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. 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 over 1,786 medical school and hospital libraries subscribe to it in print and 5,372 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 429,000 times last year, a 37% 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 over 828,000 page views (about twice the previous year). More than 47,800 reprint requests were ordered last year. Annals is the emergency medicine journal most frequently cited by authors. In 2007 Annals again increased its impact factor (average citation rate per article); over the past 10 years Annals has averaged an increase in impact factor more than 4 times greater than the average for all medical journals combined. Among 6,417 science and medical journals in the Science Citation Index, Annals ranked in the top 12% by citation frequency and the top 12% by impact factor. Annals continues to have the highest impact factor of all 11 emergency medicine/resuscitation journals tracked by SCI, but has further increased the size of its lead over its nearest competitor this year (37%). In the past 5 years, 1,224 different journals in the ISI science journal database cited an article in Annals. In a typical year, Annals articles are cited by over 400 different scientific journals, most of them from a broad range of specialties outside of emergency medicine. Annals , of course, is also the journal most frequently cited by other emergency medicine journals. Annals articles also generate considerable interest in the lay media, with approximately 620 hits in print, radio and television, not including audio news releases. Major outlets included the New York Times , the Wall St. Journal , National Public Radio, the Washington Post , the Los Angeles Times , USA Today , Modern Healthcare , Reuters, Associated Press and CNN, as well as many trade publications. We distributed two audio news releases about Annals studies to radio stations around the country. One on rising rates of elderly patients in the emergency department (study author Mary Pat McKay, MD, MPH) was aired 4,798 times on radio stations around the country and reached 20 million listeners. Another audio news release on low rates of reimbursement for Medicaid patients (study author Renee Hsia, MD, MSc) was aired 4,019 times on radio stations and reached 10 million listeners. Annals is an international journal; half of the full text articles accessed via ScienceDirect were downloaded by readers in 79 countries outside the U.S. Our contributors are also international in scope; in 2008 submissions came to us from 39 different countries, with 36% of submissions originating outside the United States, and 19% originating outside North America and Western Europe. Asia and Europe each contributed 15%, and the Middle East 2%. The largest volume other than the U.S. was submitted from Taiwan, Turkey, Canada, France, United Kingdom, Korea, Netherlands, and Australia, in descending order. But the list also includes Brazil, Thailand, Mexico, Tunisia, Georgia, Finland, and Bulgaria. Annals of Emergency Medicine is ranked 1 st of 12 in the Emergency Medicine category on the 2009 Journal Citation Reports®, published by Thomson Reuters, and has an Impact Factor of 3.755. In 2009 Annals was chosen one of the 100 most influential scientific journals of the past 100 years by the Special Libraries Association ( www.sla.org ). The Special Libraries Association is one of the most respected and largest (11,000 members) library organizations. The entire list is at ( www.sla.org/content/Events/centennial/dbio100.cfm ). Some of the high profile medical journals on the list were Cell, Circulation, JAMA, The Lancet, Nature, NEJM, and Science. Annals is flattered to have received this recognition, which is testimony to the hard work, talent, and dedication of its editorial board, its staff, and all the authors who contribute to it. http://www.annemergmed.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. Annals of Emergency Medicine0196-0644552February 2010 © 2009 Published by Elsevier Inc. healthpermissions@elsevier.comhttp://www.annemergmed.com/article/PIIS0196064409012839/abstract?rss=yesStudy objective: Prolonged emergency department (ED) wait time and length of visit reduce quality of care and increase adverse events. Previous studies have not examined hospital-level performance on ED wait time and visit length in the United States. The purpose of this study is to describe hospital-level performance on ED wait time and visit length.Methods: We conducted a retrospective cross-sectional study of a stratified random sampling of 35,849 patient visits to 364 nonfederal US hospital EDs in 2006, weighted to represent 119,191,528 visits to 4,654 EDs. Measures included EDs' median wait times and visit lengths, EDs' median proportion of patients treated by a physician within the time recommended at triage, and EDs' median proportion of patients dispositioned within 4 or 6 hours.Results: In the median ED, 78% (interquartile range [IQR], 63% to 90%) of all patients and 67% (IQR, 52% to 82%) of patients who were triaged to be treated within 1 hour were treated by a physician within the target triage time. A total of 31% of EDs achieved the triage target for more than 90% of their patients; 14% of EDs achieved the triage target for 90% or more of patients triaged to be treated within an hour. In the median ED, 76% (IQR 54% to 94%) of patients were admitted within 6 hours. A total of 48% of EDs admitted more than 90% of their patients within 6 hours, but only 25% of EDs admitted more than 90% of their patients within 4 hours.Conclusion: A minority of hospitals consistently achieved recommended wait times for all ED patients, and fewer than half of hospitals consistently admitted their ED patients within 6 hours.US Emergency Department Performance on Wait Time and Length of VisitLeora I. Horwitz, Jeremy Green, Elizabeth H. Bradley10.1016/j.annemergmed.2009.07.023Annals of Emergency Medicine 55, 2 (2010)2009-10-05Annals of Emergency Medicine2009-10-05552S0196-0644(09)X0015-6The Practice of Emergency Medicine133141http://www.annemergmed.com/article/PIIS0196064409005319/abstract?rss=yesAs administrators evaluate potential approaches to improve cost, quality, and throughput efficiencies in the emergency department (ED), “front-end” operations become an important area of focus. Interventions such as immediate bedding, bedside registration, advanced triage (triage-based care) protocols, physician/practitioner at triage, dedicated “fast track” service line, tracking systems and whiteboards, wireless communication devices, kiosk self check-in, and personal health record technology (“smart cards”) have been offered as potential solutions to streamline the front-end processing of ED patients, which becomes crucial during periods of full capacity, crowding, and surges. Although each of these operational improvement strategies has been described in the lay literature, various reports exist in the academic literature about their effect on front-end operations. In this report, we present a review of the current body of academic literature, with the goal of identifying select high-impact front-end operational improvement solutions.Optimizing Emergency Department Front-End OperationsJennifer L. Wiler, Christopher Gentle, James M. Halfpenny, Alan Heins, Abhi Mehrotra, Michael G. Mikhail, Diana Fite10.1016/j.annemergmed.2009.05.021Annals of Emergency Medicine 55, 2 (2010)2009-06-26Annals of Emergency Medicine2009-06-26552S0196-0644(09)X0015-6The Practice of Emergency Medicine142160.e1http://www.annemergmed.com/article/PIIS0196064409015595/abstract?rss=yesStudy objective: We develop and evaluate the Handoff Communication Assessment, using actual handoffs of patient transfers from emergency department to inpatient care.Methods: This was an observational qualitative study. We derived a Handoff Communication Assessment tool, using categories from discourse coding described in physician-patient communication, previous handoff research in medicine, health communication, and health systems engineering and pilot data from 3 physician-hospitalist handoffs. The resulting tool consists of 2 typologies, content and language form. We applied the tool to a convenience sample of 15 emergency physician-to-hospitalist handoffs occurring at a community teaching hospital. Using discourse analysis, we assigned utterances into categories and determined the frequency of utterances in each category and by physician role.Results: The tool contains 11 content categories reflecting topics of patient presentation, assessment, and professional environment and 11 language form categories representing information-seeking, information-giving, and information-verifying behaviors. The Handoff Communication Assessment showed good interrater reliability for content (κ=0.71) and language form (κ=0.84). We analyzed 742 utterances, which provided the following preliminary findings: emergency physicians talked more during handoffs (67.7% of all utterances) compared with hospitalists (32.3% of all utterances). Content focused on patient presentation (43.6%), professional environment (36%), and assessment (20.3%). Form was mostly information-giving (90.7%) with periodic information-seeking utterances (8.8%) and rarely information-verifying utterances (0.4%). Questions accounted for less than 10% of all utterances.Conclusion: We were able to develop and use the Handoff Communication Assessment to analyze content and structure of handoff communication between emergency physicians and hospitalists at a single center. In this preliminary application of the tool, we found that emergency physician–to-hospitalist handoffs primarily consist of information giving and are not geared toward question-and-answer events. This critical exchange may benefit from ongoing analysis and reformulation.Exploring Emergency Physician–Hospitalist Handoff Interactions: Development of the Handoff Communication AssessmentJulie Apker, Larry A. Mallak, E. Brooks Applegate, Scott C. Gibson, Jason J. Ham, Neil A. Johnson, Richard L. Street10.1016/j.annemergmed.2009.09.021Annals of Emergency Medicine 55, 2 (2010)2009-11-30Annals of Emergency Medicine2009-11-30552S0196-0644(09)X0015-6Patient Safety161170http://www.annemergmed.com/article/PIIS019606440901261X/abstract?rss=yesPatient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.Improving Handoffs in the Emergency DepartmentDickson S. Cheung, John J. Kelly, Christopher Beach, Ross P. Berkeley, Robert A. Bitterman, Robert I. Broida, William C. Dalsey, Heather L. Farley, Drew C. Fuller, David J. Garvey, Kevin M. Klauer, Lynne B. McCullough, Emily S. Patterson, Julius C. Pham, Michael P. Phelan, Jesse M. Pines, Stephen M. Schenkel, Anne Tomolo, Thomas W. Turbiak, John A. Vozenilek, Robert L. Wears, Marjorie L. White, American College of Emergency Physicians Section of Quality Improvement and Patient Safety10.1016/j.annemergmed.2009.07.016Annals of Emergency Medicine 55, 2 (2010)2009-10-05Annals of Emergency Medicine2009-10-05552S0196-0644(09)X0015-6Patient Safety171180http://www.annemergmed.com/article/PIIS0196064409016497/abstract?rss=yesSEE RELATED ARTICLE, P. 171. [Ann Emerg Med. 2010;55:181-183.]Communication, Communication, Communication: The Art of the HandoffScott C. Gibson, Jason J. Ham, Julie Apker, Larry A. Mallak, Neil A. Johnson10.1016/j.annemergmed.2009.10.009Annals of Emergency Medicine 55, 2 (2010)2009-12-07Annals of Emergency Medicine2009-12-07552S0196-0644(09)X0015-6Patient Safety181183http://www.annemergmed.com/article/PIIS0196064409012815/abstract?rss=yesStudy objective: Methemoglobinemia after pesticide poisoning is associated with a mortality of 12% in Sri Lanka. Treatment is complicated by the lack of laboratory facilities. We aimed to develop and validate a low-cost bedside test for quantitative estimation of clinically significant methemoglobin to be used in settings of limited resources.Methods: A method to reliably produce blood samples with 10% to 100% methemoglobin was developed. Freshly prepared methemoglobin samples were used to develop the color chart. One drop (10 μL) of prepared methemoglobin sample was placed on white absorbent paper and scanned using a flatbed Cannon Scan LiDE 25 scanner. The mean red, green, and blue values were measured with ImageJ 1.37v. These color values were used to prepare a color chart to be used at the bedside. Interobserver agreement was assessed against prepared samples. The results from clinical use were compared with formal methemoglobin measurements.Results: The red color value was linearly related to percentage methemoglobin (R2=0.9938), with no effect of absolute hemoglobin concentration. Mean interobserver (N=21) agreement and weighted κ for scanned methemoglobin spots using the color chart were 94% and 0.83, respectively. Mean interobserver (N=9) agreement and weighted κ for a freshly prepared methemoglobin sample with the chart were 88% and 0.71, respectively. Clinical use of the color chart also showed good agreement with spectrometric measurements.Conclusion: A color chart can be used to give a clinically useful quantitative estimate of methemoglobinemia.A Simple Quantitative Bedside Test to Determine MethemoglobinFathima Shihana, Dhammika Menike Dissanayake, Nicholas Allan Buckley, Andrew Hamilton Dawson10.1016/j.annemergmed.2009.07.022Annals of Emergency Medicine 55, 2 (2010)2009-10-09Annals of Emergency Medicine2009-10-09552S0196-0644(09)X0015-6Toxicology184189http://www.annemergmed.com/article/PIIS0196064409014309/abstract?rss=yesStudy objective: We describe the demographics, characteristics, treatment, and clinical course of methamphetamine body stuffers. We also determine the clinical characteristics of methamphetamine body stuffers who have severe outcomes.Methods: A 6.5-year descriptive nonconcurrent observational case series evaluated methamphetamine body stuffers about whom the Oregon Poison Center was consulted by their primary physicians. Poison center charts were supplemented by completed hospital charts (for 95% of patients).Results: Six hundred forty-eight patients with methamphetamine exposure were identified and reviewed, and 55 charts met the criteria for “methamphetamine body stuffer.” We found the following characteristics of methamphetamine body stuffers: mean age 29 years (range 16 to 57 years), men in 44 of 55 cases (80%), mean time to arrival 2.7 hours after ingestion, with a median of 1 hour after ingestion. Ninety-seven percent (53/55) stuffed methamphetamine orally (2/55 rectally). Methamphetamine was most frequently swallowed in baggies, but 25% were unpackaged. The median dose ingested was 3.5 g of methamphetamine in 1 package. Outcome-based analysis revealed 29% (16/55) of patients had severe outcomes, as defined by end-organ toxicity, with agitation requiring intubation the most common severe outcome. There was 1 death reported. Toxicity did not appear to be related to the amount of methamphetamine or number of packets. Patients with severe outcomes had higher mean initial pulse rates and temperatures. Eighty-eight percent (14/16) of patients with severe outcomes had a presenting pulse rate greater than 120 beats/min or a temperature greater than 38°C versus 18% (7/39) patients with a benign outcome. Twenty-four radiographic studies were obtained; none detected packets.Conclusion: Methamphetamine body stuffers have similar demographics to those of body stuffers of other stimulants, but tended to ingest fewer baggies with larger masses, and had a higher percentage of severe outcomes (29%) than previously reported with other stimulants. Increases in presenting pulse rate and temperature (pulse rate >120 beats/min or >38.0°C) are common in patients who will develop end-organ damage.Methamphetamine Body Stuffers: An Observational Case SeriesPatrick L. West, Nathanael J. McKeown, Robert G. Hendrickson10.1016/j.annemergmed.2009.08.005Annals of Emergency Medicine 55, 2 (2010)2009-10-12Annals of Emergency Medicine2009-10-12552S0196-0644(09)X0015-6Toxicology190197http://www.annemergmed.com/article/PIIS0196064409012803/abstract?rss=yesBreath alcohol analyzers are used to detect ethanol in motorists and others suspected of public intoxication. One concern is their ability to detect interfering substances that may falsely increase the ethanol reading. A 47-year-old-man was found in a public park, acting intoxicated. A breath analyzer test (Intoxilyzer 5000EN) measured 0.288 g/210 L breath ethanol, without an interferent noted. In the emergency department, the patient admitted to drinking HEET Gas-Line antifreeze, which contains 99% methanol. Two to three hours after ingestion, serum and urine toxicology screen results were negative for ethanol and multiple other substances. His serum methanol concentration was 589 mg/dL, serum osmolality 503 mOsm/kg, osmolar gap 193 mOsm/kg, and anion gap 17 mmol/L. The patient was treated with intravenous ethanol, fomepizole, and hemodialysis without complication. This is a unique clinical case of a breath alcohol analyzer reporting methanol as ethanol. Intoxilyzer devices have been shown to indicate some substances (acetone) as interferents in humans but not methanol. Increased serum concentrations of methanol can be reported as ethanol by a commonly used breath alcohol analyzer, which can result in a delayed diagnosis or misdiagnosis and subsequent methanol toxicity if antidotal treatment is not administered in a timely manner.Breath Alcohol Analyzer Mistakes Methanol Poisoning for Alcohol IntoxicationE. Martin Caravati, Kathleen T. Anderson10.1016/j.annemergmed.2009.07.021Annals of Emergency Medicine 55, 2 (2010)2009-10-15Annals of Emergency Medicine2009-10-15552S0196-0644(09)X0015-6Toxicology198200http://www.annemergmed.com/article/PIIS0196064409004855/abstract?rss=yesStudy objective: We evaluate, in admitted patients with transient ischemic attack, the accuracy of the ABCD2 (age [A], blood pressure [B], clinical features [weakness/speech disturbance] [C], transient ischemic attack duration [D], and diabetes history [D]) score in predicting ischemic stroke within 7 days.Methods: At 16 North Carolina hospitals, we enrolled a prospective, nonconsecutive sample of admitted patients with transient ischemic attack and with no stroke history, presenting within 24 hours of transient ischemic attack symptom onset. We conducted a medical record review to determine ischemic stroke outcomes within 7 days. According to a modified Rankin Scale Score, strokes were classified as disabling (>2) or nondisabling (≤2).Results: During a 35-month period, we enrolled 1,667 patients, of whom 373 (23%) received a diagnosis of an ischemic stroke within 7 days. Eighteen percent (69/373) of all strokes were disabling. We were unable to calculate an ABCD2 score in 613 patients (37%); however, our imputed analysis indicated this did not significantly alter results. The discriminatory power of the ABCD2 score was modest for ischemic stroke in 7 days (c statistic 0.59), and fair for disabling ischemic stroke within 7 days (c statistic 0.71). Patients characterized as low risk according to ABCD2 score (≤3) were at low risk for experiencing a disabling stroke within 7 days, with a negative likelihood ratio of 0.16 (95% confidence interval [CI] 0.04 to 0.64) with missing values excluded and 0.34 (95% CI 0.15 to 0.76) when missing values were imputed.Conclusion: Our analysis suggests the best application of the ABCD2 score may be to identify patients at low risk for an early disabling ischemic stroke. Further study of the ability to determine an ABCD2 score in all patients is needed, along with validation in a large, consecutive population of patients with transient ischemic attack.A Multicenter Evaluation of the ABCD2 Score's Accuracy for Predicting Early Ischemic Stroke in Admitted Patients With Transient Ischemic AttackAndrew W. Asimos, Anna M. Johnson, Wayne D. Rosamond, Marlow F. Price, Kathryn M. Rose, Diane Catellier, Carol V. Murphy, Sam Singh, Charles H. Tegeler, Ana Felix10.1016/j.annemergmed.2009.05.002Annals of Emergency Medicine 55, 2 (2010)2009-06-26Annals of Emergency Medicine2009-06-26552S0196-0644(09)X0015-6Neurology201210.e5http://www.annemergmed.com/article/PIIS019606440901806X/abstract?rss=yes[National Highway Traffic Safety Administration. Alcohol impaired drivers involved in fatal crashes, by gender and state, 2007-2008. Ann Emerg Med. 2010:55:211.] In response to recent data from the Federal Bureau of Investigation indicating an increase in the number of female drivers arrested for driving under the influence (DUI) of alcohol, the National Highway Traffic Safety Administration (NHTSA) undertook a study of fatal crashes in which the driver was impaired by alcohol intake. Data from the Fatality Analysis Reporting System (FARS) from 2007 and 2008 were analyzed with respect to alcohol involvement, driver sex, and the state in which the crash occurred. Alcohol-impaired drivers were defined as drivers with a blood alcohol concentration (BAC) of 0.08 g/dL or greater. Estimates of alcohol involvement are generated with a combination of BAC values that are reported to FARS and imputed BAC values when they are not reported to FARS. In all 50 states, the District of Columbia, and Puerto Rico, it is illegal per se to drive or operate a motorcycle with a BAC of .08 g/dL or above (alcohol impairment).Alcohol-Impaired Drivers Involved in Fatal Crashes, by Gender and State, 2007-20081National Highway Traffic Safety Administration10.1016/j.annemergmed.2009.12.006Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Injury Prevention211211http://www.annemergmed.com/article/PIIS0196064409018071/abstract?rss=yes[McKay MP. Commentary: Women and alcohol: increasingly willing to drive while impaired? Ann Emerg Med. 2010;55:211-214.] As I began to write this, I got to thinking about women and alcohol and driving and started to recall the voices of patients I've cared for over the years:Commentary: Women and Alcohol: Increasingly Willing to Drive While Impaired?Mary Pat McKay10.1016/j.annemergmed.2009.12.007Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Injury Prevention211214http://www.annemergmed.com/article/PIIS0196064409005356/abstract?rss=yes[Ann Emerg Med. 2010;10;55:215.] I stuff my white coat pockets with Saltines and ginger candy to forestall “evening sickness” on night shifts, hiding dry heaves with a discreet hand over my mouth. Nurses giggle as I audibly retch during an intubation. And I shelf a pregnancy book after it starts with, “Get eight hours of sleep each night, stay off your feet, eat frequently, and avoid stressful situations.” My husband (Jimmy, a surgical resident) worries about my I's and O's at work, while secretaries force hydration with ginger ale. Security guards become increasingly watchful as I examine agitated patients.Boy or Girl?Kavita Babu10.1016/j.annemergmed.2009.05.027Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Change of Shift215215http://www.annemergmed.com/article/PIIS0196064409016175/abstract?rss=yes A well-designed clinical trial will be meaningless if the outcome measure is inappropriate, irrelevant, or unhelpful.Outcome Measures, Interim Analyses, and Bayesian Approaches to Randomized Trials: Answers to the September 2009 Journal Club QuestionsAaron M. Brown, David L. Schriger, Tyler W. Barrett10.1016/j.annemergmed.2009.09.027Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Annals of Emergency Medicine Journal Club216224.e1http://www.annemergmed.com/article/PIIS0196064409006441/abstract?rss=yes[Ann Emerg Med. 2009;10;55:225.] A 60-year-old man with a history of hypertension and renal insufficiency presented to the emergency department (ED) after a single generalized tonic-clonic seizure. On awakening, he complained of a headache and blurred vision. According to his family, he was lethargic and vomited that morning and had not taken his blood pressure medications for several days. In the ED, the patient's blood pressure was 220/130 mm Hg. He was arousable to voice and displayed no neurologic deficits. A computed tomographic scan revealed bilateral posterior hypodensities without mass effect (). Magnetic resonance imaging showed increased fluid-attentuated inversion recovery signal in the same region ().Adult Male With Altered Mental Status and New-Onset SeizuresDavid M. Solomon, Maria Saccio, Krista Savarese, Barry Hahn10.1016/j.annemergmed.2009.06.013Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Images in Emergency Medicine225225http://www.annemergmed.com/article/PIIS019606440901614X/abstract?rss=yesWhen performed correctly, graphical display of clinical trial data can provide useful additional insights regarding treatments that statistically demonstrate benefit, like fibrinolytic therapy for acute ischemic stroke. Unfortunately, in their article graphically analyzing the 2 NINDS tPA trials, Drs. Hoffman and Schriger depart from best practices appropriate for the visual display of quantitative information.Response to: “A Graphic Reanalysis of the NINDS Trial”Jeffrey L. Saver, Jeffrey Gornbein, Sidney Starkman10.1016/j.annemergmed.2009.09.024Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Correspondence226227http://www.annemergmed.com/article/PIIS0196064409016163/abstract?rss=yesWe read with interest the article by Hoffman and Schriger, “A Graphic Reanalysis of the NINDS Trial” in the September issue of Annals. The authors have used a post hoc complex graphical analysis of the relationship between treatment with recombinant tissue plasminogen activator (rtPA) and a secondary outcome measure, the National Institutes of Health Stroke Scale scores (NIHSS) obtained at 90 days in the NINDS trial.Response to “A Graphic Reanalysis of the NINDS Trial”Helen M. Dewey, Leonid Churilov, David Blacker, Christopher Bladin, Stephen M. Davis, Geoffrey A. Donnan, Peter Gates, Richard P. Gerraty, Peter Hand, Christopher Levi, Richard I. Lindley, Romesh Markus, Stephen Read10.1016/j.annemergmed.2009.09.026Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Correspondence227229http://www.annemergmed.com/article/PIIS0196064409016151/abstract?rss=yesWe are hardly surprised that the only letters published in response to our article are from advocates of tPA. Regardless of the topic, there is almost always a cadre of vocal proponents and a group of unknown size whose silence reflects a lack of belief. This pattern affects the way that medical therapies are adopted; proponents, better funded and more highly motivated than all others, often carry the day. Industry and special interest groups organized around a particular disease actively lobby for each new treatment; we have never seen the “Society Against the Use of Treatment X for Condition Y.” Such a system lacks adequate checks and balances.In replyJerome R. Hoffman, David L. Schriger10.1016/j.annemergmed.2009.09.025Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Correspondence229229http://www.annemergmed.com/article/PIIS0196064409017387/abstract?rss=yes[Ann Emerg Med. 2010;55:230.] The practice of the pharmaceutical and medical device industries to give gifts to physicians has come under increasing scrutiny in recent years. Prominent professional associations have issued reports recommending a ban on accepting gifts from industry. Many US academic medical centers have implemented policies prohibiting acceptance by physicians, other health care professionals, and trainees, of any gifts from industry representatives. The leading trade associations of the pharmaceutical and medical device industries have adopted revised guidelines for interaction with health care professionals that impose new voluntary restrictions on the practice of giving gifts.Gifts to Emergency Physicians From Industry10.1016/j.annemergmed.2009.11.013Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Policy Statement230231http://www.annemergmed.com/article/PIIS0196064409015054/abstract?rss=yesThe author addresses rapid sequence intubation and has created an excellent primer for any provider learning about rapid sequence intubation. The book is easy to understand and generally well written in a conversational style. The material is focused on those providing emergent airway management and is particularly useful for out-of-hospital providers. This is not, nor does it claim to be, a definitive text for airway management. The ideal audiences for this book are providers with some understanding of airway management who are ready to learn about rapid sequence intubation. This includes paramedics, nurses, respiratory therapists, physician trainees and those physicians who practice emergency airway management who may not have had formal training in the technique.Francis X. Guyette10.1016/j.annemergmed.2009.08.022Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Book and Media Reviews232232http://www.annemergmed.com/article/PIIS0196064409015078/abstract?rss=yesThis soft cover book is a concise manual that covers a broad variety of ophthalmic disorders, many of which will be encountered in the emergency department (ED). This atlas is presented in a user-friendly design that is divided into 12 chapters, the first 11 of which are based on anatomic regions from external to internal (orbit, cornea, anterior chamber, etc) and the last chapter is on visual acuity, refractive procedures, and sudden vision loss. The reader is quickly guided through the diagnosis and management. I really liked the color-coded tabbing of each chapter and the highlighting of key components. For example, where appropriate, sections have red-bordered boxes listing “Ophthalmic Emergency.” These boxes highlight immediate actions to be taken to treat the condition. Additionally, there are “Management” boxes for quickly finding treatment recommendations of the authors for most of the non-emergency conditions.Daniel J. Dire10.1016/j.annemergmed.2009.08.024Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6Book and Media Reviews232233http://www.annemergmed.com/article/PIIS0196064409018459/abstract?rss=yesExpanded Table of Contents/Expanded Contents10.1016/S0196-0644(09)01845-9Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA3A3http://www.annemergmed.com/article/PIIS0196064409018472/abstract?rss=yesMasthead10.1016/S0196-0644(09)01847-2Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA11A13http://www.annemergmed.com/article/PIIS0196064409018496/abstract?rss=yesWhat's Coming in Annals ● March 201010.1016/S0196-0644(09)01849-6Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA14A14http://www.annemergmed.com/article/PIIS0196064409018137/abstract?rss=yesJack Coulehan's ordeal began on a Long Island beach. During an Easter sunrise service in 2008, a pain that had first appeared in his left eye the previous night flared to excruciating levels within a few moments. As he ticked through his symptoms–normal vision, normal eye movement, left side of his forehead prickly and burning–Dr. Coulehan drew upon his decades as a primary care physician to diagnose himself with shingles.A $9,000 Bill To Diagnose Shingles? Doctor's ED Visit Highlights Cost of Care IssuesEric Berger10.1016/j.annemergmed.2009.12.012Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6News and PerspectiveA15A17http://www.annemergmed.com/article/PIIS0196064409018526/abstract?rss=yesMANUSCRIPT TITLE (PLEASE TYPE OR PRINT) _________________________________________________________________Manuscript Submission Agreement10.1016/S0196-0644(09)01852-6Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA18A18http://www.annemergmed.com/article/PIIS019606440901854X/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(09)01854-XAnnals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA19A19http://www.annemergmed.com/article/PIIS0196064410000168/abstract?rss=yes9th Annual Emergency and Critical Care Medicine: The Cutting Edge. February 1-5, 2010. Palm Beach, ARUBA. Sponsors: Texas ACEP/Medical Symposiums Inc. Fee: $500.00 – $850.00. Contact: Melanie Levine, 4546 Elm St, Bellaire, TX 77401. Email: mymposiums@gmail.com. 800-583-4181. ext 5. (24)Calendar10.1016/S0196-0644(10)00016-8Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA25A44http://www.annemergmed.com/article/PIIS0196064410000193/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 2010 Advertising Rates & Information: New Value-Added Feature—Your Ad Online at no Additional Cost!10.1016/S0196-0644(10)00019-3Annals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA46A46http://www.annemergmed.com/article/PIIS019606441000020X/abstract?rss=yes FLORIDA: Multi-System Hospital-Administrative and Staff Positions. A premier physician-owned, physician-run group dedicated to providing the best clinical and operational service seeks high-quality full-time and part-time emergency medicine physicians at a multi-system facility with volume ranges between 25k and 38k located in Melbourne and Rockledge, FL. Physicians must be BC/BP and residency trained in Emergency Medicine. Melbourne and Rockledge are only one hour from Orlando and 45 minutes from Cocoa Beach, FL. No Noncompete and flexible scheduling, Growth and advancement opportunities are also available. Physician pay higher than the National average; A-rated malpx & tail included; Equal member-Partner day-one. Email CV to Heather Chappell, at hchappell@apollomd.com or call 919-461-7130. Inquiries will remain confidential.Classified10.1016/S0196-0644(10)00020-XAnnals of Emergency Medicine 55, 2 (2010)2010-02-01Annals of Emergency Medicine2010-02-01552S0196-0644(09)X0015-6FrontmatterA47A61