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Objectives The objective was to assess the performance of a clinical practice guideline for evaluation of possible appendicitis in children. The guideline incorporated risk stratification, staged imaging, and early surgical involvement in high-risk cases. Methods The authors prospectively evaluated the clinical guideline in one pediatric emergency department (ED) in a general teaching hospital. Patients were risk-stratified based on history, physical examination findings, and laboratory results. Imaging was ordered selectively based on risk category, with ultrasound (US) as the initial imaging modality. Computed tomography (CT) was ordered if the US was negative or indeterminate. Surgery was consulted before imaging in high-risk patients. Results A total of 475 patients were enrolled. Of those, 193 (41%) had appendicitis. No low-risk patient had appendicitis. Medium-risk patients had a 19% rate of appendicitis, and 83% of high-risk patients had appendicitis. Factors associated with an increased likelihood of appendicitis included decreased bowel sounds; rebound tenderness; and presence of psoas, obturator, or Rovsing's signs. Of the 475 patients, 276 (58%) were managed without a CT scan. Seventy-one of the 193 (37%) patients with appendicitis went to the operating room without any imaging. The rate of missed appendicitis was 2%, and the rate of negative appendectomy was 1%. Conclusions The clinical practice guideline performed well in a general teaching hospital. Rates of negative appendectomy and missed appendicitis were low and 58% of patients were managed without a CT scan.

ACADEMIC EMERGENCY MEDICINE 2012; 19:48–55 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Over the past decade, clinicians have become increasingly reliant on computed tomography (CT) for the evaluation of patients with suspected acute appendicitis. To limit the radiation risks and costs of CT, investigators have searched for biomarkers to aid in diagnostic decision-making. We evaluated one such biomarker, calprotectin or S100A8/A9, and determined the diagnostic performance characteristics of a developmental biomarker assay in a multicenter investigation of patients presenting with acute right lower quadrant abdominal pain. Methods: This was a prospective, double-blinded, single-arm, multicenter investigation performed in 13 emergency departments (EDs) from August 2009 to April 2010 of patients presenting with acute right lower quadrant abdominal pain. Plasma samples were tested using the investigational S100A8/A9 assay. The primary outcome of acute appendicitis was determined by histopathology for patients undergoing appendectomy or 2-week telephone follow-up for patients discharged without surgery. The sensitivity, specificity, negative likelihood ratio (LR–), and positive likelihood ratio (LR+) of the biomarker assay were calculated using the prespecified cutoff value of 14 units. A post hoc stability study was performed to investigate the potential effect of time and courier transport on the measured value of the S100A8/A9 assay test results. Results: Of 1,052 enrolled patients, 848 met criteria for analysis. The median age was 24.5 years (interquartile range [IQR] = 16–38 years), 57% were female, and 50% were white. There was a 27.5% prevalence of acute appendicitis. The sensitivity and specificity for the investigational S100A8/A9 assay in diagnosing acute appendicitis were estimated to be 96% (95% confidence interval [CI] = 93% to 98%) and 16% (95% CI = 13% to 19%), respectively. The LR− ratio was 0.24 (95% CI = 0.12 to 0.47), and the LR+ was 1.14 (95% CI = 1.10 to 1.19). The post hoc stability study demonstrated that in the samples that were shipped, the estimated time coefficient was 7.6 × 10−3 ± 2.0 × 10−3 log units/hour, representing an average increase of 43% in the measured value over 48 hours; in the samples that were not shipped, the estimated time coefficient was 2.5 × 10−3 ± 0.4 × 10−3 log units/hour, representing a 13% increase on average in the measured value over 48 hours, which was the maximum delay allowed by the study protocol. Thus, adjusting the cutoff value of 14 units by the magnitude of systematic inflation observed in the stability study at 48 hours would result in a new cutoff value of 20 units and a “corrected” sensitivity and specificity of 91 and 28%, respectively. Conclusions: In patients presenting with acute right lower quadrant abdominal pain, we found the investigational enzyme-linked immunosorbent assay (ELISA) test for S100A8/A9 to perform with high sensitivity but very limited specificity. We found that shipping effect and delay in analysis resulted in a subsequent rise in test values, thereby increasing the sensitivity and decreasing the specificity of the test. Further investigation with hospital-based laboratory analyzers is the next critical step for determining the ultimate clinical utility of the ELISA test for S100A8/A9 in ED patients presenting with acute right lower quadrant abdominal pain.

Research networks can enable the inclusion of large, diverse patient populations in different settings. However, the optimal measures of a research network's failure or success are not well defined or standardized. To define a framework for metrics used to measure the performance and effectiveness of emergency care research networks (ECRN), a conference for emergency care investigators, funding agencies, patient advocacy groups, and other stakeholders was held and yielded the following major recommendations: 1) ECRN metrics should be measurable, explicitly defined, and customizable for the multiple stakeholders involved and 2) continuing to develop and institute metrics to evaluate ECRNs will be critical for their accountability and sustainability.

Background: Diabetes is often not diagnosed until complications appear, and one-third of those with diabetes may be undiagnosed. Prediabetes and diabetes are conditions in which early detection would be appropriate, because the duration of hyperglycemia is a predictor of adverse outcomes, and there are effective interventions to prevent disease progression and to reduce complications. Objectives: The objectives were to determine the prevalence of diabetes mellitus and prediabetes in emergency department (ED) patients with an elevated random glucose or risk factors for diabetes but without previously diagnosed diabetes and to identify which at-risk ED patients should be considered for referral for confirmatory diagnostic testing. Methods: This two-part study was composed of a prospective 2-year cohort study, and a 1-week crosssectional survey substudy, set in an urban ED in Los Angeles County, California. A convenience sample was enrolled of 528 ED patients without previously diagnosed diabetes with either 1) a random serum glucose ‡ 140 mg ⁄dL regardless of the time of last food intake or a random serum glucose ‡ 126 mg ⁄dL if more than 2 hours since last food intake or 2) at least two predefined diabetes risk factors. Measurements included presence of diabetes risk factors, ED glucose, cortisol, insulin and glycosylated hemoglobin (HbA1c), and 2-hour oral glucose tolerance test results, administered at 6-week follow-up. Results: Glycemic status was confirmed at follow-up in 256 (48%) of the 528 patients. Twenty-seven (11%) were found to have diabetes, 141 (55%) had prediabetes, and 88 (34%) had normal results. Age, ED glucose, HbA1c, cortisol, and random serum glucose ‡ 140 mg ⁄dL were associated with both diabetes and prediabetes on univariate analysis. A random serum glucose ‡ 126 mg ⁄dL after 2 hours of fasting was associated with diabetes but not prediabetes; ED cortisol, insulin, age ‡ 45 years, race, and calculated body mass index (BMI) were associated with prediabetes but not diabetes. In multivariable models, among factors measurable in the ED, the only independent predictor of diabetes was ED glucose, while ED glucose, age ‡ 45 years, and symptoms of polyuria and polydipsia were independent predictors of prediabetes. All at-risk subjects with a random ED blood glucose > 155 mg ⁄dL had either prediabetes or diabetes on follow-up testing. Conclusions: A substantial fraction of this urban ED study population was at risk for undiagnosed diabetes and prediabetes, and among the at-risk patients referred for follow-up, the majority demonstrated diabetes or prediabetes. Notably, all patients with two risk factors and a random serum glucose > 155 mg ⁄dL were later diagnosed with prediabetes or diabetes. Consideration should be given to referring ED patients with risk factors and a random glucose > 155 mg ⁄dL for follow-up testing. ACADEMIC EMERGENCY MEDICINE 2009; 16:394‐402 a 2009 by the Society for Academic Emergency Medicine

Objectives: The objectives were to determine the effect of pediatric airway management training on paramedic self-efficacy and skill performance and to determine which of several retraining methods is superior. Methods: A total of 2,520 paramedics were trained to proficiency in pediatric bag-mask ventilation (BMV) and endotracheal intubation (ETI) on mannequins. Subjects were a convenience sample of 245 (10% of original cohort) presenting for voluntary retraining. A total of 212 of 245 (87%) completed skills testing. Self-efficacy was measured prior to and following initial training and retraining events. Paramedics were assigned to control (no retraining), videotape presentation, self-directed learning, or instructor-facilitated lecture and demonstration retraining. Following retraining, BMV and ETI skills were tested. Results: Paramedics from low-call-volume areas reported lower baseline self-efficacy and derived larger increases with training, but also experienced the most decline between training events. Pass rates for BMV and ETI were 66% (139 ⁄211) and 42% (88 ⁄212), respectively. However, overall cohort self-efficacy was maintained over the study period. In ordinal regression modeling, only the lecture and demonstration method was superior to control, with an odds ratio (OR) of achieving higher scores of 2.5 (95% confidence interval [CI] = 1.2 to 5.2) for BMV and 5.2 (95% CI = 2.4 to 11.2) for ETI. Poor performance with ETI but not BMV was associated with time elapsed since training (p = 0.01). Self-efficacy ratings were not predictive of skill performance. Conclusions: Training provides increases in self-efficacy, particularly among paramedics from low-callvolume areas. A gap exists between self-efficacy and skill performance, in that self-efficacy may be maintained even when skill performance declines. Pediatric airway skills decay quickly, ETI skills drop off more significantly than BMV skills, and a lecture and demonstration format seems superior to other retraining methods investigated. ACADEMIC EMERGENCY MEDICINE 2008; 15:1295‐1303 a 2008 by the Society for Academic Emergency Medicine

Objectives: A systemic inflammatory response has been reported following resuscitation from cardiac arrest. The purpose of this study was to compare the magnitude of the tumor necrosis factor-α (TNF-α) response in two different swine models of ventricular fibrillation (VF) arrest. Methods: This was a randomized comparative trial conducted with domestic swine (N = 28, mean weight 40 kg, range 34–49 kg) of both genders. Anesthetized and instrumented swine were randomized to electrically induced VF (n = 14) or spontaneous VF induced by occlusion of a coronary artery (n = 14). After 8 minutes of VF, countershocks were given and standard advanced cardiac life support was initiated. Resuscitated animals were observed for 3 hours, and hemodynamics, base excess, and TNF-α concentrations were measured at intervals. Results: TNF-α concentrations were significantly greater in the ischemic VF group throughout the postresuscitation period. Multivariate modeling demonstrated that the TNF-α level was dependent on the method of VF induction and correlated with ischemia time (untreated VF period plus time to restoration of circulation) and the degree of postresuscitation hypoperfusion as reflected in base excess measurements. Conclusions: This study demonstrates that TNF-α concentrations increase after resuscitation from cardiac arrest and that the TNF-α response is more profound in animals subjected to ischemic, spontaneous VF. The observed differences may be due to a longer resuscitation time and persistent postresuscitation hypoperfusion in the ischemic VF group. These differences need to be considered in studies evaluating mechanisms of postresuscitation organ dysfunction and defining mortality markers.

Academic emergency medicine can benefit by broadening the way in which scholarship is defined to include teaching, integration of knowledge, application of knowledge to practical clinical problems and as discovery of new knowledge. A broad view of scholarship will help foster innovation and may lead to new areas of expertise. The creation of a scholarly environment in emergency medicine faces the continued challenge of an increasing clinical demand. The solution to this dilemma will likely require a mix of clinical staff physicians and academic faculty who are appreciated, nurtured and rewarded in different ways, for the unique contributions they make to the overall success of the academic program.

Objectives: To prospectively validate a previously published out-of-hospital clinical decision rule to identify seriously injured children involved in motor vehicle crashes (MVCs). Methods: The authors selected 20 Los Angeles County Fire Department fire stations, based on pediatric MVC call volume and geographic diversity, and 21 associated hospitals for participation in the study. Immediately following an MVC call involving a pediatric patient aged 0‐14 years, each engine/paramedic squad completed a data form (15 variables, including vital signs, Glasgow Coma Scale score, and vehicular and crash characteristics). This study was conducted over a 24-month period. Outcomes included: 1) ‘‘serious injury’’ as defined by an Injury Severity Score (ISS) $ 16 (primary outcome), and 2) need for specialized trauma care (emergent intubation, major nonorthopedic operative intervention or death in the first 24 hours, or pediatric intensive care unit stay longer than 48 hours), as assessed by retrospective chart review. Accuracy measures and binominal confidence intervals (CIs) were calculated for the decision rule validation. Results: One hundred seventy-five children were prospectively enrolled in the study; 36 children were excluded due to lack of hospital participation or missing hospital charts. There were four children with ISS $ 16 (3%) and six children requiring specialized trauma care (4%). The sensitivities and specificities of the rule were: 100% (95% CI = 40% to 100%) and 73% (95% CI = 65% to 81%) for serious injury, and 83% (95% CI = 36% to 100%) and 74% (95% CI = 65% to 81%) for specialized trauma care, respectively. Conclusions: Although definitive conclusions are limited by the sample size, the decision rule identified all seriously injured children involved in MVCs and had moderate specificity. The decision rule was less sensitive for identifying children requiring specialized trauma care. Larger validation studies are needed to adequately assess the utility of this rule before implementation. Key words: clinical decision rule; pediatrics; motor vehicle collisions; trauma; prediction. ACADEMIC EMERGENCY MEDICINE 2005; 12:679‐687.

Federal rules and regulations exist to ensure the protection of human subjects involved in research (Belmont Report 1979; Title 45, Code of Federal Regulations, part 46 2001); but it is the institutional review board (IRB) that interprets, implements, and applies these guidelines in a given health care or research facility (Moreno, Caplan, and Wolpe 1998; Title 45, Code of Federal Regulations, part 46 2001). Additional federal research regulations, the Health Insurance Portability and Accountability Act (HIPAA) “Privacy Rule,” and the requirement for federalwide assurances have recently been implemented with the intent of further protecting patient privacy and standardizing institutional research standards (Title 45, Code of Federal Regulations, part 46 2001; Title 45, Code of Federal Regulations, parts 160 and 164 2002). The Privacy Rule, as applied to research, requires strict confidentiality and limited access to individual protected health information unless informed consent is provided or the research qualifies for a waiver. Federalwide assurances serve as a document or agreement that defines an institutional obligation to comply with federal research regulations (Newgard and Lewis 2002). Such “assurances” have existed for many years, being provided to centers for multiple studies or for a single study after central (i.e., federal) review of a given research protocol. In 1998, the Office for Human Research Protections began a paradigm shift of decentralizing responsibility for protocol review, changing accountability, “simplifying” assurances, and promoting the concept of accreditation and education with a single, broadly applicable federal assurance (i.e., the federalwide assurance) for all institutions participating in federally supported or federally conducted research (Newgard and Lewis 2002). While the Privacy Rule and federalwide assurances are only strictly applicable to federally supported or federally conducted research and to hospitals receiving federal funds, they have been broadly applied throughout the health care system. Whether these regulations confer any additional protection for human subjects involved in research is unclear, and concerns have been raised about the potentially negative effect of these regulations on research, particularly on population-based health services research (Kulynych and Korn 2002). In the case of federalwide assurances, there is no evidence to suggest that such an assurance further improves the protection of human subjects, particularly for minimal risk research conducted in nonacademic institutions where the individual tasked with obtaining and signing the assurance often has no involvement in or direct supervision over such research activities. Including patients from many different practice settings (e.g., academic, tertiary, and community) in health services research is important to produce valid results with broad generalizability. Regulatory burden may threaten broad participation (Kulynych and Korn 2002), especially among centers that would rarely, if ever, participate in research activities. Policies that effectively restrict the selection of research subjects to those in academic centers may have the unintentional result of reducing the generalizability of subsequent study results and raise concerns about whether important findings truly apply to the vast majority of patients who receive care in nonacademic centers. Finally, such restricted selection of research subjects potentially violates the principle of justice in research (Belmont Report 1979). The objective of this study was to describe (1) the institutional variability in study approval and willingness to obtain federalwide assurance documents for a federally supported, minimal risk health services research project conducted during the implementation of the Privacy Rule and federalwide assurances, and (2) the potential impact of such policy on selection of research subjects and generalizability of study results.

OBJECTIVES To develop and validate a practical outcome instrument applicable to a broad range of neurologic deficits in children. METHODS Reliability testing of a draft version of the Neurologic Outcome Scale for Infants and Children (NOSIC) in 100 children with a wide range of ages and levels of neurologic function was performed. After review of the reliability data by a panel of experts, the NOSIC was revised. Validity and reliability testing of the final NOSIC was performed in a new population of 157 children, 52 with cerebral palsy, motor delay, or language delay. Interrater reliability was assessed using Spearman rank correlation coefficients of two investigators' scores. NOSIC scores were correlated with scores on criterion-standard neuropsychological tests to assess validity. RESULTS The median NOSIC score for normal children was 98, interquartile range 96-100; the median score for abnormal children was 87, interquartile range 58-96. Interrater reliability of the NOSIC scores of 84 patients rated by both raters demonstrated excellent reliability (rho = 0.77, 95% confidence interval [CI] = 0.62 to 0.88). Correlation of the NOSIC scores of the 127 patients who had neuropsychological testing with applicable criterion standards was rho = 0.63, 95% CI = 0.50 to 0.74. CONCLUSIONS The NOSIC is a practical, reliable, valid, instrument applicable to infants and children with a broad range of neurologic deficits. It should be a useful research tool when neurologic function is an important outcome measure.

The ACLS (advanced cardiac life support) Score was previously developed to predict survival from out-ofhospital cardiac arrest. Whether the arrest was witnessed, initial cardiac rhythm, performance of bystander cardiopulmonary resuscitation (CPR), and the response time of the paramedic unit were determined to be predictive of survival. However, the ACLS Score has not been validated in other emergency medical services systems. Objectives: The purpose of this study was to externally validate the ACLS Score in one patient population. Methods: This was a retrospective cohort study performed at an urban county teaching hospital. The study population consisted of consecutive adult patients treated for out-of-hospital, nontraumatic cardiac arrest, and transported to the authors’ institution between November 1, 1994, and September 30, 2001. Patient records for all cardiac arrests during the study period were reviewed. Study variables included witnessed arrest, initial arrest rhythm, bystander CPR, paramedic response time, and survival to hospital discharge. Predicted probability of survival to hospital discharge was calculated for each patient using the ACLS Score. The overall predicted and observed survival rates were compared using Flora’s Z score. The Hosmer-Lemeshow test was used to evaluate the model’s goodness-of-fit over a range of survival probabilities. Results: Of 754 cardiac arrest patients enrolled in the study period, 575 (76%) patients had documentation that allowed scoring using the ACLS Score. Twenty-five (4%) patients survived to hospital discharge. The predicted number of survivors based on the ACLS Score was 104 (18%), yielding a Flora’s Z statistic of � 4.46 (p \ 0.0001). After categorizing predicted survival probabilities into four categories, the resulting Hosmer-Lemeshow statistic was 210 (p � 10 � 6 ). Both goodness-of-fit statistics demonstrated extremely poor fit of the model. A receiver operating characteristic (ROC) curve was created, yielding an area under the ROC curve of 0.33 (95% CI ¼ 0.19 to 0.47), signifying extremely poor discrimination. Conclusions: The previously published ACLS Score was not valid when applied to an external cohort of out-of-hospital cardiac arrest patients. An externally valid model is needed to predict survival to hospital discharge following out-ofhospital cardiac arrest. Key words: ACLS Score; survival; prediction; cardiac arrest; out-of-hospital cardiac arrest. ACADEMIC EMERGENCY MEDICINE 2003; 10:621–626.

This article summarizes discussions held during a conference on outcomes research in emergency medical services for children. It provides detailed information on existing outcome measures for pediatric minor head injury. Benefits and/or limitations in their applicability for use in pediatric emergency medicine and pediatric minor head injury research are highlighted.

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.

Statistical decision theory is a set of techniques for making optimal decisions in the setting of uncertainty. Both frequentist and Bayesian approaches have been developed. The definition of a Bayesian decision problem requires the specification of an unknown parameter and its prior probability density function (pdf), observed data (if any), a likelihood function, a set of possible decisions or actions, and a loss or utility function whose expectation is to be optimized. The expected loss can be defined in a number of ways, yielding a frequentist risk, the conditional Bayes risk, and the Bayes risk. The goal is generally to select a decision rule that maps the possible observed data to a set of actions so that the Bayes risk is minimized. Alternatively, a frequentist may seek to minimize the maximum frequentist risk that might be experienced over all possible fixed values of the unknown parameter, yielding the optimal “minimax” decision rule. Examples in the chapter include a problem of selecting drug therapy when the patient diagnosis is unclear and the decision to order a test to determine the disease present, choosing a sample size when the goal is to estimate an unknown mean of a normally distributed variable, sequential stopping rules determined through back induction, and sequential allocation or assignment (bandits). Keywords: prior probability; posterior probability; loss function; utility function; Bayes theorem; frequentist risk; Bayes risk; minimax; sequential analysis; adaptive assignment

Objectives In November 1996, the Food and Drug Administration (FDA) and the Department of Health and Human Services (DHHS) enacted rules allowing a narrow exception to the requirement for prospective informed consent when enrolling critically ill patients in clinical research studies of emergency treatments. These rules require that, prior to initiation of the study, the applicable institutional review board (IRB) assess the acceptability of the proposed research study to members of the community in which the research will be conducted. Specifically, the IRB must perform community consultation-a process during which community members learn about the proposed research and communicate their opinions regarding its acceptability to investigators or IRB representatives. The FDA and DHHS rules do not define specific acceptable methods for performing this community consultation. The objective of this study is to demonstrate the feasibility and utility of one proposed method for performing such community consultation. Methods Parents of children being seen for minor traumatic injuries in three pediatric EDs were asked to participate in a study regarding informed consent. After consent, an instructor described to the parent a prospective, randomized, placebo-controlled trial of phenytoin for the prophylaxis of posttraumatic seizures in children with severe closed head trauma. All parents were then asked whether they would have consented for their own child's participation, if their child had suffered such head injury. The parents were further asked to explain the reason(s) for their responses. Results Parents of 227 children (children's mean +/- SD age 8.0 +/- 4.8 years, 57% male) were interviewed. Sixty-six percent of parents (149/227) stated they would give consent for their child's participation. Of the 149 consenting parents, 85% (126/149) cited potential benefit to their child, 72% (107/149) cited potential benefit to other children, and 60% (90/149) cited furthering medical knowledge. Of the 78 nonconsenting parents (34% of total), 54% (42/78) cited fear of adverse effects, 39% (30/78) did not want their child to be a research subject in general, 27% (21/78) believed they needed to discuss participation with family members who were unavailable, and 26% (20/78) stated they were unable to decide unless they were in the actual situation. Parental ethnicity and household income were found to influence the consent decision, while the parent's gender, religion, language, and educational level were not associated with the consent decision. Conclusions Community consultation regarding the acceptability of an emergency research protocol can be obtained via interview techniques in the ED. This methodology may allow investigators to obtain data on opinion from a targeted community for IRB consideration during the review of emergency research studies proposing a waiver of informed consent.

Previous studies have suggested that the degree of difference between rectal temperature and peripheral skin temperature [rectal-skin temperature difference (RSTD)] is predictive of serious illness in young infants. The authors sought to determine the clinical utility of the RSTD in the outpatient evaluation of infants up to 2 months of age for serious infectious illness (SII).Simultaneous rectal and skin (anterior mid-lower leg) temperatures were recorded for all infantsor = 2 months of age seen in the ED over a one-year period. The physician's clinical assessment, rectal temperature, skin temperature, laboratory results, and final diagnoses were also recorded. The RSTD (rectal temperature - skin temperature) was calculated for each infant. Final diagnoses were recorded and classified as SII or nonserious illness (NSI). Mean RSTD for each group was calculated and data were analyzed by the Wilcoxon rank sum test and multivariate regression model.A total of 601 infants [mean age of 28 days (range 2-65 days)] were enrolled. Nine percent (57 of 601) of infants had SII. Forty percent (23 of 57) of infants with SII were febrile, and 60% (34 of 57) were afebrile. The mean RSTD of febrile infants with SII was 5.8 +/- 1.7 degrees C (range 3.2-9.7 degrees C) and 5.3 +/- 1.4 degrees C (range 3.0-7.6 degrees C) for febrile infants with NSI. The mean RSTD of afebrile infants with SII was 4.8 +/- 1.8 degrees C (range 2-12.5 degrees C) and 4.4 +/- 1.5 degrees C (range 0.04-10.9 degrees C) for afebrile infants with NSI. The RSTD was not associated with SII in either febrile or afebrile infants (p0.05, Wilcoxon rank sum test). A multivariate logistic regression model of age, rectal temperature, and RSTD suggested an independent association of rectal temperature with SII (p0.0001), but none between age or RSTD and SII (p0.05).Once the rectal temperature is known, the RSTD is not a clinically useful test in the evaluation of young infants for serious infectious illness.

Survival analysis is a group of statistical methods used to analyze data representing the time to an event of interest, e.g., the duration of survival after an out-of-hospital cardiac arrest or the length of time a patient stays in the ED. Survival analysis properly accounts for patients who are lost to follow-up and for patients who have not yet experienced the event of interest at the end of the study's observation period (censored data). This article acquaints the reader with the terminology, methodology, and limitations of survival analysis. Specific methods discussed include life tables, the Kaplan-Meier product limit estimate, the log-rank test, and the multivariate Cox proportional hazards model.

Accidental extubation is a potentially serious event for pediatric or neonatal patients with respiratory failure, especially in clinical settings in which personnel capable of performing reintubation may not be readily available. Thus the rate of accidental extubation in small intensive care units that operate without 24-hour in-house physician availability may be an important quality assurance indicator. The objectives of this study were to determine the accidental extubation rate at a single small pediatric intensive care unit (PICU) and compare it with published reports. This study was carried out in a six-bed PICU at Washoe Medical Center in Reno, Nevada, with a relatively low level of patient acuity, as measured by PRISM score and the frequency of intubation, and without 24-hour in-house physician availability. All intubated patients admitted during the 5-year period from January 1, 1989 to December 31, 1993 were included. The primary outcome measure was the occurrence of accidental extubation. We observed only two accidental extubations in 1,749 intubated-patient-days (IPD) (0.114 accidental extubations/100 IPD [95% confidence interval 0.014–0.413 accidental extubations/100 IPD]). This rate of accidental extubation was compared with data in published reports from neonatal intensive care units (NICUs) and PICUs, which ranged from 0.14 accidental extubations/100 IPD to 4.36 accidental extubations/100 IPD. The dependence of the observed accidental extubation rate on unit size and institutional experience with intubated patients, as measured by the average number of intubated patients, was examined. We found no evidence that the accidental extubation rate is higher in smaller units or units with less institutional experience. Low rates can be achieved in small units with low acuity. Pediatr. Pulmonol. 1997; 23:424–428. © 1997 Wiley-Liss, Inc.

Background The US President's Emergency Plan for AIDS Relief (PEPFAR) was reauthorized in June 2008 with a three-fold increase in funds, and a broader, more explicit mandate to improve health in the low- and middle-income countries that it funded. However, the ability of a disease-specific, or vertical, programme to have a spill-over effect and improve health outcomes has been questioned. In this study, we sought to examine associations between being designated as a PEPFAR focus country (and receiving increased PEPFAR funding) and non-HIV-specific health outcomes in the World Health Organization (WHO) Africa Region, the area most affected by the HIV/AIDS epidemic. Methods A retrospective analysis of publicly available health outcomes data published by the World Health Organization was performed for all countries in the WHO Africa Region. Fractional changes in health indicators between 2000 and 2006 were calculated, and PEPFAR focus and non-focus countries were then compared. Results Overall, countries in the WHO Africa Region showed a small worsening in health outcomes status when all indicators were analyzed together and weighted equally. However, more health indicators improved than worsened over this six-year period. A comparison of PEPFAR focus and non-focus countries found no significant difference in the fractional change among 13 of 14 health indicators during the study period. Conclusions This study suggests that vertical programmes, even one that is the scale of PEPFAR, may have little or no impact on health outcomes not explicitly targeted.