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Objective: To evaluate a strategy to increase use of the test (Dix-Hallpike test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for Benign Paroxysmal Positional Vertigo (BPPV) in emergency department (ED) dizziness visits. Methods: We conducted a stepped-wedge randomized trial in six EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head CT use, length-of-stay, admission, and 90-day stroke events. The analysis was multi-level logistic regression with intervention, month, and hospital as fixed effects, and provider as a random effect. We assessed fidelity with monitoring intervention use and semi-structured interviews. Results: We identified 7,635 dizziness visits over 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3077; 95% CI, 1%-1.9%) and 3.5% of intervention visits (159/4558; 95% CI, 3%-4%; difference 2% 95% CI, 1.3%, 2.7%). Head CT use was lower in intervention visits compared with controls (44.0% [1352/3077] vs 36.9% [1682/4558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. Conclusions: These findings provide evidence that an implementation strategy of a BPPV-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low which relates in part to our broad inclusion criteria for dizziness visits.

The voltage level of a distribution system can be anywhere from about 5 kV to as high as 35 kV with the most common voltages in the 15 kV class. The average short-circuit level at a distribution substation has been shown, by survey, to be about 10,000 A. There are few things more confusing in distribution engineering than trying to find out rules of over-current coordination, that is, what size fuse to pick or where to set a relay, etc. The loading of distribution transformers varies more widely than substation units. When the transformer is overloaded, the high temperature decreases the mechanical strength and increases the brittleness of the fibrous insulation. Continuous thermal rating factor (TRF)—Continuous TRF is normally designated for current transformers and is the factor by which the rated primary current is multiplied to obtain the maximum allowable primary current without exceeding temperature rise standards and accuracy requirements.

The Common Core State Standards (CCSS) and other state standards have challenged teachers to rethink how they plan units and design their assignments within constraints of time and increasingly diverse classrooms. This article describes the author's efforts to create a coherent, useable set of tools to make his teaching at the unit and daily levels more consistently effective. Through the tools and techniques he discusses here, the author presents the notion of a set of “performances” that serve as a guide for his own class and a means of facilitating important, if sometimes difficult, conversations within English departments about who is teaching what at each grade level. While the notion of these “Essential Performances” is not meant to replace the CCSS or any other set of standards, it is designed to lead to a more coherent progression aligned with the CCSS that allows teachers to collaborate when designing lessons and units to improve instructional consistency and professional collaboration.

Background and Purpose— In a previous study, 0.3 and 0.45 mg/kg of intravenous recombinant tissue plasminogen activator (rt-PA) were safe when combined with eptifibatide 75 mcg/kg bolus and a 2-hour infusion (0.75 mcg/kg per minute). The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic Stroke–Enhanced Regimen (CLEAR-ER) trial sought to determine the safety of a higher-dose regimen and to establish evidence for a phase III trial. Methods— CLEAR-ER was a multicenter, double-blind, randomized safety study. Ischemic stroke patients were randomized to 0.6 mg/kg rt-PA plus eptifibatide (135 mcg/kg bolus and a 2-hour infusion at 0.75 mcg/kg per minute) versus standard rt-PA (0.9 mg/kg). The primary safety end point was the incidence of symptomatic intracranial hemorrhage within 36 hours. The primary efficacy outcome measure was the modified Rankin Scale (mRS) score ≤1 or return to baseline mRS at 90 days. Analysis of the safety and efficacy outcomes was done with multiple logistic regression. Results— Of 126 subjects, 101 received combination therapy, and 25 received standard rt-PA. Two (2%) patients in the combination group and 3 (12%) in the standard group had symptomatic intracranial hemorrhage (odds ratio, 0.15; 95% confidence interval, 0.01–1.40; P =0.053). At 90 days, 49.5% of the combination group had mRS ≤1 or return to baseline mRS versus 36.0% in the standard group (odds ratio, 1.74; 95% confidence interval, 0.70–4.31; P =0.23). After adjusting for age, baseline National Institutes of Health Stroke Scale, time to intravenous rt-PA, and baseline mRS, the odds ratio was 1.38 (95% confidence interval, 0.51–3.76; P =0.52). Conclusions— The combined regimen of intravenous rt-PA and eptifibatide studied in this trial was safe and provides evidence that a phase III trial is warranted to determine efficacy of the regimen. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00894803.

The Irish Defence Forces (DF), through the Department of Defence, has provided military and technical advice to various government departments over many years. In recent years one of the most significant of these contributions has been support to the Department of Foreign Affairs in the implementation of Ireland’s conventional disarmament policy. DF expertise has been utilised across a broad spectrum of issues relating to conventional weapons systems and their use. These issues are somewhat loosely regarded as part of the disarmament universe but could be more precisely described as International Humanitarian Law or IHL. IHL in the military world tends to be known as the Law of Armed Conflict (LOAC) or by the older term, the Law of War.

Venlafaxine is currently marketed for treatment of depressive disorders as a conventional tablet formulation with a twice or three times daily dosage regimen. The absolute bioavailability of the conventional (CF) and extended-release (XR) formulations and their effects on electroencephalograms (EEG) and on a visual analog scale (VAS) for nausea were assessed in a randomized, double-blind, four-way crossover, placebo-controlled study of 16 healthy young men who were given either a single oral dose of 50 mg of CF venlafaxine, 75 mg of XR venlafaxine, or an intravenous dose of 10 mg of venlafaxine, or a placebo at 1-week intervals. The absolute bioavailability of venlafaxine was between 40% and 45% and was similar for both the CF and XR formulations. Venlafaxine produced central effects of a desipramine-like antidepressant. Regardless of formulation tested, the main EEG changes were an increase in fast beta (20-30 Hz) energy, which was more pronounced over the frontotemporal regions and extended within the full beta range (16-40 Hz). Maximum effect was reached at 6 hours for the CF and reached a plateau from 10 to 24 hours for the XR formulation. A dose-proportional increase in central activity, expressed as area under the effect curve (AUE) of the beta band, was observed between the CF (50 mg) and XR (75 mg) formulations. Compared with the CF tablet, the XR formulation also produced a much less intense maximum effect and a decrease of 63% in the AUE of nausea normalized by dose. The XR formulation has the same absolute bioavailability and the same central activity as assessed by EEG, but produced less intensive nausea than CF venlafaxine. The present findings suggest that a once-daily dosage regimen should be sufficient. This was confirmed by several clinical trials in depressive patients.

The purpose of this study is to determine whether, from a public policy standpoint, divestitures constitute an effective antitrust remedy in bank merger cases. A number of findings emerge from the study: Divested branches have a remarkable survival record; structural changes effected by divestitures tend to persist over time; larger buyers of divested branches tended to be more successful than smaller buyers; divestiture of the target institutions' branches rather than those of applicants proved preferable from an antitrust standpoint; and divested branches selected by the Department of Justice do not perform better than others. The findings suggest that divestitures of bank offices have generally provided an effective public policy remedy.

negligence. Upon reading a study I prepared of the entire year, which tried to provide a portrait of these students, their weaknesses, and the particular problems they faced, the principal and head counselor expressed their strong support for developing a program that would evolve as the next school year unfolded, one that would focus on those trouble areas that had surfaced. To understand who these students are, it would be best to begin with a short description of the class population. Students are placed in the class according to their reading skills and middle-school counselor recommendations. Reading abilities range from first grade to upper seventh in overall word power and comprehension. Because our school is in transition with regard to a comprehensive ESL program, basic English is generally viewed as the most appropriate placement for these students; last year I had several Middle-Eastern girls, this year I have a girl from Vietnam and a boy from Pakistan. Our school, like most others I expect, is also working towards some common idea of how to mainstream its special-education population; roughly thirty to forty percent of the students in this year's class are classified in some manner and to quite varying degrees as "exceptional." Add to this group others whose abilities end up masked or distorted because of behavioral problems that make them dysfunctional in a regular classroom, and you have a rather interesting gathering of young people in one class. The main areas of concern based on an exam

It has been suggested that monopolistically structured banking markets will perform competitively because banks have so many potential competitors and these markets are contestable. This hypothesis is tested on 2,861 banks in 1,286 markets. The tests compare rates of return of banks in markets with one, two, three and four banks with similar sized banks in metropolitan markets. The findings clearly reveal that rates of return in markets with few banks are significantly higher than those in markets with many competitors. These results question the validity of the theory of contestable markets in banking.

Bank holding companies have made significant inroads into the mortgage banking industry, primarily by acquisition. Federal Reserve Board approval of acquisitions is contingent upon the expectation of net public benefits. This study analyzes one of the benefits that BHCs claim will arise from acquisition of mortgage bankers—the flow of funds into housing will become more cyclically stable. Test results on a 33-firm sample of independent and BHC-affiliated mortgage bankers for 1973–1975 provide little support for this claimed public benefit.

Contestability in local banking markets is tested using a structure-performance (S-P) model. OLS and TSLS tests using a 38 state sample of 5,396 banks in 1,474 markets reveal a positive concentration-profitability relationship. This implies that local banking markets are not contestable. However, tests for each state separately show that the S-P relationship exists only in approximately one-fifth of states. F-tests indicate that using a national pooled sample is inappropriate. The results suggest that market structure, including entry conditions, affect performance, consequently the theory of potential competition is more relevant than contestability theory. However, generalizations may be inaccurate.