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Background: The purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency., Methods: The study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers. Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated., Results: In total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing "resuscitations," the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year. Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year., Conclusions: Residents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.

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.)

Headache is one of the most frequent symptoms prompting an emergency department (ED) visit. For many patients this is an exacerbation of a recurrent or chronic headache pattern. Our objective in this study was to determine if ED patients with recurrent headaches attempt abortive analgesics before seeking ED care. Patients with five or greater similar headache episodes presenting to the ED with the chief complaint of headache were included. There were 150 patients enrolled into the study group. Fourteen percent (95% confidence interval 1-41) of patients did not attempt abortive medication before an ED visit. Males were significantly less likely to utilize pain medication than females before their ED visit (69% vs. 91%; p = 0.003). Of those patients previously seen by a neurologist, 5% did not attempt analgesia before ED arrival, compared to 22% of those who did see a neurologist (p = 0.004). A small, but significant percentage of patients with recurrent headaches do not attempt abortive analgesic therapy before ED encounter. In particular, males and those patients not previously evaluated by a neurologist were significantly less likely to utilize such medications. Further education and selective neurology referral by practitioners may reduce ED utilization in this subset of patients.

Background: Emotional distress and psychiatric syndromes are prevalent in the breast cancer population at large. However, to date there is a paucity of literature specifically concerning presurgical breast cancer patients., Methods: The authors assessed 236 newly diagnosed patients at the time of their presurgical consultation at the Comprehensive Breast Cancer Program of Dartmouth-Hitchcock Medical Center in Lebanon, NH., Results: Of patients in this study, 41% rated their distress in the clinically significant range on the Distress Thermometer (ie, >5, 0-10 scale). Nearly one-half (47%) of patients met established thresholds for positivity on 1 or more screens for distress or psychiatric disorders. Prevalence rates were 11% for major depression (60% of these patients were moderately severe to severely depressed) and were 10% for posttraumatic stress disorder (PTSD). Emotional symptoms markedly interfered with daily function in both groups. Of depressed patients, 56% were already taking a psychotropic medication, yet they still met screening criteria for major depression., Conclusions: Emotional distress and psychiatric syndromes (major depression and PTSD) were prevalent in this population. Markedly impaired function was evident for both depressed and PTSD patients. Future research should refine current screening procedures and develop interventions to better address emotional distress and psychiatric disorders in newly diagnosed breast cancer patients., (Copyright 2006 American Cancer Society.)

Introduction: Hyperbaric oxygen therapy (HBO2) has been utilized for many years for a multitude of disease entities. One commonly encountered side-effect is otic barotrauma., Objective: To determine if patients with specific disease processes are at increased risk of requiring tympanostomy tubes during HBO2., Methods: Data was obtained from Jan. 2000 to Dec. 2004, retrospectively. The requirement for tympanostomy tubes during a course of HBO2 was established., Results: 325 met inclusion criteria. Fifteen percent of patients overall (95% CI= 11-19%) required tympanostomy tubes. Tubes were required in: 5% necrotizing soft tissue infection (p=0.33); 10% failed/threatened graft (p=0.39); 15% problem wounds; 17% chronic refractory osteomyelitis (CRO) (p=0.64); 22% soft tissue radionecrosis (STRN)/osteoradionecrosis (ORN) (p=0.02); 33% of crush injuries (p=0.10). Twenty-nine percent of nasopharyngeal radiation injury patients (p=0.001) and 10% of the non-nasopharyngeal radiation patients (p=0.36) received tympanostomy tubes., Conclusion: A significant increase in tympanostomy tubes were required in nasopharyngeal radiation injury patients.

Introduction: We previously reported that many patients who present to the ED with "migraine" headache do not meet the International Headache Society criteria (IHSC) for the diagnosis of acute migraine. Objective The aim of the study was to compare the frequency for which ED patients with migraine headache meet the Canadian Headache Society criteria (CHSC) vs the IHSC., Methods: This was a prospective, observational study, performed at a community ED. Consecutive patients who presented to study authors with a chief complaint of headache were enrolled. Historical/clinical data were collected on a standardized form. Ninety-five percent confidence intervals (95% CIs) were calculated and Fisher exact test was used as appropriate., Results: One hundred eighty-nine patients were enrolled in this study. Mean age was 38 years. Females comprised 69% of patients. Thirty-seven percent of patients had prior ED visits for headaches. A positive family history of migraines was present in 35% of patients. Diagnostic imaging was previously performed in 44 of the enrollees to evaluate the cause of their headaches. A total of 43 (23%) patients had a prior diagnosis of migraine. Overall CHSC was met in 18% of patients, compared with 15% of patients who met IHSC. Discharge diagnosis of migraine was made in 41% of patients. Of these patients, 33% met CHSC and 28% met IHSC (P=.30). For patients with discharge diagnosis of migraine, 33% of females and 36% of males fit CHSC (P=.53), whereas 26% and 36% met IHSC (P=.34), respectively. For patients with a prior diagnosis of migraine, 32% met CHSC and 26% met IHSC (P=.24). Patients with a prior diagnosis of migraine and/or a discharge diagnosis of migraine met CHSC 31% (95% CI, 22%-40%) of the time vs 25% for the IHSC (95% CI, 16%-34%) (P=.26). Four patients without a discharge and/or previous diagnosis of migraine met CHSC; 3 met IHSC., Conclusions: In our study population, only a minority of patients with headache who have prior diagnosis and/or ED diagnosis of migraine headache met CHSC. The utility of CHSC and/or IHSC to standardize ED patients for headache research may be limited.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a well-recognized clinical sleep disorder that results in chronically fragmented sleep and recurrent hypoxemia. The primary daytime sequelae of the disorder include patient reports of excessive daytime sleepiness, depression, and attention and concentration problems. It has been well established that OSAHS negatively impacts certain aspects of cognitive functioning. The primary goals of this article are to (1) clarify the pattern of cognitive deficits that are specific to OSAHS; (2) identify the specific cognitive domains that improve with treatment; and (3) elucidate the possible mechanisms of cognitive dysfunction in OSAHS. At the conclusion of the paper, we propose a potential neurofunctional theory to account for the etiology of cognitive deficits in OSAHS. Thirty-seven peer-reviewed articles were selected for this review. In general, findings were equivocal for most cognitive domains. Treatment, however, was noted to improve attention/vigilance in most studies and consistently did not improve constructional abilities or psychomotor functioning. The results are discussed in the context of a neurofunctional theory for the effects of OSAHS on the brain.

Adherence to continuous positive airway pressure (CPAP) in patients with sleep apnea hypopnea syndrome (SAHS) is poor. Previous studies have attempted to identify specific barriers to treatment, but none has identified the sole cause for the problem. We outline a behavioral approach to the problem of CPAP adherence that is based on the theories of the transtheoretical model and social cognitive theory. We used these theories to guide the development of an intervention based on the methods of motivational interviewing. We present our motivational enhancement therapy for CPAP (ME-CPAP) here, with some brief pilot data to show its efficacy. Finally, we outline some strengths and weaknesses of taking a behavior change approach to the problem of poor CPAP adherence.

A recent editorial criticized emergency medicine researchers who study the treatment of acute migraine for failing to standardize patients according to definitions provided by the International Headache Society (IHS). In fact, most emergency medicine-based studies of migraine therapies have not used IHS Criteria (IHSC) for patient inclusion and are not uniform in the definition of acute migraine. The purpose of this study was to determine the percentage of patients with complaint of headache who present to the emergency department with a prior diagnosis of migraine and/or emergency department discharge diagnosis of acute migraine that meet IHSC. The study was a prospective observational study performed in a community-based and consisted of consecutive patients with a chief complaint of headache who presented to any 1 of 6 study investigators. Patients recorded historical data on a standard form; Clinical data were recorded by the investigators. Ninety-five percent confidence intervals and the Fisher exact test were calculated as appropriate. One hundred eighty-five patients were enrolled (study group): 70% were women, 43% had prior imaging studies to diagnose the etiology of the headache, and 26% had a diagnostic workup during the current emergency department visit; the probable headache etiology was found in 12 of these cases. Only 3 patients that had an ED workup that fit IHSC. Forty-nine percent of all patients had a prior diagnosis of migraines; 41 of these patients (45%) met IHSC. Forty-two percent of all patients had an emergency discharge diagnosis of acute migraine; of these, 43 (56%) met IHSC. Forty-four out of 96 (46%; 95% confidence interval = 35%-57%) patients with a prior diagnosis of migraine and/or discharge diagnosis of acute migraine met IHSC. Modification of the IHSC, by removing restrictions for headache duration and number of prior episodes, would have markedly increased the percentage of patients with a previous migraine and/or emergency discharge diagnosis of acute migraine that met other qualitative IHSC (94%). Of the patients with prior migraine diagnosis and/or emergency department diagnosis of acute migraine, men and women were equally as likely to meet IHSC (41% v 48%, P = 0.79). Less than half of patients with a prior diagnosis and/or final emergency discharge diagnosis of acute migraine met IHSC. Our findings raise concerns about the external validity of prior emergency department-based research of acute migraine therapy and the utility of the IHSC for future research. Modification of the IHSC for emergency medicine research should be considered., (Copyright 2002, Elsevier Science (USA). All rights reserved.))

Raters called a convenience sample of 30 helplines and claimed to be alcohol, cocaine, heroin, marijuana or tobacco dependent persons seeking treatment. Responses were categorized as helpful, neutral or unhelpful. The median Kappa for agreement between pairs of raters rating a single call was 0.91. Between 36 and 78% of the helplines gave inconsistent responses to two calls giving the same scenario. Across the 346 calls, 43, 40 and 40% of responses to alcohol, cocaine and heroin scenarios were helpful and 28 and 25% of responses to tobacco and marijuana calls were helpful. These preliminary results indicate that much of the time responses to calls to national helplines are not consistent and not helpful.

This study compared two behavioral treatments on their efficacy and acceptability in reducing smoking, using a crossover design with interposed return to baseline, 2 weeks/condition. 20 US cigarette smokers reporting an interest in reducing, but not quitting, their smoking either increased the inter-cigarette interval or selected easy cigarettes to eliminate, with a goal of 50% reduction. Nicotine gum accompanied both treatments. Measurements taken were self-reported cigarettes per day, carbon monoxide, cotinine, and thiocyanate; self-rated acceptability of the treatments; adverse events. Both treatments decreased self-reported cigarettes per day (-45% and -38%) and carbon monoxide (-20% and -19%), but not cotinine or thiocyanate. Increasing the inter-cigarette interval produced slightly more reduction in cigarettes per day than cigarette selection, but no other differences were found. Both treatments were acceptable and safe. Although our sample size was small and the duration of reduction documented short, both treatments appear to be acceptable and efficacious behavioral treatments for reduction.

Dizocilpine (MK-801) administration to an outbred strain of NIH Swiss mice elicits discrete episodes of explosive jumping behavior designated as "popping." This behavior may serve as a useful preclinical paradigm for the screening of potentially novel antipsychotic medications. Both nicotine and mecamylamine, a nicotinic antagonist, dose-dependently blocked dizocilpine-induced popping. The data suggest that nicotine may be of therapeutic benefit in the treatment of schizophrenia and that some of its effects may be mediated by non-nicotinic receptors.

Adaptive changes in the NMDA receptor complex occur in response to exposure to stress. We have previously shown that the ability of MK-801, an uncompetitive NMDA receptor antagonist, to antagonize electrically precipitated tonic hind-limb extension is reduced 24 h after mice are forced to swim for up to 10 min in cold water. The stress-induced reduction of the antiseizure efficacy of MK-801 stimulated the proposal that mice exposed to swim stress may serve as "an intact animal model" of altered or diminished NMDA-mediated neural transmission. In the current investigation, the dose-dependent abilities for the antagonism of electrically precipitated seizures in mice were determined for MK-801, phencyclidine, ketamine, and memantine. Interestingly, a single session of cold water swim stress reduced the antiseizure efficacies of MK-801 and memantine without affecting phencyclidine and ketamine when tested 24 h later. The data do not suggest that stress results in a simple reduction in the number of activated or open channels, but rather alters their size or charge characteristics.

We examined possible genetic contributions to MK-801-elicited "popping" behavior in mice. MK-801-elicited "popping" behavior may represent a preclinical screening paradigm for identifying novel antipsychotic medications. Specifically, we studied the sensitivity of four inbred strains of mice (BALB/c, C57BL/6, AKR, and DBA/2) to MK-801-elicited "popping" behavior and compared their response to the outbred NIH Swiss strain in which the behavior was first characterized. The BALB/c strain was most sensitive to the elicitation of MK-801 induced popping behavior, whereas the other inbred strains were less sensitive than the outbred strain. The identification of strain differences in MK-801-elicited "popping" behavior suggests an important role for genetic factors in the elicitation of MK-801 "popping" behavior in mice.

It has been suggested that frontal lobe pathology is associated with negative symptoms in patients with chronic alcoholism. In his exploratory study, the authors examined 19 chronic alcoholic inpatients on an alcohol treatment unit and found a significant relationship between severity of frontal atrophy (as measured by CT) and negative symptoms (as measured by the Scale for the Assessment of Negative Symptoms).

In the current investigation, the ability of CPP (3-(2-carboxypiperazine-4-yl) propyl-1-phosphate) to elicit mouse popping behavior in a manner similar to that of MK-801 was studied. Unlike MK-801, CPP (3.2-32 mg/kg) did not elicit any popping. The data show that a reduction in NMDA-mediated neural transmission alone is not sufficient to elicit popping behavior in mice. Moreover, pretreatment of mice with CPP attenuated MK-801's ability to elicit popping. These results suggest that popping requires the channel to be in the "active", or open, configuration and that it depends on MK-801's access and binding to its unique site in the hydrophobic channel domain.

The effect of the use of a number of popular solubility treatments was examined on alfaxolone- and diazepam-induced ataxia. The effects of diazepam were not significantly altered by solution in cyclodextrin, Alkamuls EL-620 or a mixture of propylene glycol and ethanol. The effects of alfaxolone were not altered by solution in Alkamuls EL-620, but were significantly lessened by solution in cyclodextrin. In a dose-response experiment, the ED50 of alfaxolone increased from 15.3 mg kg-1 (in Alkamuls EL-620) to 25.6 mg kg-1 (in hydroxypropyl-beta-cyclodextrin). The results suggest that although cyclodextrins are popular and effective solubilizers, their use must be considered carefully in the context of the experiments in which they are to be used.

A case study of the treatment of a 10-month-old baby with necrotic perineal and abdominal wounds.

A medical center is using a monthly videotaped television news program to effectively inform its departments and personnel about one another, to provide them with special recognition, and to help nurture their esprit de corps. For these reasons, staff participation, especially by nonsupervisory personnel, both in producing and in appearing on the program is emphasized.