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D R Nelson

Publications and source records attributed to D R Nelson.

At least 73 records · Page 4Linked to original sources

Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents.

STUDY OBJECTIVES: No large study has addressed whether parents want to be present when invasive procedures are performed on their children in the emergency department. We conducted a survey to address this question. METHODS: The study used a self-administered, written survey consisting of 5 pediatric scenarios with increasing level of procedural invasiveness. Parents in an urban, teaching hospital ED waiting area were asked to participate. RESULTS: Of 407 persons asked to participate, 400 (98%) completed the survey. The number of parents expressing a desire to be present during a procedure performed on their child was 387 (97.5%) for venipuncture of the extremity, 375 (94.0%) for laceration repair, 341 (86.5%) for lumbar puncture, and 317 (80.9%) for endotracheal intubation. For a major resuscitation scenario, 316 (80.7%) wished to be present if their child were conscious during the resuscitation, 277 (71.4%) wanted to be present if their child were unconscious during the resuscitation, whereas 322 (83.4%) indicated a desire to be present if their child were likely to die during the resuscitation. Of the 400, 261 (65.3%) wished to be present for all 5 scenarios. Only 26 (6.5%) wanted the physician to determine parental presence in all 5 scenarios. CONCLUSION: Most parents surveyed would want to be present when invasive procedures are performed on their children. With increasing procedural invasiveness, parental desire to be present decreased. However, most parents would want to be in attendance if their child were likely to die, and nearly all parents want to participate in the decision about their presence.

Adolescent↗

Antibodies to endothelial cells identify myocardial damage and predict development of coronary artery disease in patients with transplanted hearts.

BACKGROUND: Transplant-induced coronary artery disease is a leading cause of graft failure in cardiac allograft recipients after the first year of transplantation, but there presently is no test to identify patients at high risk for developing the disease. Our research is focused on development of a predictive test to identify patients at high risk of developing the disease. METHODS: Sixty-eight cardiac allograft recipients transplanted and followed at Methodist Hospital between 1982 and 1996 were studied. Serial annual angiograms were used to diagnose coronary artery disease, and serial endomyocardial biopsies were used to detect cellular infiltrates and microvascular disease. Biopsy-matched serum samples were used for cardiac troponin-T determinations as measures of myocardial damage, and serum antibodies to endothelial cells were determined by using flow cytometry, enzyme-linked immunosorbent assay and immunoblotting techniques. The endothelial antibody data were evaluated statistically for associations with angiographic changes, biopsy findings and biochemical evidence of myocardial damage. FINDINGS: Antibodies to endothelial cells were identified by all three techniques, and significant associations were found for the amount of antibody identified by Western immunoblotting with histological rejection grades in biopsies, which were confirmed immunocytochemically as macrophages (p<0.01) and T lymphocytes (P = 0.03). These antibodies also associated significantly with vascular antithrombin depletion (p = 0.02), biochemical evidence of myocardial damage (p = 0.005) and subsequent development of coronary artery disease (p = 0.03). INTERPRETATION: The significant association of anti-endothelial antibodies with cellular infiltrates, depletion of vascular antithrombin and myocardial damage suggests a role for antibody in the development of transplant-induced arteriopathy. The significant association of antiendothelial antibodies with the future development of coronary artery disease further suggests that assessment of these antibodies may provide a non-invasive test to predict the development of transplant-induced coronary artery disease.

Adult↗

Relationship of total motile sperm count and percentage motile sperm to successful pregnancy rates following intrauterine insemination.

PURPOSE: This study sought (i) to investigate the relationship between postwash total motile sperm count and postwash percentage motile sperm in predicting successful intrauterine insemination and (ii) to determine the minimal postwash total motile sperm count required to achieve pregnancy with intrauterine insemination. METHODS: Five hundred four women, who underwent 1636 intrauterine insemination cycles with their partner's sperm for infertility treatment from 1993 through 1995, were included in this retrospective study. All patient charts were reviewed for age, infertility etiology, ovarian stimulation regimens, semen characteristics, and treatment outcome. To determine the relationship between total motile sperm count and intrauterine insemination outcome, patients were grouped as (1) less than 0.5 million, (2) 0.5 to 1 million, (3) 1 to 5 million, (4) greater than 5 million, and (5) greater than 20 million. RESULTS: Similar live birth rates (per cycle) were seen among the postwash total motile sperm count groups: group 1, 3.5%; group 2, 2.4%; group 3, 7.0%; group 4, 6.9%; and group 5, 7.0% (P = 0.37). However, regardless of the postwash total motile sperm count, the postwash motility predicted intrauterine insemination success at a cutoff value of 40%. CONCLUSIONS: The percentage of postwash sperm motility, and not the postwash total motile sperm count, can predict successful intrauterine insemination outcome. Such information can be useful in counseling patients regarding their chance of success with intrauterine insemination and in determining when alternate methods of assisted reproduction may be a better approach.

Female↗

The reactive oxygen species-total antioxidant capacity score is a new measure of oxidative stress to predict male infertility.

The imbalance between reactive oxygen species (ROS) production and total antioxidant capacity (TAC) in seminal fluid indicates oxidative stress and is correlated with male infertility. A composite ROS-TAC score may be more strongly correlated with infertility than ROS or TAC alone. We measured ROS, TAC, and ROS-TAC scores in semen from 127 patients and 24 healthy controls. Of the patients, 56 had varicocele, eight had varicocele with prostatitis, 35 had vasectomy reversals, and 28 had idiopathic infertility. ROS levels were higher among infertile men, especially those with varicocele with prostatitis (mean +/- SE, 3.25 +/- 0.89) and vasectomy reversals (2.65 +/- 1.01). All infertile groups had significantly lower ROS-TAC scores than control. ROS-TAC score identified 80% of patients and was significantly better than ROS at identifying varicocele and idiopathic infertility. The 13 patients whose partners later achieved pregnancies had a mean ROS-TAC score of 47.7 +/- 13.2, similar to controls but significantly higher than the 39 patients who remained infertile (35.8 +/- 15.0; P < 0.01). ROS-TAC score is a novel measure of oxidative stress and is superior to ROS or TAC alone in discriminating between fertile and infertile men. Infertile men with male factor or idiopathic diagnoses had significantly lower ROS-TAC scores than controls, and men with male factor diagnoses that eventually were able to initiate a successful pregnancy had significantly higher ROS-TAC scores than those who failed.

Antioxidants↗

Implant support for removable partial overdentures: a case report.

Functional stability and the preservation of remaining alveolar bone are primary, and often elusive, goals when restoring the partially edentulous arch. The incorporation of dental implants for the partial support of removable prostheses offers a practical adjunct in the fulfillment of these objectives. Planning for complex courses of treatment that include dental implants requires close coordination between the surgeon and the restorative dentist. Decisions that deal with type, location, size, number of implant fixtures, and design of the prosthesis are critical. All of these areas must be discussed and established as acceptable to the patient and each clinician before the initiation of treatment. In this report, we present a course of patient treatment in which a removable partial denture is supported by natural remaining teeth in conjunction with osseointegrated implants.

Adult↗

Induction of protease activity in Vibrio anguillarum by gastrointestinal mucus.

The effect of gastrointestinal mucus on protease activity in Vibrio anguillarum was investigated. Protease activity was measured by using an azocasein hydrolysis assay. Cells grown to stationary phase in mucus (200 microg of mucus protein/ml) exhibited ninefold-greater protease activity than cells grown in Luria-Bertani broth plus 2% NaCl (LB20). Protease induction was examined with cells grown in LB20 and resuspended in mucus, LB20, nine-salts solution (NSS [a carbon-, nitrogen-, and phosphorus-free salt solution]), or marine minimal medium (3M) ( approximately 10(9) CFU/ml). Induction of protease activity occurred 60 to 90 min after addition of mucus and was >/=70-fold greater than protease activity measured in cells incubated in either LB20 or 3M. Mucus was fractionated into aqueous and chloroform-methanol-soluble fractions. The aqueous fraction supported growth of V. anguillarum cells, but did not induce protease activity. The chloroform-methanol-soluble fraction did not support growth, nor did it induce protease activity. When the two fractions were mixed, protease activity was induced. The chloroform-methanol-soluble fraction did not induce protease activity in cells growing in LB20. EDTA (50 mM) inhibited the protease induced by mucus. Upon addition of divalent cations, Mg(2+) (100 mM) was more effective than equimolar amounts of either Ca(2+) or Zn(2+) in restoring activity, suggesting that the mucus-inducible protease was a magnesium-dependent metalloprotease. An empA mutant strain of V. anguillarum did not exhibit protease activity after exposure to mucus, but did grow in mucus. Southern analysis and PCR amplification confirmed that V. anguillarum M93 contained empA. These data demonstrate that the empA metalloprotease of V. anguillarum is specifically induced by gastrointestinal mucus.

Animals↗

Future options for the management of hepatitis C.

Current therapy for hepatitis C virus (HCV) infection is believed to be based in part on the ability of interferons to directly inhibit intracellular HCV replication and prevent infection of uninfected hepatocytes, although the exact mechanisms by which this therapy exerts its effect remain unknown. There are several potential avenues open to development of new antiviral treatment strategies for HCV infection. These include extracellular neutralization of virus to prevent new infection, inhibition of viral entry and uncoating, impairment of intracellular replication by either inhibition of host or viral enzymes or by destruction of the viral genome, enhancement of the host immune response to HCV, or control of the hepatic inflammation that results in progressive liver injury. Although the potential of these therapeutic approaches have been demonstrated in vitro or have been used for the treatment of other infections, their use in man, and so their future and potential efficacy, require further investigation.

Adjuvants, Immunologic↗

Fertility outcome after repeat vasoepididymostomy.

PURPOSE: Historically, epididymal obstruction has been treated with surgical reconstruction. We determine whether it is worthwhile for patients to undergo repeat surgical reconstruction after failed vasoepididymostomy or whether they should be advised only to undergo sperm acquisition for assisted reproductive technique. MATERIALS AND METHODS: A total of 18 patients underwent repeat vasoepididymostomy performed by a single urologist (A. J. T.). Cases were divided based on the etiology of obstruction into groups 1--prior vasectomy (4), 2--congenital (7) and 3--inflammatory (7). Data were available regarding time of obstruction between initial and repeat vasoepididymostomy, quality of epididymal fluid, levels of anastomoses, semen analyses at least 12 months after surgery for all 18 men and pregnancy rates based on more than 18 months of followup in 12. RESULTS: Mean patient age at repeat vasoepididymostomy was 40.6 years (50.5, 36 and 39.4 years for groups 1, 2 and 3, respectively). Mean interval between vasectomy and initial vasoepididymostomy was 12.3 years (range 10 to 18). Mean interval between initial and repeat vasoepididymostomy was 19 months (range 12 to 41). Of the patients 10 underwent unilateral and 8 bilateral anastomoses, for a total of 26 repeat anastomoses. Overall patency rate was 66.7% (12 of 18) with sperm in the ejaculate in 75, 85 and 43% of patients in groups 1, 2 and 3, respectively. The patency rates according to the levels of the anastomosis were 66.7, 62.5 and 100% in the caput, corpus and cauda, respectively. Natural conception occurred in 3 of 12 couples (25%, 2 caput and 1 caudal anastomosis) during a mean followup of 23 months (range 13 to 34). All 3 cases had congenital obstruction. Pregnancy was achieved in 2 group 1 cases with cryopreserved sperm extracted at repeat vasoepididymostomy, and in 1 case each in groups 1 and 2 with microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection. CONCLUSIONS: After repeat vasoepididymostomy two-thirds of men have sperm in the semen. Natural conception occurred in 25% of patients (3 of 12) followed for more than 18 months. Inability to establish pregnancy in the remaining 7 of 9 patients with sperm in the semen with a followup longer than 18 months may be due to epididymal dysfunction or partial obstruction and subsequent poor sperm quality. Aspiration of motile sperm and cryopreservation were possible in 11 of 18 cases at repeat vasoepididymostomy and should be recommended in case azoospermia remains or occurs after surgery. It appears worthwhile to offer patients repeat vasoepididymostomy after a failed initial procedure.

Adult↗

Serum cardiac troponin-T concentrations predict development of coronary artery disease in heart transplant patients.

BACKGROUND: Development of coronary artery disease in cardiac allograft recipients is the major cause of graft failure after the first year of transplantation. Unfortunately, there is no noninvasive method of identifying patients at greatest risk of developing this disease. We have asked whether serum concentrations of cardiac troponin-T predict development of coronary artery disease. METHODS: Annual coronary angiograms, serial endomyocardial biopsies, and serum cardiac troponin-T concentrations were obtained from 68 cardiac transplant patients who were followed for 68.8+/-11.9 months after surgery. Troponin-T concentrations were measured by using an enzyme-linked immunosorbent assay, and biopsies were assessed histologically for rejection grades and immunohistochemically for cellular infiltrates, arteriolar endothelial activation, fibrin deposits, and vascular fibrinolytic and anticoagulant components. RESULTS: Troponin-T values did not associate with demographic, clinical, or laboratory findings, but they significantly associated with arteriolar endothelial activation (P<0.001), fibrin deposition (P<0.001), depletion of vascular fibrinolytic (P=0.007) and anticoagulant components (P=0.02), and infiltration of macrophages (P <0.001) but not T lymphocytes (P=0.36). Troponin-T concentrations also significantly associated with future development of coronary artery disease (P<0.001). Patients with persistent troponin-T values of 0.10 ng/ml or greater were found to develop the disease within 8.7+/-2.1 months, whereas patients who had initial troponin-T values of 0.10 ng/ml or greater and subsequently fell and remained below 0.10 ng/ml did not develop coronary artery disease in 40 months. CONCLUSIONS: Troponin-T concentrations significantly associated with macrophage infiltrates, microvascular fibrin deposits, arteriolar endothelial activation, depletion of vascular fibrinolytic and anticoagulant components, and the future development of coronary artery disease. The troponin-T assay is an outpatient procedure performed on small amounts of blood at little cost, risk, or inconvenience, and it appears to be the first biochemical predictor of transplant-induced coronary artery disease.

Adult↗

Factors that affect social cue recognition in schizophrenia.

Earlier research (Corrigan and Green, Am. J. Psychiatry, 150 (1993) 589-594) showed fairly symptomatic persons with schizophrenia give more false-positive responses when answering questions about abstract cues in a social situation (i.e. affect, rules, and goals inferred about an interpersonal situation) than concrete cues (i.e. actions and dialogue observed in a situation). It is unclear, however, whether differential cue recognition is due to schizophrenia per se, or some aspect of the illness commensurate with significant symptoms and in-patient care. Moreover, the abstract and concrete dimension in the earlier study had not been independently validated. In this study, the 288 items of the Social Cue Recognition Test (SCRT) were divided into three sets based on abstraction ratings provided by 38 college students. The SCRT was then completed by 48 participants with DSM-III-R diagnoses of schizophrenia or schizoaffective disorder. Participants with schizophrenia were divided into low and high symptom groups using scores from the Brief Psychiatric Rating Scale. Results showed both low symptom and high symptom groups exhibited a differential deficit in cue recognition. False positives were greater for items rated as more abstract. Implications for understanding the social cognitive deficits of persons with schizophrenia are discussed.

Adult↗

Highly conserved charge-pair networks in the mitochondrial carrier family.

Selection for regain-of-function mutations in the yeast ADP/ATP carrier AAC2 has revealed an unexpected series of charge-pairs. Four of the six amino acids involved are found in the mitochondrial energy transfer motifs used to define this family of proteins. As such, the results found with the ADP/ATP carrier may apply to the family as a whole. Mitochondrial carriers are built from three homologous domains, each with the conserved motif PX(D,E)XX(K,R). Neutralization of the conserved positive charges at K48, R152 or R252 in these motifs results in respiration defective yeast. Neutralization of the negative charges at D149 and D249 also make respiration defective yeast, though E45G or E45Q mutants are able to grow on glycerol. Regain of function occurs when a complementary charge is lost from another site in the molecule. This phenomenon has been observed independently eight times and thus is strong evidence for charge-pairs existing between the affected residues. Five different charge-pairs have been detected in the yeast AAC2 by this method and three more can be predicted based on homology between the domains. The highly conserved charge-pairs occurring within or between the three mitochondrial energy transfer signatures seem to be a critical feature of mitochondrial carrier structure, independent of the substrates transported. Conformational switching between alternative charge-pairs may constitute part of the basis for transport.

Amino Acid Sequence↗

Intrahepatic hepatitis C virus-specific cytotoxic T lymphocyte activity and response to interferon alfa therapy in chronic hepatitis C.

Hepatitis C virus (HCV)-specific cytotoxic T lymphocytes (CTL) have been shown to play a role in host defense and pathogenesis of chronic HCV infection. Our aim was to test the hypothesis that intrahepatic HCV-specific CTL activity may impact subsequent response to interferon alfa (IFN-alpha) therapy. Of the 37 patients that we have prospectively evaluated for HCV-specific CTL activity in liver, 21 received IFN therapy, and 19 completed a 6-month course and attended 6 to 18 months of follow-up. Intrahepatic CD8+ cells were isolated from liver biopsy tissue and tested against target cells expressing HCV antigens to determine intrahepatic CTL activity. The relationship between treatment response and HCV-specific CTL activity and other factors known to associate with response (genotype, viremia, histology) was analyzed. HCV-specific CTL activity was detected in 9 of 21 patients (and 9 of 19 who completed therapy). After 6 months of IFN therapy, 8 of 19 (42%) patients had normal serum alanine transaminase (ALT) (complete responders). After 18 months of follow-up, only 3 patients (16%) had a sustained biochemical response. Of the 9 patients with detectable HCV-specific CTL activity in their liver before treatment, 7 (78%) developed a complete response. In contrast, only 1 of the 10 patients with no detectable HCV-specific CTL activity developed a complete response to IFN (P < .01). In 6 of 8 patients with a complete response, including the 3 sustained responders, the CTL response appeared to be directed predominately to the HCV core region. These data suggest that the host immune response, particularly that mediated by CD8+ CTL, may be important in determining the outcome of IFN therapy for chronic HCV infection. Further understanding of the mechanism of action of IFN should impact the design of better therapeutic strategies against chronic HCV infection.

Adult↗

Myocardial fibrin deposits in the first month after transplantation predict subsequent coronary artery disease and graft failure in cardiac allograft recipients.

PURPOSE: To determine whether fibrin deposition during the first month following cardiac transplantation predicts development of coronary artery disease and graft failure in cardiac allograft recipients. PATIENTS AND METHODS: We prospectively studied 121 consecutive adult patients who received cardiac transplants between 1988 and 1995. Serial endomyocardial biopsies obtained during the first month posttransplant (2.3 + 0.6 biopsies/patient) were studied immunohistochemically for fibrin deposits. Patients were followed up with annual angiograms (3.2 + 1.7/patient) evaluated with side-by-side comparisons for the presence and progression of coronary artery disease. RESULTS: All pretransplant biopsies were fibrin-negative; 60 allografts (50%) remained without fibrin, and 61 (50%) contained fibrin during the first posttransplant month. Of allografts with fibrin, 72% developed coronary artery disease, while 27% of allografts without fibrin developed the disease (P <0.001). Coronary artery disease was progressive in 61% of allografts with fibrin, and in 25% of allografts without fibrin (P <0.001). Graft failure was more frequent and time-to-graft-failure occurred earlier in patients whose allografts had fibrin during the first month after transplantation (P <0.001). CONCLUSIONS: Fibrin in biopsies during the first month after transplantation identifies patients at high risk for developing coronary artery disease or graft failure, thereby allowing the opportunity to initiate preventive procedures.

Adult↗

Treatment of erectile dysfunction after radical prostatectomy with sildenafil citrate (Viagra).

OBJECTIVES: To determine whether the response to the new oral medication, sildenafil citrate (Viagra), was influenced by the presence or absence of the neurovascular bundles, as recent reports on its success did not specify the efficacy of the drug in patients with erectile dysfunction after radical prostatectomy. METHODS: Baseline and follow-up data from 28 healthy patients presenting with erectile dysfunction after radical prostatectomy were obtained. Patients receiving any neoadjuvant/adjuvant hormones or adjuvant radiation therapy were excluded. Patients reported what their erectile status was before surgery, before sildenafil therapy, and after using a minimum of four doses of sildenafil. Both the patients and their spouses were interviewed using the Cleveland Clinic post-prostatectomy questionnaire, which includes questions about response to therapy, duration of intercourse, spousal satisfaction, side effects, and related topics. The patients were compared on the basis of the type of surgical procedure they had undergone-nerve sparing or non-nerve sparing. A positive response to sildenafil was defined as erection sufficient for vaginal penetration. RESULTS: Of the 15 patients who had bilateral nerve-sparing procedures, 12 (80%) had a positive response to sildenafil, with a mean duration of 6.92 minutes of vaginal intercourse. These 12 patients also reported a spousal satisfaction rate of 80%. All 12 of the responders had a positive response within the first three doses, and 10 of the 12 responded with the first or second dose. None of the 3 patients who had undergone a unilateral nerve-sparing procedure responded, nor did any of the 10 patients who had undergone a non-nerve-sparing procedure. The two most common side effects of the drug were transient headaches (39%) and abnormal color vision (11%). No patients discontinued the medication because of side effects. CONCLUSIONS: Successful treatment of erectile dysfunction in a patient after prostatectomy with sildenafil citrate may depend on the presence of bilateral neurovascular bundles. No patient who had undergone a non-nerve-sparing procedure responded. Whether patients who undergo unilateral nerve-sparing procedures will respond to sildenafil is still unclear because of the small number of patients in our study. These findings should encourage urologists to continue to perform and perfect the nerve-sparing approach. The ability to restore potency with an oral medication after radical prostatectomy will impact our discussion with the patient on the surgical morbidity of radical prostatectomy.

Enzyme Inhibitors↗

Prehospital oral endotracheal intubation by rural basic emergency medical technicians.

STUDY OBJECTIVE: To determine whether basic emergency medical technicians (EMT-B) can perform prehospital oral endotracheal intubation with success rates comparable to those of paramedics. METHODS: This was a nonrandomized, controlled trial using historical controls. Seven basic life support emergency medical services systems in six counties and their corresponding emergency departments in rural Indiana participated. Eighty-seven full-time EMTs with no prior or concurrent paramedic training volunteered for intubation training. Apneic prehospital patients aged 16 years or older without an active gag reflex or massive facial trauma were eligible for intubation and study enrollment. The EMTs completed a 9-hour didactic and airway manikin training course in direct laryngoscopic endotracheal intubation. The course was adapted from the national paramedic curriculum. RESULTS: Thirty-four (39%) of the EMT-Bs attempted to intubate 57 eligible patients. In 49.1% of these patients, successful endotracheal tube placement was confirmed by the receiving physician (95% confidence interval, 36.4% to 61.9%); in contrast, the prehospital intubation success rates from three previous studies of manikin-trained paramedics ranged from 76.9% to 90.6% (P < .001). Complications included five (9%) inadvertent extubations, two endotracheal tube cuff ruptures, two prolonged intubation attempts, and one mainstem bronchus intubation. There were no unrecognized esophageal intubations. Two of the seven EMS agencies did not report any intubation data. CONCLUSION: Rural EMTs with didactic and airway manikin training failed to achieve prehospital intubation success rates comparable to those of paramedic controls. Possible explanations include training deficiencies, poor skill transference from manikin to human intubation, infrequent intubation experiences, and inconsistent supervision.

Aged↗

How do physicians and nurses spend their time in the emergency department?

STUDY OBJECTIVES: To determine how emergency physicians and nurses spend their time on emergency department activities. METHODS: An observational time-and-motion study was performed at a 36-bed ED with annual census of 84,000 in a central city teaching hospital sponsoring an emergency medicine residency program. Participants were emergency medicine faculty physicians, second- and third-year emergency medicine resident physicians, and emergency nurses. A single investigator followed individual health care providers for 180-minute periods and recorded time spent on various activities, type and number of activities, and distance walked. Activities were categorized as direct patient care (eg. history and physical examination), indirect patient care (eg. charting), or non-patient care (eg. break time). RESULTS: On average, subjects spent 32% of their time on direct patient care, 47% on indirect patient care, and 21% on non-patient care Faculty physicians, residents, and emergency nurses differed in the time spent on these three categories of activities. Although the overall time spent on direct patient care activities was not significantly different, emergency nurses spent more of their time (2.2%) providing comfort measures (a subcategory of direct patient care) than did faculty physicians (.05%) or resident physicians (.03%). Emergency nurses spent 38.9% of their time performing indirect care, whereas faculty physicians spent 51.3% and resident physicians 53.7%. Resident physicians spent more time charting than did faculty physicians or emergency nurses (21.4%, 11.9%, and 6.9%, respectively). Emergency nurses spent more time on personal activities than did physicians, and faculty physicians walked less than either emergency nurses or resident physicians. CONCLUSION: Emergency physicians and nurses spent almost half of their time on indirect patient care. Physicians spent significantly more time on indirect patient care activities and significantly less time on personal activities than did nurses.

Adult↗

Fractures and other injuries from falls after an ice storm.

This is a retrospective review of all patients seen at an urban emergency department for 9 days after an ice storm because of a fall on ice. Date of presentation, age, sex, and anatomic location and type of injury were tabulated. Risk factors for fractures were identified. A total of 327 injuries were identified in 259 patients. Back injury was most common (19.3%). Ninety-one patients sustained 93 fractures. Ankle fractures were most common (24.7%), followed by fractures of wrist (19.4%) and hip (14.0%). Ankle fractures were more common than other studies of falls after a snow storm. Fracture was significantly related to age (P = .0001). There was a trend for women to sustain fractures (P = .07). Unlike other mass casualty events, fractures and injuries peaked on the 5th and 6th day after the storm, allowing adequate time for mobilizing resources to care for the injured.

Accidental Falls↗

Metazoan cytochrome P450 evolution.

There are 37 cytochrome P450 families currently identified in animals. The concept of higher order groupings of P450 families called P450 CLANS is introduced. The mammalian CYP3 and CYP5 families belong to the same clan as insect CYP6 and CYP9. All mitochondrial P450s seem to belong to the same clan. Lack of mitochondrial P450s in C. elegans suggests that mitochondrial P450s probably arose from the mistargeting of a microsomal P450 after the coelomates diverged from acoelomates and pseudocoelomates. Different taxonomic groups appear to have recruited different ancestral P450s for expansion as they evolved, since each major taxon seems to have one large cluster of P450s. In insects, this cluster derives from the ancestor to the CYP4 family. Vertebrates and C. elegans may have used the same ancestor independently to generate the CYP1, 2, 17, and 21 families in vertebrates and a large distinctive clan with 45 genes in C. elegans.

Animals↗