IV amantadine improves chorea in Huntington's disease: an acute randomized, controlled study.
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Adult↗
Biomedical subjects
D Sklar
Publications and source records attributed to D Sklar.
Prevalence of insomnia symptoms in patients with sleep-disordered breathing.
OBJECTIVE: To assess the prevalence of insomnia symptoms in patients with objectively diagnosed sleep-disordered breathing (SDB). DESIGN: Retrospective medical chart review of a representative sample of patients with SDB. SETTING: University sleep-disorders clinic and laboratory. PATIENTS: Two hundred thirty-one patients with SDB were selected from a pool of approximately 2,000 patients with sleep disorders. MEASUREMENTS: Data were extracted from intake questionnaires and polysomnographic studies. RESULTS: Of 231 patients with SDB diagnoses, 115 patients reported no insomnia complaints (SDB-only patients) and 116 patients reported clinically meaningful insomnia complaints (SDB-plus patients). Compared to SDB-only patients, SDB-plus patients reported significantly worse mean sleep characteristics consistent with insomnia, including sleep latency (17 min vs 65 min), total sleep time (7.2 h vs 5.6 h), and sleep efficiency (92% vs 75%). SDB-plus patients experienced significantly more psychiatric disorders, cognitive-emotional symptoms, and physical and mental symptoms that disrupted or prevented sleep. SDB-plus patients also reported greater use of sedative and psychotropic medications and had significantly more primary complaints of insomnia, restless legs or leg jerks, and poor sleep quality despite having relatively similar referral rates for sleep apnea or complaints of loud snoring. CONCLUSIONS: Problematic insomnia symptoms were reported by 50% of a representative sample of patients with objectively diagnosed SDB. Research is needed to determine the degree to which insomnia and related symptoms and behaviors interfere with SDB treatment.
Adult↗
Cross-tool communication: from protocol authoring to eligibility determination.
To be effective, informatics tools for clinical trial protocols must inter-operate and share knowledge. We demonstrate a simple XML-based communication of eligibility criteria information between two independently-developed informatics tools. Using a shared DTD model of criteria, an authoring tool (developed within the Protégé environment) can send a list of eligibility criteria to a commercial system for automatic eligibility determination (the "iKnowChart" system by iKnowMed). The criteria model, developed as a Protégé ontology, includes both the terminology and the logic needed to compute eligibility for a given patient. As a demonstration of cross-tool communication, we have encoded criteria from an active clinical trial protocol (E1199), and shown how use of the authoring tool can effectively update the eligibility knowledge and the behavior of the commercial iKnowChart system. As part of the cross-tool knowledge sharing, we use Common Data Elements, an oncology terminology developed by the National Cancer Institute.
Clinical Protocols↗
Hospital factors associated with emergency center patients leaving without being seen.
We developed a statistical model that would identify and quantify the relative contributions of different factors hypothesized to impact the frequency of emergency center (EC) patients who leave without being seen (LWBS). We performed an analysis of the daily counts of patients that registered in our EC during a 21-month period who then LWBS. Candidate predictor variables included the number of patients seen, and the number admitted to the hospital, for each area of our EC, as well as the hours of faculty double coverage, and the day of the week. Univariate analyses were performed using standard methods. Multivariate analysis was performed using the general linear model. A backward selection procedure was used to eliminate statistically insignificant variables until all remaining independent variables had P-values < or = .05. External validation and analysis of the stability of the estimated regression coefficients of the model were evaluated using bootstrap methods. Two-tailed tests and a type I error of 0.05 were used. During the period studied, 133,666 patients were registered in the EC and 9,894 (7.4%) left. Multivariate analysis identified six variables that were significantly associated with LWBS. The fitted model containing all six variables explained 52.8% of the variability observed in LWBS frequency. The most powerful predictor of LWBS was total number of patients cared for in the main ED. This accounted for 46.4% of the observed variation in LWBS. The total number of trauma and resuscitation patients, and the total number of observation unit admissions to the hospital were also associated with increased LWBS. More pediatric cases seen in the main ED, weekends, and additional faculty coverage were associated with fewer patients leaving. Efforts to decrease the LWBS rate will be most successful if they address the issue of main ED volume.
Adolescent↗
Repeat ambulance use by pediatric patients.
OBJECTIVE: To compare pediatric patients transported by ambulance on more than one occasion (repeat) with those transported only once. METHODS: The authors analyzed pediatric (patient < 21 years old) transports for 1992-1995 by the ambulance service that provides 99% of transports for a non-innercity metropolitan area. Repeat transports were compared with single transports with regard to patient age, gender, chief complaint, and payment source. RESULTS: There were 17,448 transports involving 15,168 patients. Nearly half (49.0%) of the repeat transports involved patients in the oldest age category, 17 to 20.9 years, contrasted with 38.0% of single transports (p < 0.00001). Females comprised 51.4% of the repeat transports and 48.5% of the single transports (p = 0.0008). Traumatic complaints accounted for one-third (33.0%) of the repeat transports and half (51.1%) of the single transports (p < 0.0001). Chief complaints of the patients with repeat transports were more likely to be seizure, assault, abdominal pain, and respiratory problems, and less likely to be falls and motor vehicle-related complaints, than chief complaints of the patients with single transports (p < 0.0001). More than one-third (39.0%) of the repeat transports were funded by Medicaid, in contrast with 19.8% of the single transports (p < 0.0001). CONCLUSIONS: Compared with single transports, repeat transports were more likely to involve patients more than 16 years of age, female, and with a chief complaint of seizure, assault, abdominal pain, or respiratory distress, and more likely to be funded by public insurance (Medicaid). Repeat pediatric transports warrant further investigation. This information may be useful in designing interventions targeted at reducing emergencies and hence ambulance use.
Adolescent↗
Health indicators and intimate partner violence among women who are members of a managed care organization.
BACKGROUND: There have been no population-based studies estimating the prevalence of intimate partner violence (IPV) in an insured population. There is also little information on how well routinely collected health status information predicts IPV risk. Many women now obtain health care from providers who are members of a managed care organization (MCO). To justify efforts to routinely screen for IPV, it is essential to know the prevalence of IPV in this growing population and to identify correlates of IPV among female MCO members. METHODS: A telephone survey with questions on health status, behavioral risk factors, preventive services use, and the Conflict Tactics Scale was completed by 2,415 female members of a New Mexico MCO. RESULTS: Overall, 13.5% of respondents reported experiencing major verbal aggression and 6.7% reported experiencing physical aggression. Younger age, degree of sadness, and inability to handle stress, and a perception of a poorer general health status were significantly associated with major verbal aggression. Race/ethnicity, degree of sadness, and average number of drinks consumed at one sitting were significantly associated with physical aggression. CONCLUSIONS: There is a low but important annual prevalence of IPV among female members of a MCO that occurs across all variables studied. This information is needed to develop appropriate screening protocols and interventions in this population.
Adult↗
The effect of physician gender on women's perceived pain and embarrassment during pelvic examination.
In this article we try to determine if the examiner's gender affects women's perceived pain and embarrassment during emergency department pelvic examination, using a prospective comparative study in a university teaching hospital. Test subjects were taken from a convenience sample of female emergency department (ED) patients undergoing pelvic examination as part of their evaluation. 100 mm visual analog scales were used to gauge each subject's perceived pain and embarrassment. Subject age and complaint, and the examiner's gender and level of training were collected. Two-tailed Mann-Whitney or Kruskal-Wallis tests were used to test for significant differences among group median pain and embarrassment scores. One hundred and sixty-seven subjects completed the study (median age = 25 y, interquartile range 20-33 y). Seventy-seven subjects had abdominal or pelvic pain, 49 complained of vaginal bleeding, and the rest had dysuria, pregnancy, genital lesions, or other conditions. Ninety-four examiners were female and 73 were male. The mean pain scores were similar for female (33.6 mm) and male (38.8 mm) examiners. The medians were 19.5 mm and 41.0 mm respectively (difference, 21.5 mm; 95% Cl, -3.5 to 34 mm; P = 0.385). The mean embarrassment score was lower for female (19.6 mm) than for male (37.4 mm) examiners. The medians were 5.0 mm and 28.0 mm respectively (difference, 23 mm; 95% Cl, 11.5 to 40 mm; P = 0.00012). The level of examiner training did not appear to affect either score (P > 0.6). Emergency department patients perceive pelvic examination by a male examiner as more embarrassing but not more painful than examination by a woman.
Adolescent↗
Guns, alcohol, and intimate partner violence: the epidemiology of female suicide in New Mexico.
Suicide is among the leading causes of death in the United States, and in women the second leading cause of injury death overall. Previous studies have suggested links between intimate partner violence and suicide in women. We examined female suicide deaths to identify and describe associated risk factors. We reviewed all reports from the New Mexico Office of the Medical Investigator for female suicide deaths occurring in New Mexico from 1990 to 1994. Information abstracted included demographics, mechanism of death, presence of alcohol/drugs, clinical depression, intimate partner violence, health problems, and other variables. Annual rates were calculated based on the 1990 census. The New Mexico female suicide death rate was 8.2/100,000 persons per year (n = 313), nearly twice the U.S. rate of 4.5/100,000. Non-Hispanic whites were overrepresented compared to Hispanics and American Indians. Decedents ranged in age from 14 to 93 years (median = 43 years). Firearms accounted for 45.7% of the suicide deaths, followed by ingested poisons (29.1%), hanging (10.5%), other (7.7%), and inhaled poisons (7.0%). Intimate partner violence was documented in 5.1% of female suicide deaths; in an additional 22.1% of cases, a male intimate partner fought with or separated from the decedent immediately preceding the suicide. Nearly two-thirds (65.5%) of the decedents had alcohol or drugs present in their blood at autopsy. Among decedents who had alcohol present (34.5%), blood alcohol levels were far higher among American Indians compared to Hispanics and non-Hispanic Whites (p = .01). Interpersonal conflict was documented in over 25% of cases, indicating that studies of the mortality of intimate partner violence should include victims of both suicide and homicide deaths to fully characterize the mortality patterns of intimate partner violence.
Adolescent↗
Academic emergency medicine's future. The SAEM Task Force on Emergency Medicine's Future. Society for Academic Emergency Medicine.
Emergency medicine (EM) will change over the next 20 years more than any other specialty. Its proximity to and interrelationships with the community, nearly all other clinicians (physicians and nonphysicians), and scientific/technologic developments guarantee this. While emergency physicians (EPs) will continue to treat both emergent and nonemergent patients, over the next decades our interventions, methods, and place in the medical care system will probably become unrecognizable from the EM we now practice and deliver. This paper, developed by the Society for Academic Emergency Medicine (SAEM) Task Force on Academic Emergency Medicine's Future, was designed to promote discussions about and actions to optimize our specialty's future. After briefly discussing the importance of futures planning, it suggests "best-case," "worst-case," and most probable future courses for academic EM over the next decades. The authors predict that EPs will practice a much more technologic and accurate form of medicine, with diagnostic, patient, reference, and consultant information rapidly available to them. They will be at the center of an extensive consultation network stemming from major medical centers and the purveyors of a sophisticated home health system, very similar to or even more advanced than what is now delivered on hospital wards. The key to planning for our specialty is for EM organizations, academic centers, and individuals to act now to optimize our possible future.
Academic Medical Centers↗
Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness.
Three chronic conditions were examined--acute alcohol intoxication, seizure disorder, and respiratory illness--to quantify the extent of repetitive emergency medical services (EMS) use in a defined population. Urban EMS system ambulance data from 1992 to 1994 were analyzed for the three designated conditions with respect to transports by condition and individual patient. Analysis by chi2 was used for comparing proportions. Analysis of variance after square root transformation was used to evaluate differences among means. The total number of transports analyzed was 15,541: 7,488 for acute alcohol intoxication, 4,670 for respiratory illness, and 3,383 for seizure disorder. These transports involved 8,692 patients who were transported at least once for one of the three designated conditions. The mean number of transports for alcohol was 1.96 (95% confidence intervals [CI]: 1.92, 2.01), seizure 1.32 (95% CI: 1.27, 1.36), and respiratory 1.18 (95% CI: 1.15, 1.21). Of 369 patients transported five or more times during the study period, 260 (70.5%) were for alcohol, 56 (15.2%) for seizure, and 53 (14.4%) for respiratory complaints. This group comprised only 4.3% of patients, but 28.4% of all transports. Acute alcohol intoxication resulted in more repetitive ambulance transports than either seizure disorder or respiratory illness. A small number of patients were responsible for a large number of transports. Focused intervention for patients with high ambulance transport deserves further study.
Adult↗
Program for reducing pedestrian-motor vehicle crashes.
Injury prevention has been identified as a component of emergency medicine. However, involvement of emergency physicians in injury prevention has been hindered by clinical responsibilities, lack of financial support, and limited expertise in skills necessary for effective injury prevention programs. This article describes the development and content of a statewide pedestrian safety plan prepared by the Department of Emergency Medicine at the University of New Mexico. The plan included a written document, community input through focus groups, and a public information campaign. The written document included a synthesis of published literature, state-specific data, information on community interventions, and recommendations for state agencies and other groups interested in reducing pedestrian injuries. This project can be modeled at other academic EDs with an interest in injury prevention and pedestrian safety.
Accidents, Traffic↗
Relationships between ambulance transports for alcohol intoxication and assault.
OBJECTIVE: To evaluate the association between ambulance transports for assault and those for alcohol intoxication. METHODS: A retrospective analysis of emergency medical services (EMS) calls was performed. The authors used logistic regression models to compare patients transported for alcohol intoxication with a control group of patients transported for respiratory distress (asthma or shortness of breath) with respect to whether they had been transported on a separate occasion for a chief complaint of assault. RESULTS: Patients transported for alcohol intoxication had 9 times the risk of transport for assault as compared with the control group (OR = 9.3; 95% CI = 6.4, 13.6). The odds of transport for assault among the alcohol patients increased 17.1% with each alcohol transport (OR = 1.17; 95% CI = 1.14, 1.20) but decreased for the control group (OR = 0.34; 95% CI = 0.26, 0.44). Repeat transports for assault were more common among the alcohol patients than among the control group (OR = 3.3; 95% CI = 1.1, 11.3). The mean number of assault transports was higher among the alcohol patients than among the patients never transported for alcohol intoxication (p < 0.0001). CONCLUSIONS: Patients transported on multiple occasions for acute alcohol intoxication are at relatively high risk for assault. This risk group should be targeted for focused assault prevention interventions that include components designed to reduce incidents of repeat alcohol intoxication.
Adult↗
Emergency medicine and injury control research: past, present, and future.
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Emergency Medicine↗
Guns and knives in New Mexico: patterns of penetrating trauma, 1978-1993.
OBJECTIVE: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data. METHODS: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978-1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults. RESULTS: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased. CONCLUSIONS: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.
Adolescent↗
Increasing emergency physician recognition of domestic violence.
STUDY OBJECTIVE: To determine whether recognition of domestic violence in the emergency department is affected by restructuring of the ED chart to include a specific question about domestic violence, to evaluate whether training concerning domestic violence further increases its recognition, and to develop a profile of women who present to the ED as a result of domestic violence. METHODS: We collected prospective data on all females aged 15 to 70 years who presented to an urban Level I trauma center during a 3-month period. Two keywords were used to define domestic violence: (1) mechanism (eg, kicked, hit, pushed) and (2) perpetrator (eg, current/former boyfriend, spouse). We used the first month to define the baseline number of domestic violence cases. We modified charts in the second and third months (intervention months) to include, "Is the patient a victim of domestic violence?" In addition, the third month included a 1-hour educational lecture on the identification of domestic violence in the ED. RESULTS: We identified 123 cases of domestic violence from a survey population of 4,073: 25 (2.0%) in the baseline month, 49 (3.4%) in the chart-modification month, and 49 (3.6%) in the education month. The proportion of cases identified during the intervention months was 1.8 times higher than during the control month (relative risk [RR], 1.78; 95% confidence interval [CI], 1.15 to 2.75), but did not differ between each other (RR, 1.06; 95% CI, .72 to 1.57). Women identified as domestic violence cases ranged in age from 15 to 61 years (median, 28.5 years). Most of the identified domestic violence patients presented with a triage classification of assault (54.5%), trauma (8.1%), or abdominal complaints (7.3%). Triage complaint differed for domestic violence and non-domestic violence cases (chi 2 = 830; P < .0001). Nearly one third of domestic violence patients (31.7%) presented between 11 PM and 6:59 AM, compared with 19.0% of non-domestic violence patients (chi 2 = 12.4; P = .005). CONCLUSION: Modification of the chart significantly increased the recognition rate of domestic violence. An education intervention did not significantly improve this rate. The profile of a woman presenting to the ED differs from those of other women with respect to chief complaint and time of presentation.
Adolescent↗
Safe at home? Domestic violence and other homicides among women in New Mexico.
STUDY OBJECTIVE: To define the contribution of domestic violence (DV) to homicides in women in New Mexico and to examine differences in ethnicity, mechanism, previous documented injuries, incidence of sexual assault, and use of alcohol or illicit drugs between DV- and non-DV-related homicides. METHODS: We carried out a retrospective analysis of reports of the state office of the medical investigator (OMI) reports from all female homicides from 1990 to 1993 in New Mexico. A homicide was defined as being related to DV if the perpetrator was a current or former male intimate partner. The chi-squared and Mann-Whitney tests were used to analyze data. RESULTS: The OMI investigated 134 homicides in women for an overall fatality rate of 4.3 per 100,000. A male intimate partner was the perpetrator in 62 cases (46%). The rate of DV homicide among American Indians (4.9 per 100,000) was significantly higher than that among Hispanics (1.7) and non-Hispanic whites (1.8)(RR=2.8; 95% confidence interval (CI), 1.5 to 5.1). Firearms were almost two times as likely to be used in DV homicides as in non-DV homicides (RR=1.8; 95% CI, 1.2 to 2.6). Evidence of old injuries was found more often in DV homicide cases (35.5%) than in non-DV cases (83%) (RR=4.3; 95% CI, 1.8 to 9.8). The presence of alcohol or other drugs was higher among non-DV homicide victims (69%) than DV homicide victims (54.3%) (P=.03). CONCLUSION: American Indian women are at particularly high risk of homicide, including DV homicide. Firearms were overrepresented in DV homicides, suggesting that removing firearms from the homes of previous DV perpetrators would be a useful public health strategy. Alcohol or illicit drugs were found in approximately two thirds of New Mexico women who were victims of homicide. The high prevalence of history of previous injuries among DV homicide victims indicates that early identification of DV victims in the emergency department and other health care settings is an important point of intervention.
Domestic Violence↗
Occupational injury mortality in New Mexico.
STUDY OBJECTIVE: To examine specific risks for occupational injury deaths in New Mexico. DESIGN: Retrospective review of state medical investigator reports from 1980 through 1991 with regard to industry, agent of death, gender, ethnicity, location, and alcohol and other drug involvement. PARTICIPANTS: New Mexico residents who were fatally injured while on the job. RESULTS: We identified 613 deaths: 87.1% unintentional, 10.6% homicides, and 2.3% suicides. Industries with the most fatalities were construction (11.8%), oil/gas (10.6%), and farming (8.6%). The primary agents of death were motor vehicles (41.7%), firearms (10.1%), and falling objects (10.0%). Almost all (95.6%) of the decedents were male. However, females were overrepresented among homicide deaths (P < .0001). Most unintentional injuries occurred in rural areas (69.1%), whereas most homicides (73.4%) and suicides (71.4%) occurred in urban areas. Drug or alcohol use was evident in 19.4% of cases. CONCLUSION: New Mexico has a high rate of occupational injury death, which appears to be associated with rural location and use of motor vehicles and alcohol.
Accidents, Occupational↗