of the classroom, 2) judging the professor's response as correct, and 3) asserting that the behavior was likely to happen to anyone. Further, the higher participants' endorsement of color-blind attitudes the more likely they were to evaluate racial microaggressions as appropriate. However, reasoning centered on 1) assuming differential treatment based on race, 2) perceiving the behavior as harmful, and 3) considering the behavior was against conventional expectations was associated with finding racial microaggressions to be more negative. The current study highlights the value of investigating underlying reasoning behind evaluating racial microaggressions in addition to color-blind attitudes. The findings suggest that higher education professionals should consider interventions which pay particular attention to unpacking students' reasoning, untangling acceptance of Ethnocentric narratives and providing information that challenges classroom behaviors that, while potentially appearing conventional, in fact perpetuate harm through microaggressions.

Women and racially minoritized college students report frequent experiences of being targets of gender and race-based microaggressions in the classroom context. However, while much research has focused on reports of experiences by targets, less is known about how observers would evaluate and make sense of these microaggressive experiences. Thus the present study used vignettes based on real-life situations to ascertain how 272 college students (76% White, 52% ciswomen) in the United States interpreted gender-based and intersectional microaggressions occurring in the classroom. Thematic analysis revealed that microaggressions were deemed acceptable when participants believed: 1) the situation humorous, 2) the instructor did not cause the situation, or 3) the stereotype/statement to be true. Microaggressions were evaluated negatively when: 1) the topic was deemed sensitive, 2) the classroom was perceived as unsuitable, or the instructor was seen as: 3) making students uncomfortable, 4) being defensive, or 5) teaching misinformation. The findings highlight the complexity involved in observers evaluating and interpreting gender-based and intersectional microaggressions.

Theories of altered inhibitory/excitatory signaling in autism spectrum disorder (ASD) suggest that gamma amino butyric acid (GABA) and glutamate (Glu) abnormalities may underlie social and sensory challenges in ASD. Magnetic resonance spectroscopy was used to measure Glu and GABA+ levels in the amygdala-hippocampus region and cerebellum in autistic children (n = 30), a clinical control group with sensory abnormalities (SA) but not ASD (n = 30), and children with typical development (n = 37). All participants were clinically assessed using the Autism Diagnostic Interview-Revised, the Autism Diagnostic Observation Scale-2, and the Child Sensory Profile-2. The Social Responsiveness Scale-2, Sniffin Sticks Threshold Test, and the University of Pennsylvania Smell Identification Test were administered to assess social impairment and olfactory processing. Overall, autistic children showed increased cerebellar Glu levels compared to TYP children. Evidence for altered excitatory/inhibitory signaling in the cerebellum was more clear-cut when analyses were restricted to male participants. Further, lower cerebellar GABA+/Glu ratios were correlated to more severe social impairment in both autistic and SA males, suggesting that the cerebellum may play a transdiagnostic role in social impairment. Future studies of inhibitory/excitatory neural markers, powered to investigate the role of sex, may aid in parsing out disorder-specific neurochemical profiles., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier B.V.)

Background: There is currently no format-independent method to determine delta-9-tetrahydrocannabinol (THC) in milligrams for self-report studies. Objectives: Validate self-report method for quantifying mg THC from commercially available cannabis products using product labeling, which includes both net weight and product potency. Methods: 53 adult cannabis users (24 M, 29F), 21-39 years of age ( M  = 28.38, SD = 4.15), were instructed to report daily use via a weekly survey for two consecutive weeks, provide product label photographs, abstain from use for 24 h, submit a urine sample and complete the Cannabis Use Disorder Identification Test - Revised (CUDIT-R) and the Marijuana Craving Questionnaire - Short Form (MCQ-SF). Milligrams of THC were determined by multiplying quantity of product used by its THC concentration. Urine was analyzed for the urine metabolite 11-nor-carboxy-THC (THC-COOH) via liquid chromatography mass spectroscopy. THC and THC-COOH values were log10 transformed prior to correlational analyses. Results: Median daily THC consumption was 102.53 mg ( M  = 203.68, SD = 268.13). Thirty-three (62%) of the 53 participants reported using two or more formats over the 2-week period. There was a significant positive correlation between log10 THC-COOH and log10 THC mg (r(41) = .59, p  < .001), log10 THC mg and MCQ-SF score (r(41) = .59, p  < .001), and log10 THC mg dose and CUDIT-R score, (r(41) = .39, p  = .010). Conclusion: Our label-based methodology provides consumption information across all modalities of cannabis use in standard units that can be combined across products for calculation of dose. It is a viable and valid method for quantifying mg of THC consumed and can be utilized in any region where cannabis is legal, and labeling is regulated.

Across many cultural contexts, the majority of women conduct the majority of their household labor. This gendered distribution of labor is often unequal, and thus represents one of the most frequently experienced forms of daily inequality because it occurs within one's own home. Young children are often passive observers of their family's distribution of labor, and yet little is known about the developmental onset of their perceptions of it. By the preschool age, children also show strong normative feelings about both equal resource distribution and gender stereotypes. To investigate the developmental onset of children's recognition of the (in)equality of household labor, we interviewed 3 to 10-y-old children in two distinct cultural contexts (US and China) and surveyed their caregivers about who does more household labor across a variety of tasks. Even at the youngest ages and in both cultural contexts, children's reports largely matched their parents', with both populations reporting that mothers do the majority of household labor. Both children and parents judged this to be generally fair, suggesting that children are observant of the gendered distribution of labor within their households, and show normalization of inequality from a young age. Our results point to preschool age as a critical developmental time period during which it is important to have parent-child discussions about structural constraints surrounding gender norms and household labor.

The aim of the current study was to explore Chinese adolescent's social and moral transgressions and strategies for self-correction. For this study, following protocols that have been approved by an Institutional Review Board, 61 Chinese adolescents living in Guangzhou, distributed across three age groups: 10-11-year-olds ( N =21, M age =11. 03, SD =.43), 12-13-year-olds ( N = 20, M age =12.92, SD =.35), and 15-16-year-olds ( N =20, M age =16.15, SD =.30), participated in one-on-one semi-structured interviews. The study employed a deductive analytical approach based on prior social domain research on children's and adolescents' transgressions and strategies for self-correction. This study found that Chinese youth reported conventional transgression events more frequently than any other domain. Moreover, many of adolescents' transgressions involved academic considerations, suggesting that how adolescents' time is organized and the social expectations for adolescent behavior influence the types of transgressions and justifications adolescents will make. Furthermore, participants reported developing self-correcting strategies following 73.6% of events, while 74.5% of strategies were reported to be developed by the adolescents themselves. Therefore, the findings suggest that there is room for adults to collaborate with adolescents in developing strategies to prevent future misbehavior and to encourage youth to not only be "good" or "moral," but to be and do better.

Parent-child conversations are a widely recognized socializing mechanism, linked to children's developing moral agency, empathy, and emotional competence. Similarly, parent-child conversations about gratitude have been linked to growth in children's gratitude. However, the messages that parents and children exchange in conversations about children's gratitude have yet to be investigated in depth. In the current study, we investigate the types of events that parents discuss with their children during times when they saw displays of children's gratitude and events when the children missed the opportunity to display gratitude, along with the messages that parents and children share during these conversations. The study involved a thematic analysis of the gratitude conversations of 43 parent-child dyads (88% mothers, 77% European American, 51% boys, child M age =10.62, SD=1.15) living in the United States. Gratitude and missed opportunity events primarily involved situations in which the child had the opportunity to attend an event or to receive a material gift, food, or assistance. Three themes characterized parent and child messages. First, parents suggested that being happy was a sign of being grateful, a way to make others happy, and the goal of benefactors' behavior. Second, parents suggested that children should focus on what they receive rather than on what they did not receive. Finally, children conveyed that they could not always be grateful, but that in several cases they were able to both feel and display their excitement and gratitude. In particular, children reported feeling grateful when they received something they thought was special or enjoyable, unique or unexpected, that they knew would make their parent happy or that they felt lucky to have since others did not have it. Together these findings suggest the importance of future research investigating how children and parents coordinate and prioritize the various elements of gratitude moments in deciding how to be grateful and to socialize children's gratitude.

We examined US parent and youth perceptions of how life events, both positive and negative, associated with COVID-19 resulted in changes in family and youth functioning. Families ( n = 105, 80% white, 48% male, and 87% mothers) completed surveys during the pandemic (May to July 2020) and 3 years prior (for youth ages M = 10.6, SD = 1.17 and M = 13.6, SD = 1.19) . Declines in youth, though not parent, report of open family communication, parental support, and family satisfaction were found. Declines were associated with various domains of pandemic-related stress in parent report, though positive life events served as buffers. Pre-pandemic family functioning also predicted pandemic stress. Spillover effects in turn impacted youth functioning. The current findings shed light on how experiences of the pandemic are linked with family functioning and have implications for how to support families during this time., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Many U.S. women report balancing competing demands for labor within the family and the workplace. Prior research has found that young adult heterosexual U.S. women are still anticipating doing the majority of their future family's childcare and housework, though they hold more progressive gender role attitudes than in the past. The aim of the present study was to investigate the assumptions of 176 heterosexual college students in the U.S. ( M  age = 20.57, 88.64% European American, 51.70% ciswomen, 48.30% cismen) about how childcare and housework should be balanced in the context of work responsibilities. Participants were asked to rate their level of agreement with two items about working mothers and childcare and working fathers and household care, and provided open-ended responses to explain their justifications for their rating. Open-ended responses were thematically coded. Results revealed that most participants wanted mothers to have the choice to work but considered childcare a limiting problem that (primarily) mothers should solve. Similarly, participants believed that working full-time did not excuse a husband from helping with chores, however they did not express concerns with the term "helping" which implies that the husband would not hold any primary responsibility. Overall, the findings suggest the importance for educational and policymaking interventions and future research to highlight practices that support and encourage the role of men in addressing childcare and household needs., Competing Interests: Conflicts of InterestThe authors have no relevant financial or non-financial conflicts of interests to disclose., (© The Author(s) 2021.)

The current longitudinal study examines changes in overall mental health symptomatology from before to after the COVID-19 outbreak in youth from the southeastern United States as well as the potential mitigating effects of self-efficacy, optimism, and coping. A sample of 105 parent-child dyads participated in the study (49% boys; 81% European American, 1% Alaska Native/American Indian, 9% Asian/Asian American; 4% Black/African American; 4% Latinx; and 4% other; 87% mothers; 25% high school graduate without college education; 30% degree from 4-year college; 45% graduate or professional school). Parents completed surveys when children were aged 6-9, 8-12, 9-13, and 12-16, with the last assessments occurring between May 13, 2020 and July 1, 2020 during the COVID-19 outbreak. Children also completed online surveys at ages 11-16 assessing self-efficacy, optimism, and coping. Multi-level modeling analyses showed a within-person increase in mental health symptoms from before to after the outbreak after controlling for changes associated with maturation. Symptom increases were mitigated in youth with greater self-efficacy and (to some extent) problem-focused engaged coping, and exacerbated in youth with greater emotion-focused engaged and disengaged coping. Implications of this work include the importance of reinforcing self-efficacy in youth during times of crisis, such as the pandemic, and the potential downsides of emotion-focused coping as an early response to the crisis for youth., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

This study investigated American heterosexual emerging adults' evaluations and reasoning about the fairness of their parents' gendered division of household labor, their future expectations of their own division, and in a third-party situation. A total of 161 American heterosexual (88.20% European American; 50.93% cisgender women), emerging adults ( M = 20.60, SD = 1.21) participated in this study. The majority of participants evaluated their parents' and future expected division to be fair. On the other hand, participants were less likely to consider a hypothetical gendered division fair. Equality justification usage, as well as reported parental childcare division predicted differences in fairness evaluations. The present study highlights the importance of employing methods that can capture the complex and multi-faceted nature of fairness evaluations and reasoning about the gendered division of household labor., Competing Interests: Declaration of Interests: The authors declare that they have no competing or conflicting financial or personal interests.

To date the majority of the research on microaggressions has focused on the experiences of targets, rather than the perpetrators, of microaggresive behaviors. The present study set out to investigate 278 college students' ( M age = 19.12, SD = 1.34, 52.52% cisgender women, 74.82% European American) reported types of experience (a) unaware, b) aware, c) observer, d) perpetrator, and e) target) with race and gender-based microaggressive behaviors and the association between their experiences and ambivalent sexist and colorblind racial attitudes. Participants completed an online survey composed of a modified Racial and Ethnic Microaggression Scale (REMS), a modified Female Microaggression Scale (FMS), an Ambivalent Sexism Index, and a Color-Blind Racial Attitudes Scale. As hypothesized (H1), participants were more likely to have heard of or observed than to report having been the target or perpetrator of microaggressions. In support of our second hypothesis (H2), significant gender and race differences were found in the frequencies of type of exposure to microaggressions. Finally, as expected (H3), exposure to microaggressions was associated with colorblind and ambivalent sexist attitudes. Unexpectedly, however, complete unawareness of the existence of microaggressions did not show any significant associations with social attitudes. This study's findings highlight the importance of unpacking social experiences of discrimination to better understand what types of experiences contribute to being critical of and reducing the commission of microaggressions.

Objective: The present study set out to investigate how Chinese and South Korean families conceptualize fairness and a fair division of household labor., Background: Previous cross-cultural research has found that a good portion of women and men find the gendered division of household labor fair. In response, scholars have attempted to discover what factors lead to a greater likelihood of reporting a gendered division fair. However, the majority of the scholarship on fairness perceptions has been limited to survey methods, in which fairness is not defined, and the individual's reasons for their fairness perception is not investigated., Method: This study employed thematic analysis of in-depth interviews with the members of 12 Chinese (N=39) and 12 Korean (N=40) families., Results: No participation in household labor was considered across families to be unfair. On the other hand, the majority of participants justified an unequal division to be fair based on gendered applications of differences in time-availability and levels of tiredness, in which the amount of housework that each member should do was left unspecified., Conclusion: Many adult participants believed that fairness should not apply to the family context. Instead, most participants argued that household labor should be divided based on emotional satisfaction, maintained through mechanisms of understanding and agreement., Implications: Future studies on fairness perceptions should clearly define what they mean by "fairness," and the gendering of gender-neutral appearing justifications such as time-availability should be further investigated.

This study explored age-related changes in Chinese and Korean children's fairness judgments and reasoning regarding the gendered division of household labor. The majority of previous research on this issue has focused on adults' experiences and has been conducted in Western countries. Interviews were conducted with 133 children, 65 Chinese and 68 South Korean, ages 9-11 ( N = 48), 12-14 ( N = 43), and 16-18 ( N = 42). Despite country differences in women's involvement in the workforce, in both countries women do most of the housework. Most participants across ages evaluated a hypothetical scenario in which the mother did most of the work as unfair and endorsed a hypothetical scenario in which housework was divided evenly as fair. Developmental effects were found with younger children in both countries employing more equality justifications and adolescents providing more social convention justifications. In both countries, children described their mother as doing most of the housework and, in contrast with their judgments about hypothetical situations, were evenly divided overall in their evaluations of whether this unequal distribution in their actual families was fair. Korean children were more likely to view their family's division as unfair than Chinese children and were more likely to employ equality justifications in support of those judgments. Unexpectedly, across countries moral reasoning in the form of expectations of equity rather than gender stereotyping was employed to justify an unequal division of labor. This study's findings suggest the value of investigating children's fairness judgments and moral reasoning regarding both hypothetical and actual situations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background: Vertigo is a debilitating disease that is commonly encountered in the emergency department (ED). Diazepam and meclizine are oral medications that are commonly used to alleviate symptoms., Objectives: We sought to determine whether meclizine or diazepam is superior in the treatment of patients with peripheral vertigo in the ED., Methods: We performed a double-blind clinical trial at a suburban, teaching ED. We randomized a convenience sample of adult patients with acute peripheral vertigo (APV) to diazepam 5 mg or meclizine 25 mg orally. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of vertigo on a 100-mm visual analog scale (VAS) and after 30 min (t30) and 60 min (t60). The primary outcome parameter was the mean change in VAS score from t0 to t60. Differences between groups and 95% confidence intervals were calculated. Our a priori power calculation estimated that a sample size of 20 patients in each group was required to have an 80% power to detect a difference of 20 mm between treatment groups., Results: There were 20 patients in the diazepam group and 20 in the meclizine group. The two groups were similar with respect to patient demographics and presenting signs and symptoms. At t60, the mean improvements in the diazepam and meclizine groups were 36 and 40, respectively (difference -4; 95% confidence interval -20 to 12; p = 0.60)., Conclusion: We found no difference between oral diazepam and oral meclizine for the treatment of ED patients with acute peripheral vertigo., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Fish from the Great Lakes contain polychlorinated biphenyls (PCBs) which have been shown to disrupt endocrine function and mimic thyroid hormones, but they also contain beneficial omega-3 fatty acids that may offer protection against endocrine cancers. The purpose of this study was to examine the effects of Lake Ontario fish consumption and the estimated consumption of PCBs and omega-3 fatty acids on the risk of thyroid cancer in a group of sport fishermen. Anglers from the New York State Angler Cohort Study were followed for cancer incidence from 1991-2008. Twenty-seven cases of incident thyroid cancer and 108 controls were included in the analyses. Total estimated fish consumption, estimated omega-3 fatty acid consumption, and estimated PCB consumption from Lake Ontario fish were examined for an association with the incidence of thyroid cancer, while matching on sex, and controlling for age and smoking status. Results from logistic regression indicate no significant associations between fish consumption, short-term estimated omega-3 fatty acids, or estimated PCB consumption from Great Lakes fish and the development of thyroid cancer, but it was suggested that long-term omega-3 fatty acid from Great Lakes fish may be protective of the development of thyroid cancer. In conclusion, fish consumption, with the possible concomitant PCBs, from the Great Lakes does not appear to increase the risk of thyroid cancer in New York anglers. Further research is needed in order to separate the individual health effects of PCBs from omega-3 fatty acids contained within the fish., (Copyright © 2015. Published by Elsevier B.V.)

Introduction: The loss of a loved one adversely affects the bereaved., Materials and Methods: Using data from the 2010 and 2012 waves of Health and Retirement Study (HRS), we estimate the risk for death in a 2-year span after the loss of a parent, spouse, or child for adults aged 50 to 70 years., Conclusion: A respondent with a loss was twice as likely to die when compared similarly aged persons with no loss (OR 2.32; 95 % CI 1.14, 5.30). Loss of either a parent (OR 1.93; 95 % CI 1.01, 4.07), or a child (OR 1.77; 95 % CI 1.08, 2.96) also increased respondent mortality. This elevated risk persists after adjustment for gender and other high-risk health conditions. Any physical activity reduces survivor death rates during this critical period by more than 85 %.

As stereotypes of social groups undergo change, group members gain access to previously denied social and cultural roles. Although such access is desirable, to the extent that the behavior, traits, and attitudes required to succeed in a new role are in opposition to those required to do well in a still-valued old role, conflict in the self-concept may ensue. Specifically, the individual must necessarily fall short in social comparisons of the self to the ideal group member in 1 or both roles, threatening self-integrity. Examining the specific case of oppositional identities between career and mom roles, we argue that women respond to this conflict by shifting back and forth between activation of whichever identity is relevant in a given situational context in a way that men do not. This shifting of self-associations is hypothesized to deplete scarce cognitive resources, interfering with performance on a task that requires executive function capacity. In addition, to the extent the identities are viewed as trading off against one another, failure in 1 domain may be responded to by activating the alternate identity in an effort to restore self-integrity, again in a way that is not true for men. These hypotheses are explored across 4 studies, utilizing both college students in the midst of formulating--and working parents in the midst of negotiating--these identities.

Background: Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24-48 h., Objective: To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED., Methods: Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24-72 h after the ED visit to assess headache recurrence., Results: A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5-30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9-42.1) in the placebo arm had recurrent headaches (p = 0.21)., Conclusion: We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: In February 2003, many physicians in New Jersey participated in a work slowdown to publicize large increases in malpractice premiums and generate support for legislative reform. It was anticipated that the community physician slowdown (hereafter referred to as "slowdown") would increase emergency department (ED) visits. The authors' goal was to help others prepare for anticipated increases in ED volumes by describing the preparatory staffing changes made and quantifying increases in ED volume., Methods: This was a retrospective cohort study performed at a New Jersey suburban teaching hospital with 70,000 annual visits. Consecutive patients seen by emergency physicians were enrolled. The authors extracted patient visit data from the computerized tracking system and analyzed hours worked by personnel, patient volumes, admission rates, and patient throughput times. Variables from each day of the slowdown with baseline values for the same day of the week for the four weeks before and after the slowdown were compared. A Bonferroni correction was used, with p < 0.01 considered statistically significant., Results: Total patient volume increased 79% from baseline (95% confidence interval [CI] = 20% to 137%). Pediatric volume increased 223% (95% CI = 171% to 274%). Overall admission rate decreased 29% compared with baseline (95% CI = 8% to 51%). Patient throughput times did not change significantly. Similar results for these variables were found for the second through fourth days of the slowdown., Conclusions: Emergency department visits, especially pediatric visits, increased markedly during the community physician slowdown. Anticipatory increases in staffing effectively prevented increased throughput times.

Introduction: In October of 2001, after letters processed in Trenton, New Jersey, resulted in multiple cases of anthrax, emergency departments (EDs) in New Jersey experienced an increase in visits from patients concerned about possible exposure to agents of biologic terrorism. Information about the effect of an actual biologic terrorism attack on the emergency department population might be useful in the design of biosurveillance systems, particularly with regard to their performance during the mitigation phase that occurs after an attack. In addition, such information might help identify issues that arise regarding the public health response in the ED setting., Objectives: The objectives of this report were to identify and characterize ED visits, by patients concerned with exposure to biologic terrorism agents, in selected New Jersey hospitals after the anthrax attack in fall 2001., Methods: A retrospective cohort design was used in this study. The setting was 15 New Jersey EDs within a 55-mile radius of Trenton. Participants were consecutive patients evaluated by ED physicians for the following four periods in 2001: 1 month before September 11; 1 month after September 11; 1 month after October 11; and for the second month after October 11. Percentages of visits were calculated with a concern for exposure (CE) visits by using International Classification of Diseases, Ninth Revision (ICD-9) descriptors: Feared Complaint-No Diagnosis (ICD-9 code v65.6) and Screening for Infectious Disease (ICD-9 code v75.9) for all hospitals and for Trenton versus non-Trenton hospitals as a percentage of ED visits. Charts were reviewed by using a structured data form., Results: A total of 225,403 ED visits occurred during the 4 months, of which 698 were CE visits. The percentages of CE visits for the four periods were 0.06%, 0.06%, 0.92%, and 0.10%, respectively. For the peak third period, the percentage was increased for the two Trenton hospitals, 1.81%, versus 0.82% for the 13 non-Trenton hospitals. This report is a summary of the 508 visits associated with concern for anthrax exposure during the peak third period: 47% reported exposure to powder, 13% were postal workers, 4% received chest radiographs, 65% had a nasal swab for anthrax, 13% had ED decontamination, and 32% received antibiotics., Conclusion: An increase in CE visits occurred during the 1-month period after October 11, 2001. During the peak month, a higher increase occurred in Trenton EDs. Considering the substantial variation in diagnostic evaluation and treatment, readily available guidelines are needed.

The objective of our study is to identify and compare the prevalence of nausea after parenteral administration of opioids in the Emergency Department (ED). This prospective study utilized a convenience sample at a community-based ED with a volume of 60,000 annual visits. Patients who were in acute pain or had an exacerbation of chronic pain requiring treatment with an opioid analgesic agent were eligible. Demographic and historical features were recorded on a standardized closed data collection form. The main study endpoint was the occurrence of nausea. The prevalence of nausea and vomiting was compared between morphine and meperidine. There were 37 patients in the morphine group and 156 in the meperidine group. The two groups were similar with respect to mean age, gender, and weight. The reported nausea was 0 of 37 in the morphine group and 20 of 156 (12.8%) in the meperidine group. This difference between morphine and meperidine groups of 12.8% (95% confidence intervals 2-24%) was statistically significant. In our patient population, morphine caused significantly less nausea then meperidine when it was used as an analgesic in the ED.

Heart failure, a disease of epidemic proportions, has a tremendous clinical and financial impact on the US health care system. With more than 5 million Americans diagnosed with heart failure and 5-year mortality approaching 50%, it is the most common cause of hospitalization in patients older than 65 years and is the single most expensive diagnosis in the US health care system. Because the average US hospital loses more than 1000 dollars per heart failure admission, effective therapies that decrease length of stay, reduce hospital costs, and prevent 30-day readmissions are needed. This article reviews the relevant pathophysiology of heart failure, discusses the newest diagnostic strategies for emergency department diagnoses, evaluates recent advances and effects of early aggressive therapies, and presents a suggested algorithm for the treatment of acutely decompensated heart failure in emergency departments.

Objective: The emergency department (ED) treatment of acute peripheral vertigo (APV) has not been well studied. The purpose of this study was to determine the efficacy of intramuscular (IM) droperidol vs IM dimenhydrinate, in the treatment of ED patients with APV., Methods: The study was a randomized, double-blinded clinical trial, performed at a suburban, teaching ED. A convenience sample of adult patients with symptoms and signs consistent with rigid diagnostic criteria for APV were randomized to one of two treatment groups. Patients more than 65 years of age were excluded to reduce the likelihood of diagnostic misclassification. Demographic and historical features were recorded on a standardized data form. Patients recorded their initial level (t0) of discomfort on a 10-centimeter (cm) visual analog scale (VAS). Treatment group 1 received 2.5 mg droperidol IM, while treatment group 2 received 50 mg dimenhydrinate IM. After 30 minutes (t30), patients again recorded the severity of their symptoms on the VAS. Chi-square, t-tests, and Mann-Whitney were used for statistical comparison as appropriate. All tests were two-tailed, with alpha set at 0.05. Primary outcome parameters were the mean change in VAS score from t0 to t30, and the percentage of patients in each treatment group who felt well enough to go home after t30 without further ED intervention., Results: There were 20 patients in the droperidol group and 20 in the dimenhydrinate group. The two groups were similar with respect to mean age (40 +/- 13 years droperidol vs. 42 +/- 13 years dimenhydrinate; p = 0.6), female sex (60% vs. 50%; p = 0.7), and mean median duration of symptoms [3 (interquartile range 2-12) vs 9 (interquartile range 2-30) hours; p = 0.2]. Mean initial t0 VAS scores were 7.2 +/- 2.3 and 7.8 +/- 1.9 (p = 0.47). Both treatment groups had mean reductions in VAS scores at t30 of 3.3 [95% confidence interval (95% CI) = 2.3 to 4.3]. At t30, 42% of patients in the droperidol group and 45% of patients in the dimenhydrinate group felt well enough to go home without further ED intervention., Conclusions: The authors found no difference between the therapeutic efficacies of IM droperidol and dimenhydrinate for the treatment of acute peripheral vertigo.

In a recent case series, we reported that intramuscular droperidol appeared to be an effective therapy for the treatment of acute migraine headache. The objective of the study was to further assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache. The study design was a randomized, clinical trial set in a community-based ED. The population was a convenience sample of ED patients who met International Headache Society acute migraine criteria. Exclusions included pregnancy, use of narcotic or phenothiazine medications within 24 hours. For the protocol, patients were randomized to 1 of 2 treatment groups. Patients and physicians were blinded as to the treatment provided. Patients recorded their initial pain on a 100mm Visual Analog Scale (VAS) Patients were randomized to receive either 2.5 mg droperidol intramuscularly; the other group received 1.5 mg/kg meperidine intramuscularly. After 30 minutes patients recorded their pain on the VAS and recorded their preference for the medication on a Likert Scale. Physicians recorded the incidence of any side effects and the need for rescue medication. Statistical analysis consisted of categorical variables that were analyzed by chi-square, continuous interval data by t-tests and ordinal data by Mann-Whitney U test. The primary outcome parameters were mean VAS score change and the percentage of patients who wanted to go home without rescue medication. The study had an 80% power to detect a 26 mm difference in the mean change in VAS between groups. Of the 29 patients who were enrolled, 15 received droperidol. Both groups were similar with respect to age (30.7 +/- 8.9 years droperdol v 32.7 +/- 9.9 years meperidine; P =.59), female sex (73% v 71%; P =.91), mean headache duration (24.7 +/- 28.3 v 18.3 +/- 25.8 hours; P =.55). The droperidol group had a higher mean initial VAS score (88 v 76 mm; P =.03). The 2 groups were similar with regard to outcome, including: mean change in VAS score (47 v 37 mm; P =.33), average Likert score (1.1 v 1.9; P =.85), and the percentage of patients who did not want rescue medication (67% v 57%; P =.61). The incidence of sedation was 6.7 v 14.3%. Akathisia occurred in 13.3% of pts who received droperidol. We found that intramuscular droperidol was similar in efficacy to meperidine with a low incidence of side effects.

Objective: To determine whether there are patterns in the incidence of emergency department (ED) visits for congestive heart failure (CHF) by month of the year, day of the week, or hour of the day., Methods: This was a retrospective analysis of a computerized billing database of ED visits, involving seven northern New Jersey hospitals EDS: Consecutive patients seen by emergency physicians over an 11-year period (January 1, 1988--December 31, 1998) were included. Chi-square tests were used to evaluate for significant differences (p < 0.05)., Results: There were a total of 2,370,233 patients in the database, of whom 26,224 had a primary ED diagnosis of CHF. The chi-square test rejected uniformity for month of the year, for day of the week, and for hour of the day (p < 0.0001). Visits for CHF were increased in the winter months. Compared with the average of the other months, December was the highest (14.3% above, p < 0.0001) and August was the lowest (15.5% below, p < 0.0001). There was also a day-of-the-week variation. Compared with the average of the other days, Monday was the highest (14.5% above, p < 0.0001) and Saturday was the lowest (9.6% below, p < 0.0001). There was also an hour-of-the-day pattern, with a rapid rise after 8 AM and a downtrend after 3 PM., Conclusions: These data revealed a higher incidence of ED visits for CHF in the winter months, on Mondays, and during the hours of 8 AM to 3 PM. In comparison with previous studies, these data revealed a similar pattern by month of the year and a different pattern by hour of the day.

Objective: To determine if magnesium sulfate (MgSO(4)) improves outcome in cardiac arrest patients initially in ventricular fibrillation (VF)., Methods: Randomized, prospective, double blind, placebo-controlled, multicenter prehospital trial using 2 g of MgSO(4). Eligible patients were non-traumatic cardiac arrest patients (> or =18 years of age) presenting in VF. The protocol included those patients refractory to three electroshocks. Epinephrine and either 2 g of MgSO(4) or placebo (normal saline) were then administered. The primary outcome variable was return of spontaneous circulation (ROSC) in the field and a perfusing pulse on arrival at the ED. Secondary endpoints included admission to the hospital (ADMT) and hospital discharge (DISC). IRB approval was obtained at all participating centers., Results: Total 116 patients (58 MgSO(4), 58 placebo) were enrolled during the period from 4/1992 to 10/96 with 109 available. There were no significant differences between the groups in baseline characteristics and times to cardio pulmonary resuscitation (CPR), advanced life support (ALS), and first defibrillation, except for time to study drug administration. There was no significant differences in ROSC (placebo, 18.5%, and MgSO(4), 25.5%, P=0.38), ADMT (placebo rate=16.7%, MgSO(4)=16.4%, P=1.0) or DISC (placebo rate=3.7%, MgSO(4)=3.6%, P=1.0)., Conclusions: We failed to demonstrate that the administration of 2 g of MgSO(4) to prehospital cardiac arrest patients presenting in VF improves short or long term survival.

Objective: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program., Methods: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05., Results: One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]., Conclusion: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.

Study Objective: To determine whether the use of diclofenac ophthalmic solution is a safe and effective analgesic in the treatment of traumatic corneal abrasions in the emergency department., Methods: We conducted a prospective, randomized, double-blinded, placebo-controlled clinical trial. Consenting consecutive patients with corneal abrasions who presented to a community-based ED from August through February 1998 were randomly assigned to receive either diclofenac or control vehicle drops. Pain relief was measured using a visual Numeric Pain Intensity Scale (NPIS) before and after treatment. Exclusion criteria were as follows: age younger than 18 years, pregnancy, history of glaucoma, ocular infection, recent eye surgery, other signs of ocular trauma, narcotics within 6 hours, minimal pain (NPIS score <3), and any allergy to diclofenac or nonsteroidal anti-inflammatory drugs. Patients were discharged with study drug or control vehicle solution, a topical antibiotic, oxycodone-acetaminophen as a rescue analgesic, and a pain diary. The outcome measurements were improvement in NPIS score 2 hours after treatment, use of oxycodone-acetaminophen, and occurrence of any adverse effects., Results: Forty-nine patients were enrolled in the study; 25 received diclofenac and 24 received control vehicle drops. Both groups were similar in gender, age, pretreatment pain duration, NPIS score, and analgesic use. There was significantly greater improvement in the 2-hour NPIS score in the diclofenac group (3.1; 95% confidence interval [CI] 2.3 to 4) compared with the control group (1.0; 95% CI 0.1 to 2.0). The difference between the 2 groups was 2.1+/-1.3 (95% CI 0.8 to 3.4). There was a trend toward fewer patients taking rescue oxycodone-acetaminophen in the diclofenac group (20%; 95% CI 4% to 36%) versus the control group (42%; 95% CI 22% to 62%). Other than transient mild stinging, there were no complications associated with diclofenac use., Conclusion: Diclofenac ophthalmic solution appears to be a safe and effective analgesic in the treatment of traumatic corneal abrasions in the ED.

Introduction: The safety and efficacy of medications stored on air medical helicopters may be adversely affected by extreme temperatures. The purpose of this study was to determine whether temperatures inside an air medical helicopter drug box were within the U.S. Pharmacopeia recommendations for controlled room temperature. This is defined as a temperature between 15 degrees and 30 degrees C (59 degrees and 86 degrees F) with a mean kinetic temperature of less than 25 degrees C (77 degrees F). An additional goal was to determine whether time/temperature indicator labels can reliably monitor mean kinetic temperatures., Methods: Temperatures were monitored with miniature electronic temperature recorders and color-changing time/temperature indicator labels., Results: The mean kinetic temperatures for the summer and winter periods were 25.1 degrees C (77.2 degrees F) and 12.7 degrees C (54.8 degrees F), respectively. In the summer, the electronic recorders logged temperatures exceeding 25 degrees C (59 degrees F) 37% of the time and more than 30 degrees C (86 degrees F) 6% of the time. In the winter, temperatures less than 15 degrees C (59 degrees F) were recorded 83% of the time. The mean kinetic temperatures obtained from the electronic recorder and the time/temperature indicator labels differed by less than 0.7 degree C (1.3 degrees F). The results show that medications on an air medical helicopter are subject to temperatures out of the recommended range and that time/temperature indicator labels can reliably monitor mean kinetic temperatures.

Objectives: To determine whether temperatures inside drug boxes used in the out-of-hospital setting are within the U.S. Pharmacopeia recommendations for "controlled room temperature," which is defined as a temperature maintained between 15 degrees C and 30 degrees C with a mean kinetic temperature less than 25 degrees C, and to determine whether time-temperature indicator labels can reliably monitor mean kinetic temperatures., Methods: Two methods were used to monitor temperatures: miniature electronic temperature recorders and color-changing time-temperature indicator labels. These were placed in drug storage boxes of advanced life support units over three summer months and two winter months., Results: In summer, the electronic recorders logged temperatures exceeding 30 degrees C in all drug storage boxes, ranging from 3% to 29% of the total time. The mean kinetic temperatures by location for the whole period ranged from 21 degrees C to 30 degrees C. In the winter, the electronic recorders logged temperatures exceeding 30 degrees C at one location 2% of the total time. There were significant temperature excursions below 15 degrees C at all locations, ranging from 16% to 90% of the total time. At one location, there were temperature readings below 0 degrees C for 9% of the total time. The mean kinetic temperatures obtained from the electronic recorders and the indicator labels differed by less than 1 degrees C., Conclusions: This study demonstrates that out-of-hospital medications are subject to temperatures both above and below recommended storage temperatures. Time-temperature indicator labels can reliably monitor exposure to elevated temperatures.

The use of intramuscular droperidol to treat acute migraine headache has not been previously reported in the emergency medicine literature. It is a promising therapy for migraine. The authors performed a pilot review of all patients receiving droperidol for migraine in our emergency department (ED) to evaluate its efficacy. We used a retrospective case series, in a suburban ED with an annual patient census of 48,000. All patients with a discharge diagnosis of migraine headache who were treated with i.m. droperidol during a consecutive 5-month period in our ED were identified. All patients received droperidol 2.5 mg intramuscular. As per ED protocol, their clinical progress was closely followed and documented at 30 minutes after drug administration (t30). Demographic and clinical variables were recorded on a standardized, closed-question, data collection instrument. The primary outcome measurement was relief of symptoms at t30 to the point that the patient felt well enough to go home without further ED intervention (symptomatic relief). Thirty-seven patients were treated (84% female), with an ED diagnosis of acute migraine with droperidol during the study period. The mean age was 36 +/- 12 years. Analgesics had been used within 24 hours before ED presentation by 62% of patients. At t30, 30 (81%) patients had symptomatic relief, 2 (5%) felt partial relief but required rescue medication, and 5 (14%) had no relief of symptoms. Drowsiness (14%) and mild akathisia (8%) were the only adverse reactions observed following drug administration. Droperidol 2.5 mg intramuscular may be a safe and effective therapy for the ED management of acute migraine headache. Randomized, controlled trials are warranted to further validate the findings of this preliminary study.

This randomized, double-masked, placebo-controlled, multicenter trial was conducted in 9 countries to assess the safety and efficacy of 2 doses of intravenous ondansetron (8 and 16 mg) for the control of opioid-induced nausea and vomiting. A total of 2574 nonsurgical patients who presented with pain requiring treatment with an opioid analgesic agent participated in this trial. The most common presenting painful condition was back or neck pain, reported by approximately one third of patients. A total of 520 patients (317 females, 203 males) developed nausea or vomiting after opioid administration and were randomly assigned to receive a single dose of 1 of 3 study treatments: placebo (n = 94), ondansetron 8 mg (n = 215), or ondansetron 16 mg (n = 211). Ondansetron 8 and 16 mg led to complete control of emesis in 134 of 215 patients (62.3%) and 145 of 211 patients (68.7%), respectively. Results with both doses were significantly better than those seen with placebo (43 of 94 patients [45.7%]). Complete control of nausea was achieved in 6.8% of placebo patients, 14.8% of ondansetron 8-mg-treated patients, and 19.4% of ondansetron 16-mg treated patients; only ondansetron 16 mg was significantly better than placebo (P = 0.007). Significantly more patients who received ondansetron 8 mg than patients who received placebo were satisfied/very satisfied with their antiemetic treatment, as assessed by 4 patient-satisfaction questions. Significantly more patients who received ondansetron 16 mg compared with placebo were satisfied/very satisfied on 2 of 4 satisfaction questions. In conclusion, based on the observed incidence of opioid-induced nausea and vomiting in this study, it may be more appropriate to treat symptoms on occurrence rather than administering antiemetic agents prophylactically. The results of this study demonstrate that intravenous ondansetron in doses of 8 or 16 mg is an effective antiemetic agent for the control of opioid-induced nausea and vomiting in nonsurgical patients requiring opioid analgesia for pain.

Emergency physicians and nurses were trained in telemedicine techniques in two emergency departments, one rural (low volume) and one suburban (high volume). Fifteen patient complaints were selected as appropriate for the study. Of 122 patients who met the inclusion criteria, 104 (85%) consented to participate. They were randomized to control and experimental groups. The suburban emergency physician diagnosed and treated the control patients. Experimental patients presenting to the high-volume emergency department were evaluated and treated by the telemedicine nurse in person and the rural emergency physician via the telemedicine link. Immediately before discharge all telemedicine patients were re-evaluated by the suburban emergency physician. Data collected on each patient included: diagnosis; treatment; 72 h return visits; need for additional care; and satisfaction of patient, physicians and nurses. There were no significant differences (P > 0.05) for occurrence of 72 h return visits, need for additional care or overall patient satisfaction. The average patient throughput time (from admission to discharge) was 106 min for the telemedicine group and 117 min for the control group. Telemedicine was a satisfactory technique for the chosen group of patients in the emergency department and was acceptable to the participants.

Objective: To describe the epidemiology of pediatric visits to the emergency departments (EDs) of 10 general hospitals by age and gender., Design: Review of ICD-9 codes from the billing database of a practice of emergency physicians., Setting: Ten hospitals in north/central New Jersey., Patients: All children <18 years treated by group physicians in EDs of study hospitals., Interventions: None., Main Outcome Measures: Diagnoses and visits., Results: There were 319,430 diagnoses recorded for 241,839 children (18.9% of the 1,277,233 total visits by all ages). The number of visits was highest in the <2 and >14 years age groups, with males predominating in all age groups. The number of visits from trauma increased with age. Otitis accounted for over 3% of all ED visits in this sample, over 7000 visits., Conclusions: Children account for a significant portion of ED visits in general hospitals. EDs need to be equipped and staffed to handle this clientele.

The most common diagnoses of elderly patients in the emergency department (ED) were compared among three age subgroups: 65 to 74, 75 to 84, and 85 and older. The computerized billing records for patient visits to 10 northern New Jersey hospital EDs for the years 1985 to 1991 were retrospectively analyzed. The most frequently occurring ICD-9-CM codes for elderly patients were compared among the three age subgroups. Elderly persons comprised 174, 146 (14% of the total) patient visits. The 176,146 patient visits were assigned 259,440 ICD-9-CM codes. The most common ICD-9-CM codes for medical diagnoses included chest pain, cardiac dysrhythmias, congestive heart failure, syncope, abdominal pain, and dyspnea. Fractures, particularly of the lower limb and upper limb; contusions; open wounds, particularly of the head, neck, and trunk; and falls were among the most common trauma diagnoses. The proportions in the three age subgroups of each diagnosis were statistically significantly different, except for cardiac arrest and contusions of the trunk and of multiple sites. The diagnoses with clinically significant higher relative risks in older age subgroups were atrial fibrillation, congestive heart failure, syncope, hypovolemia/dehydration, gastrointestinal hemorrhage, dyspnea, pneumonia, pulmonary edema, cerebrovascular accident, septicemia, urinary tract infection, fractures, and open wounds of the head, neck, trunk, particularly the scalp, and falls. Clinically significant lower relative risks were found in older age subgroups for chest pain, acute myocardial infarction, hypertension, angina, chronic airway obstruction not elsewhere classified, epistaxis, contusions of the upper limb, and open wounds of the finger.

A prospective study of emergency department telemedicine was carried out at two hospitals in northern New Jersey. One hundred and twenty-two patients met the inclusion criteria. One hundred and four (85%) consented to participate, with 54 being randomized to the telemedicine group and 50 to the control group. Four patients did not complete the protocol. No significant differences were seen between the groups for: occurrence of 72 h emergency department return visits (0% vs 0%); need for additional care (2.3% vs 2.4%); positive patient-physician interaction (98% vs 100%); positive patient-nurse interaction (98% vs 98%); positive overall patient satisfaction (98% vs 95%). The average patient throughput time (time from admission to discharge) for the telemedicine group was 106 min; the average for the control group was 117 min. Telemedicine was found to be a satisfactory technique for pre-selected emergency department patients and was viewed by the physicians as an acceptable method of complementary care.

Spontaneous cervical epidural hematoma is a rare cause of neck pain. We present the case of a 64-year-old woman who presented to the emergency department with neck pain from a partial Brown-Sequard syndrome secondary to spontaneous cervical epidural hematoma. The prompt recognition of this entity resulted in a favorable outcome.

A prospective case series was conducted to demonstrate the safety and efficacy of intravenous nitroglycerin (i.v. NTG) boluses in the treatment of ischemic chest pain (CP) in the emergency department (ED). Patients with CP symptomatic after sublingual nitroglycerin (SL NTG) therapy with a systolic blood pressure (SBP) greater than 95 mmHg were included. Patients were treated with i.v. NTG boluses of 0.05 mg to 0.4 mg during a 1- to 2-minute period per a protocol based on the patient's prebolus SBP. This was followed by a maintenance infusion. Additional NTG boluses were repeated every 5 minutes as needed. The end point of treatment was the resolution of chest discomfort, thrombolysis, or a SBP less than 95 mmHg. There were 16 cases of CP. All 16 patients treated, ie, 5 with acute myocardial infarction and 11 with unstable angina showed significant decrease in chest discomfort after 1 to 2 boluses. Two of five with acute myocardial infarction and 9 of 11 patients with unstable angina had complete relief of chest pain after 1 to 4 boluses. There were no episodes of hypotension (SBP < 90 mmHg) in any of the 16 cases. The judicious use of i.v. NTG boluses administered during a 1- to 2-minute period, in the ED, appears safe and efficacious in patients with CP unresponsive to SL NTG therapy.

The objective of this study was to report the authors' experience using intravenous ketorolac (Syntex Laboratories, Palo Alto, CA) as an analgesic in the treatment of renal colic in a convenience sample at three suburban community hospital emergency departments. Twenty-five patients with renal colic were participants. Pregnant women, patients with a history of renal or hepatic impairment, bleeding diathesis, active peptic ulcer disease, or hypersensitivity to aspirin or nonsteroidal antiinflammatory drugs (NSAID) were excluded. Ketorolac 30 mg administered intravenously during a 1-minute period, and the following parameters were monitored at times 0, 5, 10, 20, 30, and 60 minutes: pain on a scale of 0 to 10, pulse rate, blood pressure, and adverse side effects. A total of 25 patients were included in our series. Initially, they had a median pain score of 9 with an interquartile range of 1. Thereafter, the median pain scores and (interquartile ranges) were 8 (three) at 5 minutes, 5 (four) at 10 minutes, 2 (four) at 20 minutes, 1 (three) at 30 minutes, and 0 (one) at 60 minutes. There were no adverse side effects observed in any patients. Therefore, it can be concluded that intravenous ketorolac is an effective analgesic agent for the control of pain in patients with renal colic.

The authors polled emergency medicine groups in an attempt to identify whether equity was offered and the time, costs, and methods of achieving equity. Several characteristics of equity and nonequity groups were compared. A survey was distributed to 514 groups from a list identified by the American College of Emergency Physicians. Nonresponders received a second mailing. Valid responses were received from 127 groups representing 3,405 physicians. Of the respondent groups, 69 allowed full equity participation. The mean time to full partnership was 2.2 years for new physicians. Single hospital groups tended to have shorter (1.6 years) buy-in periods compared with multihospital groups (3-4 years). The most common method of buy-in was a differential in the "bonus" structure between new physicians and partners. The actual cost to attain full equity varied greatly with a range of from $0 to $500,000. Groups not owning their accounts receivable had a total mean buy-in cost of approximately $40,000 as compared with those that did own their accounts receivable, where the average buy-in cost was approximately $106,000. The proportion of equity groups that had two thirds or more physicians board-certified in emergency medicine was significantly greater than those groups without equity. The detailed structure for attaining equity varied greatly between groups. The authors conclude that many emergency physician groups allow full equity participation. The average time to full partnership is generally less than 3 years. There are many diverse schemes of entering into partnership. The cost of acquiring full equity varies greatly.

A 46-year-old man suffered a witnessed cardiac arrest. Ventricular fibrillation persisted despite 62 minutes of basic and advanced cardiac life support measures in the field. On arrival in the emergency department, he received 4 g magnesium sulfate IV and was defibrillated successfully to normal sinus rhythm with the next countershock. The patient was discharged neurologically intact. We discuss the possible mechanisms of action and clinical use of IV magnesium sulfate in cardiac arrest.