Annals of Emergency Medicine RSS feed: Current Issue. Scope and Stature of the Journal Annals of Emergency Medicine , the official journal of the American College of Emergency Physicians, is an international, peer-reviewed journal dedicated to improving the quality of care by publishing the highest quality science for emergency medicine and related medical specialties. Annals publishes original research, clinical reports, opinion, and educational information related to the practice, teaching, and research of emergency medicine. In addition to general emergency medicine topics, Annals regularly publishes articles on out-of-hospital emergency medical services, pediatric emergency medicine, injury and disease prevention, health policy and ethics, disaster management, toxicology, and related topics. The journal welcomes submissions from international contributors and researchers of all specialties. Although Annals of Emergency Medicine is the official journal of the American College of Emergency Physicians (ACEP) the journal maintains editorial independence from ACEP. Its content is selected by the editorial board and does not necessarily reflect the policies and beliefs of ACEP. Annals continues to be the largest circulation peer review journal in emergency medicine (over 28,000 subscribers, several times its nearest competitor). It is also one of the most accessible to non-subscribing readers, since 6,400 institutions include Annals in their online licenses for ScienceDirect (the world's largest electronic collection of science, technology and medicine full text and bibliographic information). ScienceDirect was utilized for access to Annals articles approximately 658,000 times last year, a 19% increase from the prior year. Annals is also available on the Web (with full text of all articles dating back to its inception), where it received more than 392,000 visitors. Annals is the emergency medicine journal most frequently cited by authors and has the highest impact factor over the years of all 19 journals in the emergency medicine category of the SCI (Science Citation Index). The impact factor (the average number of citations per published article) is the commonest measure of journal influence; the 2010 impact factor for Annals was 4.14, placing it in the top 12% of all 8,005 science and medical journals tracked by the SCI. Not only is Annals most frequently cited, but it is cited more promptly and longer than any other emergency medicine journal (9.5 years, 83% longer than its nearest competitor). In the past 5 years, more than1,200 different journals in the ISI science journal database cited an article in Annals , and in a typical year, Annals articles are cited by more than 400 different scientific journals, most of them from a broad range of specialties outside of emergency medicine. Annals ' articles generate considerable interest in the lay media. From October 2009 through September 2010, there were 5,089 hits in various media outlets, including print, radio and blogs. Major outlets included Wall St. Journal , ABC News, Boston Globe, Business Week, Los Angeles Times, MSNBC, USA Today, New York Times, Modern Healthcare, Washington Post, the AM News, EM News, JEMS, and Reuters Health, as well as many trade publications. Annals is an international journal; 54% of the full text articles accessed via ScienceDirect were downloaded by readers in 93 countries outside the U.S. Our contributors are also international in scope; in 2010 submissions came to us from 46 different countries, with 41% of submissions originating outside the United States, and 25% originating outside North America and Western Europe. The largest volume other than the U.S. was submitted from Taiwan, Canada, Turkey, France, United Kingdom, China, Australia, Korea, Netherlands, Italy, and Japan, in descending order. But the list also includes Brazil, Thailand, Tunisia, India, Iran, Nigeria, and Serbia. We strongly believe we have an obligation to make our journal available to international audiences regardless of their financial resources, and therefore have participated for many years in the HINARI initiative sponsored by large journal publishers ( http://www.healthinternetwork.org/src/eligibility.php ), which makes Annals available free or at greatly reduced cost in low-income countries. http://www.annemergmed.com/?rss=yesElsevier Inc.en © 2011 Published by Elsevier Inc. Annals of Emergency Medicine0196-0644592February 2012 © 2011 Published by Elsevier Inc. healthpermissions@elsevier.comhttp://www.annemergmed.com/article/PIIS0196064411002010/abstract?rss=yes[Ann Emerg Med. 2012;59:87-88.] A large number of books have appeared in recent years, bemoaning the influence of industry over academic research. The list of sins alleged in them and at congressional hearings and in various journal articles is serious. They include industry seeding the literature with studies intended to create space for new drugs in their pipelines, hiring medical ghostwriters to spin study results in the most positive light possible, withholding publication from studies with poor or, worse, life-threatening outcomes, clandestinely sponsoring special journal supplements to promote their research, exporting studies overseas in which oversight is often lax and prospective study subjects ask fewer questions, and contracting to hold first rights over the research generated by entire medical school departments.Is Industry Money the Root of All Conflicts of Interest in Biomedical Research?Arthur L. Caplan10.1016/j.annemergmed.2011.03.001Annals of Emergency Medicine 59, 2 (2012)2011-04-04Annals of Emergency Medicine2011-04-04592S0196-0644(11)X0015-XEthics8788http://www.annemergmed.com/article/PIIS0196064411014120/abstract?rss=yes In October 2009, the board of directors of the American College of Emergency Physicians (ACEP) approved a major revision to ACEP's “Gifts to Emergency Physicians from Industry” policy. The revised policy is a response to increasing debate and calls for restriction of the long-standing biomedical industry practice of giving promotional gifts to individual physicians. This article outlines the history of professional attention to gift giving and reviews recent contributions to the ongoing debate over its justifiability, including professional association recommendations for limitation or prohibition of the practice. The article concludes with a description of the provisions of the revised ACEP gifts policy and brief reflection on the future of this practice. Gifts to Physicians From Industry: The Debate EvolvesJohn C. Moskop, Kenneth V. Iserson, Andrew L. Aswegan, Gregory Luke Larkin, Raquel M. Schears10.1016/j.annemergmed.2011.08.001Annals of Emergency Medicine 59, 2 (2012)2011-08-29Annals of Emergency Medicine2011-08-29592S0196-0644(11)X0015-XEthics8997http://www.annemergmed.com/article/PIIS0196064411005142/abstract?rss=yes[Ann Emerg Med. 2012;59:98.] A 30-year-old woman was referred to the emergency department (ED) after presumably having had an anaphylactic reaction to cotrimoxazole tablets. In the ED, she was conscious, oriented, tachypneic, tachycardic, and hypotensive (systolic blood pressure of 60 mm Hg). She was fluid resuscitated; a central venous catheter was placed in the left internal jugular vein uneventfully, and an epinephrine infusion was started. A chest radiograph was obtained after line placement ().Woman With Supposed Anaphylactic ReactionAshok Elangovan, Jose Chacko, Somnath Chatterjee, Basavaraj Kuntoji10.1016/j.annemergmed.2011.05.021Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XImages in Emergency Medicine9898http://www.annemergmed.com/article/PIIS0196064411015575/abstract?rss=yesSEE RELATED ARTICLE, P. 89. [Ann Emerg Med. 2012;59:99-100.]Limiting Gifts, Harming PatientsPaul H. Rubin10.1016/j.annemergmed.2011.09.009Annals of Emergency Medicine 59, 2 (2012)2011-10-03Annals of Emergency Medicine2011-10-03592S0196-0644(11)X0015-XEthics99100http://www.annemergmed.com/article/PIIS0196064411016957/abstract?rss=yesSEE RELATED ARTICLE, P. 89. [Ann Emerg Med. 2012;59:101-102.]Coffers Brimming, Ethically BankruptRobert C. Solomon10.1016/j.annemergmed.2011.10.011Annals of Emergency Medicine 59, 2 (2012)2011-11-14Annals of Emergency Medicine2011-11-14592S0196-0644(11)X0015-XEthics101102http://www.annemergmed.com/article/PIIS0196064411013382/abstract?rss=yes Study objective: Automated external defibrillators are essential for treatment of cardiac arrest by lay rescuers and must determine when to shock and if they are functioning correctly. We seek to characterize automated external defibrillator failures reported to the Food and Drug Administration (FDA) and whether battery failures are properly detected by automated external defibrillators. Methods: FDA adverse event reports are catalogued in the Manufacturer and User Device Experience (MAUDE) database. We developed and internally validated an instrument for analyzing MAUDE data, reviewing all reports in which a fatality occurred. Two trained reviewers independently analyzed each report, and a third resolved discrepancies or passed them to a committee for resolution. Results: One thousand two hundred eighty-four adverse events were reported between June 1993 and October 2008, of which 1,150 were failed defibrillation attempts. Thirty-seven automated external defibrillators never powered on, 252 failed to complete rhythm analysis, and 524 failed to deliver a recommended shock. In 149 cases, the operator disagreed with the device's rhythm analysis. In 54 cases, the defibrillator stated the batteries were low and in 110 other instances powered off unexpectedly. Interrater agreement between reviewers 1 and 2 ranged by question from 69.0% to 98.6% and for most likely cause was 55.9%. Agreement was obtained for 93.7% to 99.6% of questions by the third reviewer. Remaining discrepancies were resolved by the arbitration committee. Conclusion: MAUDE information is often incomplete and frequently no corroborating data are available. Some conditions not detected by automated external defibrillators during self-test cause units to power off unexpectedly, causing defibrillation delays. Backup units frequently provide shocks to patients. Analysis of Automated External Defibrillator Device Failures Reported to the Food and Drug AdministrationLawrence A. DeLuca, Allan Simpson, Dan Beskind, Kristi Grall, Lisa Stoneking, Uwe Stolz, Daniel W. Spaite, Ashish R. Panchal, Kurt R. Denninghoff10.1016/j.annemergmed.2011.07.022Annals of Emergency Medicine 59, 2 (2012)2011-08-29Annals of Emergency Medicine2011-08-29592S0196-0644(11)X0015-XCardiology103111http://www.annemergmed.com/article/PIIS0196064411015393/abstract?rss=yesSEE RELATED ARTICLE, P. 103. [Ann Emerg Med. 2012;59:112-114.] The first principle is that you must not fool yourself, and you are the easiest person to fool. —Richard FeynmanProcess Without Progress: Emergency Medicine, Patient Safety, and the Need for ScienceChristopher Nemeth10.1016/j.annemergmed.2011.08.016Annals of Emergency Medicine 59, 2 (2012)2011-09-26Annals of Emergency Medicine2011-09-26592S0196-0644(11)X0015-XCardiology112114http://www.annemergmed.com/article/PIIS0196064411013436/abstract?rss=yes Study objective: Evaluation of emergency department (ED) patients with chest pain who are at low risk for acute coronary syndrome is resource intensive and may lead to false-positive test results and unnecessary downstream procedures. We seek to identify patients at low short-term risk for a cardiac event for whom additional ED investigations might be unnecessary. Methods: We prospectively enrolled patients older than 24 years and with a primary complaint of chest pain from 3 academic EDs. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 30 days. We used recursive partitioning to derive the rule and validated the model with 5,000 bootstrap replications. Results: Of 2,718 patients enrolled, 336 (12%) experienced a cardiac event within 30 days (6% acute myocardial infarction, 10% revascularization, 0.2% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100% sensitive (95% confidence interval 97.2% to 100.0%) and 20.9% specific (95% confidence interval 16.9% to 24.9%) for a cardiac event within 30 days. Conclusion: This clinical prediction rule identifies ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice. Development of a Clinical Prediction Rule for 30-Day Cardiac Events in Emergency Department Patients With Chest Pain and Possible Acute Coronary SyndromeErik P. Hess, Robert J. Brison, Jeffrey J. Perry, Lisa A. Calder, Venkatesh Thiruganasambandamoorthy, Dipti Agarwal, Annie T. Sadosty, Marco L.A. Silvilotti, Allan S. Jaffe, Victor M. Montori, George A. Wells, Ian G. Stiell10.1016/j.annemergmed.2011.07.026Annals of Emergency Medicine 59, 2 (2012)2011-09-02Annals of Emergency Medicine2011-09-02592S0196-0644(11)X0015-XCardiology115125.e1http://www.annemergmed.com/article/PIIS0196064411018762/abstract?rss=yesSEE RELATED ARTICLE, P. 115. [Ann Emerg Med. 2012;59:126-127.]Risk Stratification in the Era of High-Sensitivity Troponin AssaysAndrew Worster, Peter A. Kavsak, Michael Brown10.1016/j.annemergmed.2011.11.035Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XCardiology126127http://www.annemergmed.com/article/PIIS0196064411015939/abstract?rss=yes Study objective: Nearly 3 million patients present to US emergency departments (EDs) annually with undifferentiated musculoskeletal low back pain. Little is known about short- and longer-term outcomes in this group. We seek to describe the pain and functional outcomes 1 week and 3 months after discharge in a sample of ED patients presenting with undifferentiated musculoskeletal low back pain. Methods: We used a prospective observational descriptive cohort design, enrolling ED patients with a chief complaint of low back pain classified as musculoskeletal in origin by the ED attending physician. We defined low back pain as pain originating in the posterior back between the tips of the scapulae and upper buttocks and excluded any patient with a traumatic back injury occurring within the previous month. We interviewed patients in the ED and then by telephone follow-up 1 week and 3 months after ED discharge, using a scripted closed-question data collection instrument. Our primary outcome was functional limitation attributable to low back pain assessed with a validated scale. Secondary outcomes included pain and analgesic use during the 24 hours before each follow-up telephone call. Results: During a 9-month period beginning in July 2009, we approached 894 patients, of whom 556 were enrolled. We obtained follow-up on 97% of our sample at 1 week and 92% at 3 months. One week after ED discharge, 70% (95% confidence interval [CI] 66% to 74%) of patients reported back pain–related functional impairment, 59% (95% CI 55% to 63%) reported moderate or severe low back pain, and 69% (95% CI 65% to 73%) reported analgesic use within the previous 24 hours. Three months after ED discharge, 48% (95% CI 44% to 52%) of patients reported functional impairment, 42% (95% CI 38% to 46%) reported moderate or severe pain, and 46% (95% CI 44% to 50%) reported analgesic use within the previous 24 hours. Conclusion: There is substantial short- and longer-term morbidity and ongoing analgesic use among patients who present to an ED with undifferentiated musculoskeletal low back pain. One-Week and 3-Month Outcomes After an Emergency Department Visit for Undifferentiated Musculoskeletal Low Back PainBenjamin W. Friedman, Sean O'Mahony, Laura Mulvey, Michelle Davitt, Hong Choi, Shujun Xia, David Esses, Polly E. Bijur, E. John Gallagher10.1016/j.annemergmed.2011.09.012Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XPain Management and Sedation128133.e3http://www.annemergmed.com/article/PIIS0196064411014454/abstract?rss=yes Study objective: We study whether mandatory triage pain scoring and an educational program reduces the time to initial analgesic treatment. Methods: We performed a prospective interventional study in the emergency department (ED) of an adult tertiary referral hospital and major trauma center. After an observational assessment of baseline time to analgesic administration, we mandated the recording of triage pain scores through our computerized information system. In a second separate phase, we administered a staff educational package on the importance of timely analgesia. We measured time to initial analgesia after each phase and at 12-month follow-up. Results: We studied 35,628 patients (8,743 baseline, 8,462 after mandating pain scoring, 9,043 after the educational program, and 9,380 at follow-up), with 12,925 patients (36.3%) overall receiving analgesics. At baseline, the median time to analgesia was 123 minutes (interquartile range [IQR] 58 to 231 minutes), which reduced with pain scoring (95 minutes; IQR 45 to 194 minutes) but no further with the educational package (98 minutes; IQR 45 to 191 minutes). At 12-month follow-up, the median time to analgesia was 78 minutes (IQR 45 to 143 minutes), 45 minutes (36.4%) faster than at baseline. Conclusion: The simple act of altering our ED computerized information system to require pain scoring at triage led to substantially faster provision of initial analgesia, with the effect sustained at 12 months. Mandatory Pain Scoring at Triage Reduces Time to AnalgesiaJaideep Vazirani, Jonathan C. Knott10.1016/j.annemergmed.2011.08.007Annals of Emergency Medicine 59, 2 (2012)2011-09-12Annals of Emergency Medicine2011-09-12592S0196-0644(11)X0015-XPain Management and Sedation134138.e2http://www.annemergmed.com/article/PIIS019606441100477X/abstract?rss=yesBed rest of any duration after a lumbar puncture has not been shown to decrease the incidence of post–lumbar puncture headache. The authors searched the Cochrane Controlled Trials Register as their primary source. MEDLINE from 1994, EMBASE from 1980, and reference lists for identified trials and reviews were also searched. When contact was made with study authors, they were asked about any other relevant studies.Does Bed Rest Prevent Post–Lumbar Puncture Headache?Christian H. Jacobus10.1016/j.annemergmed.2011.05.010Annals of Emergency Medicine 59, 2 (2012)2011-06-20Annals of Emergency Medicine2011-06-20592S0196-0644(11)X0015-XPain Management and Sedation139140http://www.annemergmed.com/article/PIIS0196064411018919/abstract?rss=yes[National Highway Traffic Safety Administration. High visibility enforcement demonstration programs in Connecticut and New York reduce hand-held phone use. Ann Emerg Med. 2012;141-142.]High Visibility Enforcement Demonstration Programs in Connecticut and New York Reduce Hand-Held Phone Use1National Highway Traffic Safety Administration10.1016/j.annemergmed.2011.12.007Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XInjury Prevention141142http://www.annemergmed.com/article/PIIS0196064411018920/abstract?rss=yes[Ann Emerg Med. 2012;142-144.] Enforcement works. That is the lesson of NHTSA's Traffic Safety Facts Research Note “High Visibility Enforcement Demonstration Programs in Connecticut and New York Reduce Hand-Held Phone Use.” And publicly announced, visible, open enforcement is even better. The authors reviewed a program that demonstrated significant changes in driver behavior according to a funded, well-publicized enforcement campaign.Commentary: Enforcement WorksB. Tilman Jolly10.1016/j.annemergmed.2011.12.008Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XInjury Prevention142144http://www.annemergmed.com/article/PIIS0196064411006032/abstract?rss=yes[Ann Emerg Med. 2012;59:145-146.] Some patients need their ER doc to be a lover, not a fighter. I provide “customer service,” hold hands, and reassure. Not this time. It's Monday night in my emergency department (ED) when the paramedic radio goes off. The battle begins.A Perfect Save by an Imperfect Health Care SystemBoris D. Veysman10.1016/j.annemergmed.2011.05.028Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XChange of Shift145146http://www.annemergmed.com/article/PIIS0196064411016702/abstract?rss=yes Kravitz et al performed a randomized clinical trial to compare the efficacy of 2 steroid preparations in adult emergency department (ED) patients with acute asthma exacerbations. The responsible conduct of research mandates clinical equipoise as the ethical basis for enrolling human subjects in clinical trials. This principle of clinical equipoise states that there exists genuine uncertainty among investigators about the relative therapeutic benefits of each treatment arm in a clinical trial. A Tale of Two Steroids: Answers to the September 2011 Journal Club QuestionsMatthew A. Waxman, Tyler W. Barrett, David L. Schriger10.1016/j.annemergmed.2011.10.005Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XAnnals of Emergency Medicine Journal Club147155http://www.annemergmed.com/article/PIIS0196064411006135/abstract?rss=yesA 21-year-old man presented with several days of fever, sinus pain, decreased vision, and pain with eye movement. Examination revealed proptosis and periorbital edema/erythema, with an afferent pupillary defect and a visual acuity of hand-motion in the right eye (). A computed tomography (CT) scan showed opacification of the frontal, ethmoid, and maxillary sinuses bilaterally, with right-sided orbital inflammatory changes and a subperiosteal abscess in the superomedial orbit (). The patient began receiving vancomycin, ceftazidime, and metronidazole. He underwent an orbitotomy with subperiosteal abscess drainage and right-sided ethmoidectomy that same day. Abscess cultures grew Staphylococcus aureus and Streptococcus sanguis. Although the external examination showed apparent improvement, the patient continued to note a lack of appetite, generalized malaise, and intractable headache. Several days thereafter, the patient developed left-sided extremity weakness and altered mental status. A right-sided subdural empyema was identified (), requiring an urgent craniotomy. During the following week, the patient recovered dramatically, although vision improved only to counting fingers and mild aphasia remained.Young Man With Fever and Eye PainSeongmu Lee, Michael T. Yen10.1016/j.annemergmed.2011.06.004Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XImages in Emergency Medicine156156http://www.annemergmed.com/article/PIIS0196064411014053/abstract?rss=yesA 34-year-old man with diabetes presented to the emergency department with a 1-week history of fever, general malaise, and bilateral blurred vision. He had no history of ocular surgery. On ophthalmologic consultation, his visual acuity was 20/50 in the right eye and counting fingers in the left eye. Slit-lamp biomicroscopic and fundus examination was performed. Slit-lamp biomicroscopic examination showed 3+ cells without a hypopyon in the anterior chamber of each eye. Fundus examination revealed multiple subretinal/choroidal infiltrations and vitreous opacities, especially in the left eye (). Blood, urine, and vitreous cultures were obtained.Man With Blurred VisionKuan-Jen Chen, Tun-Lu Chen10.1016/j.annemergmed.2011.07.033Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XImages in Emergency Medicinee3e4http://www.annemergmed.com/article/PIIS019606441101540X/abstract?rss=yesWe read with great interest the News and Perspective article “Stand By to Repel Boarders” by Millard. We applaud his emphasis of the importance of reducing ambulance diversion across the country. As an example of an organized regional diversion plan, he mentions our work in greater Sacramento. Between 2001 and 2003, we decreased diversion hours regionally by 74%. Continued progress, however, stalled during the next few years until we implemented an aggressive, collaborative plan moving step by step toward the ultimate elimination of ambulance diversion. Using our sequential “3-2-1 Plan,” we reduced diversion by an additional 87% by the end of 2009. In June 2010, our entire region piloted a no-diversion plan and successfully eliminated all ambulance diversion from September 2010 to date. The difference between our region and Massachusetts is that we reduced ambulance diversion gradually, whereas the Massachusetts plan called for an abrupt end to all ambulance diversion. These are 2 alternative approaches toward the same end, both of which are significant steps toward Dr. Millard's next mission “to repel boarders.”Stand By to Repel BoardersPankaj B. Patel, David R. Vinson10.1016/j.annemergmed.2011.06.598Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XCorrespondence157158http://www.annemergmed.com/article/PIIS0196064411019354/abstract?rss=yesTable of Contents10.1016/S0196-0644(11)01935-4Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA3A3http://www.annemergmed.com/article/PIIS0196064411019378/abstract?rss=yesEditors10.1016/S0196-0644(11)01937-8Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA11A13http://www.annemergmed.com/article/PIIS0196064411019391/abstract?rss=yesWhat's Coming in Annals ● March 201210.1016/S0196-0644(11)01939-1Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA14A14http://www.annemergmed.com/article/PIIS0196064411015526/abstract?rss=yesPracticing a learned profession within a commercial culture has never been simple. The overlapping status of medicine in the United States as both a vocation and a business means that the borderlines of ethics and self-interest are constantly being drawn and redrawn. Medical professional organizations, like physicians, need to balance their healing mission and their cash flow. To an increasingly visible community of observers, many of these groups have lost this balance, even to the point of forfeiting the credibility as an independent professional authority.Professional Societies and Commercial Conflicts of Interest: Critics Blast Circuslike Atmosphere, Barker Marketing at ConferencesWilliam B. Millard10.1016/j.annemergmed.2011.09.005Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XNews and PerspectiveA19A25http://www.annemergmed.com/article/PIIS0196064411018890/abstract?rss=yesState legislators trying desperately to balance their budgets are targeting the nation's trauma system, already under severe financial pressure. In California, emergency services advocates managed to stave off a legislative budget committee's plan to divert the Maddy Fund, which has been providing millions of dollars in uncompensated care funding to trauma centers for the past 30 years. The budget panel wanted to move the dollars to the cash-strapped Medi-Cal program.Trauma Systems at Risk: Funding Cuts Fray Strained Safety NetJan Greene10.1016/j.annemergmed.2011.12.005Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XNews and PerspectiveA25A27http://www.annemergmed.com/article/PIIS0196064411019421/abstract?rss=yesAnnals adheres to the International Committee of Medical Journal Editor's specific requirements regarding authorship (see www.icmje.org). On behalf of all authors, I verify that all listed authors meet the www.icmje.org authorship requirements. ❒ Yes ❒ No, explain in cover letterRequired Conflict of Interest Information from Authors10.1016/S0196-0644(11)01942-1Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA29A29http://www.annemergmed.com/article/PIIS0196064411019445/abstract?rss=yesAnnals of Emergency Medicine is the official publication of the American College of Emergency Physicians (www.acep.org). The journal is provided to all ACEP members as a membership benefit. For information about becoming an ACEP member, contact ACEP's member services department at the address below. For your convenience, a postage-paid card for obtaining membership information is included in every issue of the journal.Information for Readers10.1016/S0196-0644(11)01944-5Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA30A30http://www.annemergmed.com/article/PIIS0196064412000303/abstract?rss=yes2012 Midwest Winter Symposium. February 2-5, 2012. Boyne Falls, MI. Sponsor: MI Colg of Emer Phys. Fee: $50.00 – $495.00. Contact: Christy Snitgen, 6647 West St. Joseph Hwy., Lansing, MI, 48917. Email: mcep@mcep.org. 5173275700. (14)Calendar10.1016/S0196-0644(12)00030-3Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA33A47http://www.annemergmed.com/article/PIIS0196064412000315/abstract?rss=yesAds and complete payments must be received in writing by the issue's deadline date. These deadlines apply to insertions, cancellations, and changes. Classified 2012 Advertising Rates & Information: New Value-Added Feature—Your Ad Online at no Additional Cost!10.1016/S0196-0644(12)00031-5Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA48A48http://www.annemergmed.com/article/PIIS0196064412000327/abstract?rss=yes TEXAS, Austin: RARE MEDICAL DIRECTOR OPPORTUNITY IN AUSTIN! Ideal candidate will be board-certified in Emergency Medicine with previous medical director experience. EXCEPTIONAL LOCATION: Live the good life in highly sought-after Austin, Texas. EXCEPTIONAL FACILITY: Work in 35,000-volume ED at award-winning flagship hospital. EXCEPTIONAL GROUP: Emergency Service Partners, LP is a stable, physician-owned and operated partnership with 20+ hospitals and 300+ providers, dedicated to quality care and patient satisfaction. Enjoy competitive productivity-based compensation, excellent work environment, two-year partnership track, equitable scheduling, and paid malpractice/tail coverage—all with tort reform and no state income tax. Strong medical director leadership is the key to our success! Contact Lisa Morgan today at (512) 610-0315 or e-mail lisa@eddocs.com for more details and mention job #135311-12.Classified10.1016/S0196-0644(12)00032-7Annals of Emergency Medicine 59, 2 (2012)2012-02-01Annals of Emergency Medicine2012-02-01592S0196-0644(11)X0015-XFrontmatterA49A62