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 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. Annals of Emergency Medicine0196-0644553March 2010 © 2009 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.annemergmed.com/article/PIIS0196064409012840/abstract?rss=yesStudy objective: The first hour after the onset of out-of-hospital traumatic injury is referred to as the “golden hour,” yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality.Methods: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged ≥15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was inhospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders.Results: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings.Conclusion: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective CohortCraig D. Newgard, Robert H. Schmicker, Jerris R. Hedges, John P. Trickett, Daniel P. Davis, Eileen M. Bulger, Tom P. Aufderheide, Joseph P. Minei, J. Steven Hata, K. Dean Gubler, Todd B. Brown, Jean-Denis Yelle, Berit Bardarson, Graham Nichol, Resuscitation Outcomes Consortium Investigators10.1016/j.annemergmed.2009.07.024Annals of Emergency Medicine 55, 3 (2010)2009-09-24Annals of Emergency Medicine2009-09-24553S0196-0644(10)X0002-6Emergency Medical Services235246.e4http://www.annemergmed.com/article/PIIS019606441000003X/abstract?rss=yesEditor's Capsule Summary for Newgard et al: What is already known on this topic: The “golden hour” concept in trauma is pervasive despite little evidence to support it.What question this study addressed: Is there an association between various emergency medical services (EMS) intervals and inhospital mortality in seriously injured adults?What this study adds to our knowledge: In 3,656 injured patients with substantial perturbations of vital signs or mental status, transported by 146 EMS agencies to 51 trauma centers across North America, no association was found among any EMS interval and mortality.How this might change clinical practice: This study suggests that in our current out-of hospital and emergency care system time may be less crucial than once thought. Routine lights-and-sirens transport for trauma patients, with its inherent risks, may not be warranted.Journal Club: Is the Golden Hour Tarnished? Registries and Multivariable RegressionTyler W. Barrett, Jeremy J. Brywczynski, David L. Schriger10.1016/j.annemergmed.2010.01.001Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Annals of Emergency Medicine Journal Club247248http://www.annemergmed.com/article/PIIS019606440901556X/abstract?rss=yesStudy objective: Survival after out-of-hospital cardiac arrest depends on the links in the chain of survival. The Utstein elements are designed to assess these links and provide the basis for comparing outcomes within and across communities. We assess whether these measures sufficiently predict survival and explain outcome differences.Methods: We used an observational, prospective data collection, case-series of adult persons with nontraumatic out-of-hospital cardiac arrest from December 1, 2005, through March 1, 2007, from the multisite, population-based Resuscitation Outcomes Consortium Epistry–Cardiac Arrest. We used logistic regression, receiver operating curves, and measures of variance to estimate the extent to which the Utstein elements predicted survival to hospital discharge and explained outcome variability overall and between 7 Resuscitation Outcomes Consortium sites. Analyses were conducted for all emergency medical services–treated cardiac arrests and for the subset of bystander-witnessed patient arrests because of presumed cardiac cause presenting with ventricular fibrillation or ventricular tachycardia.Results: Survival was 7.8% overall (n=833/10,681) and varied from 4.6% to 14.7% across Resuscitation Outcomes Consortium sites. Among bystander-witnessed ventricular fibrillation or ventricular tachycardia, survival was 22.1% overall (n=323/1459) and varied from 12.5% to 41.0% across sites. The Utstein elements collectively predicted 72% of survival variability among all arrests and 40% of survival variability among bystander-witnessed ventricular fibrillation. The Utstein elements accounted for 43.6% of the between-site survival difference among all arrests and 22.3% of the between-site difference among the bystander-witnessed ventricular fibrillation subset.Conclusion: The Utstein elements predict survival but account for only a modest portion of outcome variability overall and between Resuscitation Outcomes Consortium sites. The results underscore the need for ongoing investigation to better understand characteristics that influence cardiac arrest survival.Predicting Survival After Out-of-Hospital Cardiac Arrest: Role of the Utstein Data ElementsThomas D. Rea, Andrea J. Cook, Ian G. Stiell, Judy Powell, Blair Bigham, Clifton W. Callaway, Sumeet Chugh, Tom P. Aufderheide, Laurie Morrison, Thomas E. Terndrup, Tammy Beaudoin, Lynn Wittwer, Dan Davis, Ahamed Idris, Graham Nichol, Resuscitation Outcomes Consortium Investigators10.1016/j.annemergmed.2009.09.018Annals of Emergency Medicine 55, 3 (2010)2009-11-30Annals of Emergency Medicine2009-11-30553S0196-0644(10)X0002-6Emergency Medical Services249257http://www.annemergmed.com/article/PIIS0196064409014292/abstract?rss=yesStudy objective: We determine whether the use of capnography is associated with a decreased incidence of hypoxic events than standard monitoring alone during emergency department (ED) sedation with propofol.Methods: Adults underwent ED propofol sedation with standard monitoring (pulse oximetry, cardiac and blood pressure) and capnography and were randomized into a group in which treating physicians had access to the capnography and a blinded group in which they did not. All patients received supplemental oxygen (3 L/minute) and opioids greater than 30 minutes before. Propofol was dosed at 1.0 mg/kg, followed by 0.5 mg/kg as needed. Capnographic and SpO2 data were recorded electronically every 5 seconds. Hypoxia was defined as SpO2 less than 93%; respiratory depression, as end tidal CO2 (etco2) greater than 50 mm Hg, etco2 change from baseline of 10%, or loss of the waveform.Results: One hundred thirty-two subjects were evaluated and included in the final analysis. We observed hypoxia in 17 of 68 (25%) subjects with capnography and 27 of 64 (42%) with blinded capnography (P=.035; difference 17%; 95% confidence interval 1.3% to 33%). Capnography identified all cases of hypoxia before onset (sensitivity 100%; specificity 64%), with the median time from capnographic evidence of respiratory depression to hypoxia 60 seconds (range 5 to 240 seconds).Conclusion: In adults receiving ED propofol sedation, the addition of capnography to standard monitoring reduced hypoxia and provided advance warning for all hypoxic events.Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled TrialKenneth Deitch, Jim Miner, Carl R. Chudnofsky, Paul Dominici, Daniel Latta10.1016/j.annemergmed.2009.07.030Annals of Emergency Medicine 55, 3 (2010)2009-09-25Annals of Emergency Medicine2009-09-25553S0196-0644(10)X0002-6Pain Management258264http://www.annemergmed.com/article/PIIS0196064409014462/abstract?rss=yesSEE RELATED ARTICLE, P. 258. [Ann Emerg Med. 2010;55:265-267.]Should Capnographic Monitoring Be Standard Practice During Emergency Department Procedural Sedation and Analgesia? Pro and ConSteven M. Green, Jay Pershad10.1016/j.annemergmed.2009.08.019Annals of Emergency Medicine 55, 3 (2010)2009-10-12Annals of Emergency Medicine2009-10-12553S0196-0644(10)X0002-6Pain Management265267http://www.annemergmed.com/article/PIIS0196064409017995/abstract?rss=yesStudy objective: During a pandemic, emergency departments (EDs) may be overwhelmed by an increase in patient visits and will foster an environment in which cross-infection can occur. We developed and tested a novel drive-through model to rapidly evaluate patients while they remain in or adjacent to their vehicles. The patient's automobile would provide a social distancing strategy to mitigate the person-to-person spread of infectious diseases.Methods: We conducted a full-scale exercise to test the feasibility of a drive-through influenza clinic and measure throughput times of simulated patients and carbon monoxide levels of staff. We also assessed the disposition decisions of the physicians who participated in the exercise. Charts of 38 patients with influenza-like illness who were treated in the Stanford Hospital ED during the initial H1N1 outbreak in April 2009 were used to create 38 patient scenarios for the drive-through influenza clinic.Results: The total median length of stay was 26 minutes. During the exercise, physicians were able to identify those patients who were admitted and discharged during the real ED visit with 100% accuracy (95% confidence interval 91% to 100%). There were no significant increases of carboxyhemoglobin in participants tested.Conclusion: The drive-through model is a feasible alternative to a traditional walk-in ED or clinic and is associated with rapid throughput times. It provides a social distancing strategy, using the patient's vehicle as an isolation compartment to mitigate person-to-person spread of infectious diseases.Drive-Through Medicine: A Novel Proposal for Rapid Evaluation of Patients During an Influenza PandemicEric A. Weiss, Jessica Ngo, Gregory H. Gilbert, James V. Quinn10.1016/j.annemergmed.2009.11.025Annals of Emergency Medicine 55, 3 (2010)2010-01-18Annals of Emergency Medicine2010-01-18553S0196-0644(10)X0002-6Infectious Disease268273http://www.annemergmed.com/article/PIIS0196064409018009/abstract?rss=yesNovel H1N1 influenza spread rapidly around the world in spring 2009. Few places were as widely affected as the New York metropolitan area. Emergency departments (EDs) in the region experienced daily visit increases in 2 distinct temporal peaks, with means of 36.8% and 60.7% over baseline in April and May, respectively, and became, in a sense, the “canary in the coal mine” for the rest of the country as we braced ourselves for resurgent spread in the fall. Biosurveillance efforts by public health agencies can lead to earlier detection, potentially forestalling spread of outbreaks and leading to better situational awareness by frontline medical staff and public health workers as they respond to a crisis, but biosurveillance has traditionally relied on manual reporting by hospital administrators when they are least able: in the midst of a public health crisis. This article explores the use of health information exchange networks, which enable the secure flow of clinical data among otherwise unaffiliated providers across entire regions for the purposes of clinical care, as a tool for automated biosurveillance reporting. Additionally, this article uses a health information exchange to assess H1N1's effect on ED visit rates and discusses preparedness recommendations and lessons learned from the spring 2009 H1N1 experience across 11 geographically distinct EDs in New York City that participate in the health information exchange.Health Information Exchange, Biosurveillance Efforts, and Emergency Department Crowding During the Spring 2009 H1N1 Outbreak in New York CityJason S. Shapiro, Nicholas Genes, Gilad Kuperman, Kevin Chason, Lynne D. Richardson, The New York Clinical Information Exchange (NYCLIX) Clinical Advisory Committee H1N1 Working Group10.1016/j.annemergmed.2009.11.026Annals of Emergency Medicine 55, 3 (2010)2010-01-18Annals of Emergency Medicine2010-01-18553S0196-0644(10)X0002-6Infectious Disease274279http://www.annemergmed.com/article/PIIS0196064409019015/abstract?rss=yesBartonella quintana in Body Lice and Head Lice From Homeless Persons, San Francisco, California, USA [Bonilla DL, Kabeya H, Henn J, et al. Bartonella quintana in body lice and head lice from homeless persons, San Francisco, California, USA. Emerg Infect Dis. 2009;15:912-915.]Update on Emerging Infections: News From the Centers for Disease Control and PreventionSunil Shroff10.1016/j.annemergmed.2009.12.029Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Infectious Disease280282http://www.annemergmed.com/article/PIIS0196064409019027/abstract?rss=yes[Ann Emerg Med. 2010;55:282-283.] The above article highlights the reemergence of B quintana infection in the urban homeless population. It appears that infection with B quintana is found exclusively in patients with louse infestation. Risk factors for louse infestation include homelessness, alcoholism, and living in cooler climates.Commentary10.1016/j.annemergmed.2009.12.030Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Infectious Disease282283http://www.annemergmed.com/article/PIIS0196064409012335/abstract?rss=yesStudy objective: We determine whether pediatric emergency physicians can use bedside ultrasonography to accurately identify hip effusions in pediatric patients.Methods: This was a prospective study conducted in the emergency department (ED) of an urban tertiary care freestanding pediatric hospital. A convenience sample of children younger than 18 years and who required hip ultrasonography as part of their ED evaluation was enrolled. Pediatric emergency physicians with focused ultrasonographic training performed bedside ultrasonography on patients' symptomatic and contralateral hips and categorized the findings as “effusion” or “no effusion,” according to a priori definitions. Physicians rated their confidence for each bedside ultrasonographic result on a scale of 1 (not confident) to 5 (very confident). Bedside ultrasonographic results were compared with the radiology department's ultrasonographic results, which were considered the criterion standard. Standard performance metrics (sensitivity, specificity, and positive and negative predictive values) were calculated.Results: Three physicians enrolled patients. Twenty-eight patients were enrolled, and 55 hips were studied. In all hips (both symptomatic and contralateral), bedside ultrasonography had a sensitivity of 80% (95% confidence interval [CI] 51% to 95%), a specificity of 98% (95% CI 85% to 99%), a positive predictive value of 92% (95% CI 62% to 99%), and a negative predictive value of 93% (95% CI 79% to 98%). In the 28 symptomatic hips, bedside ultrasonography had a sensitivity of 85% (95% CI 54% to 97%), a specificity of 93% (95% CI 66% to 99%), a positive predictive value of 92% (95% CI 60% to 99%), and negative predictive value of 88% (95% CI 60% to 98%). When physician self-rated confidence was high, the sensitivity of bedside ultrasonography in symptomatic hips was 90% (95% CI 54% to 99%), the specificity was 100% (95% CI 70% to 100%), the positive predictive value was 100% (95% CI 63% to 100%), and the negative predictive value was 92% (95% CI 62% to 99%).Conclusion: With focused training, pediatric emergency physicians were able to use bedside ultrasonography to identify hip effusions in pediatric ED patients.Bedside Ultrasonography to Identify Hip Effusions in Pediatric PatientsRebecca L. Vieira, Jason A. Levy10.1016/j.annemergmed.2009.06.527Annals of Emergency Medicine 55, 3 (2010)2009-08-21Annals of Emergency Medicine2009-08-21553S0196-0644(10)X0002-6Imaging284289http://www.annemergmed.com/article/PIIS019606440900482X/abstract?rss=yesStudy objective: Among adult emergency department (ED) patients undergoing central venous catheterization, we determine whether a greater than or equal to 50% decrease in inferior vena cava diameter is associated with a central venous pressure of less than 8 mm Hg.Methods: Adult patients undergoing central venous catheterization were enrolled in a prospective, observational study. Inferior vena cava inspiratory and expiratory diameters were measured by 2-dimensional bedside ultrasonography. The caval index was calculated as the relative decrease in inferior vena cava diameter during 1 respiratory cycle. The correlation of central venous pressure and caval index was calculated. The sensitivity, specificity, and positive and negative predictive values of a caval index greater than or equal to 50% that was associated with a central venous pressure less than 8 mm Hg were estimated.Results: Of 73 patients, the median age was 63 years and 60% were women. Mean time and fluid administered from ultrasonographic measurement to central venous pressure determination were 6.5 minutes and 45 mL, respectively. Of the 73 participants, 32% had a central venous pressure less than 8 mm Hg. The correlation between caval index and central venous pressure was –0.74 (95% confidence interval [CI] –0.82 to –0.63). The sensitivity of caval index greater than or equal to 50% to predict a central venous pressure less than 8 mm Hg was 91% (95% CI 71% to 99%), the specificity was 94% (95% CI 84% to 99%), the positive predictive value was 87% (95% CI 66% to 97%), and the negative predictive value was 96% (95% CI 86% to 99%).Conclusion: Bedside ultrasonographic measurement of caval index greater than or equal to 50% is strongly associated with a low central venous pressure. Bedside measurements of caval index could be a useful noninvasive tool to determine central venous pressure during the initial evaluation of the ED patient.Emergency Department Bedside Ultrasonographic Measurement of the Caval Index for Noninvasive Determination of Low Central Venous PressureArun D. Nagdev, Roland C. Merchant, Alfredo Tirado-Gonzalez, Craig A. Sisson, Michael C. Murphy10.1016/j.annemergmed.2009.04.021Annals of Emergency Medicine 55, 3 (2010)2009-06-26Annals of Emergency Medicine2009-06-26553S0196-0644(10)X0002-6Imaging290295http://www.annemergmed.com/article/PIIS0196064409006453/abstract?rss=yes[Ann Emerg Med. 2010;55:296-298.] This is a systematic review abstract, a regular feature of the Annals' Evidenced-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary from an emergency physician knowledgeable in the subject area.Preventing Falls in Community-Dwelling Older AdultsChristopher R. Carpenter10.1016/j.annemergmed.2009.06.014Annals of Emergency Medicine 55, 3 (2010)2009-07-21Annals of Emergency Medicine2009-07-21553S0196-0644(10)X0002-6Evidence-Based Emergency Medicine296298http://www.annemergmed.com/article/PIIS0196064409012281/abstract?rss=yes[Ann Emerg Med. 2010;55:299-300.] This is a systematic review abstract, a regular feature of the Annals' Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area.Should I Consider Treating Patients With Acute Cardiogenic Pulmonary Edema With Noninvasive Positive-Pressure Ventilation?Rawle A. Seupaul10.1016/j.annemergmed.2009.07.005Annals of Emergency Medicine 55, 3 (2010)2009-08-21Annals of Emergency Medicine2009-08-21553S0196-0644(10)X0002-6Evidence-Based Emergency Medicine299300http://www.annemergmed.com/article/PIIS0196064409014413/abstract?rss=yes[Ann Emerg Med. 2010;55:301.] We laughed at Father's sentimental side,Portrait of an Emergency DoctorPage Hudson10.1016/j.annemergmed.2009.08.015Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Change of Shift301301http://www.annemergmed.com/article/PIIS0196064409006477/abstract?rss=yes[Ann Emerg Med. 2010;55:302.] A 53-year-old man presented with a painful skin lesion on his left lower leg, without trauma. The lesion was initially pruritic and had appeared spontaneously 2 weeks earlier. The patient had been evaluated 1 week earlier and was prescribed clindamycin for presumed cellulitis. Despite this, the lesion continued to grow. The patient had a history of peripheral vascular disease and had resumed receiving warfarin sodium for this 1 week before appearance of the lesion. On physical examination, the patient was afebrile, with a 5-cm-×-7-cm nonraised area of ecchymosis with an erythematous border on the anterior left lower leg ().Man With Painful Skin LesionDerek M. Sorensen, Wesley Eilbert10.1016/j.annemergmed.2009.06.016Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Images in Emergency Medicine302302http://www.annemergmed.com/article/PIIS019606440901703X/abstract?rss=yesA novel product that combines morphine sulfate and naltrexone hydrochloride in a single capsule (Embeda) was recently approved by US Food and Drug Administration (September 2009) for the long-term management of moderate to severe pain. The unique design contains pellets of extended-release morphine sulfate surrounding a sequestered core of naltrexone hydrochloride, an orally bioavailable opioid receptor antagonist. This formulation is intended to deter abuse since crushing the extended release matrix results in naltrexone release, which would block intoxication as well as precipitate acute and prolonged opioid withdrawal in opioid-dependent individuals. We present a case of a woman who chewed and swallowed Embeda.Severe Opioid Withdrawal Due to Misuse of New Combined Morphine and Naltrexone Product (Embeda)David H. Jang, John C. Rohe, Robert S. Hoffman, Lewis S. Nelson10.1016/j.annemergmed.2009.10.013Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Correspondence303304http://www.annemergmed.com/article/PIIS0196064409017417/abstract?rss=yesThe News & Perspective section recently published a piece, “For Whom the Bell Commission Tolls: Unintended Effects of Limiting Residents' Hours,” which purports to address potential negative implications of limits on resident work hours and of the Institute of Medicine (IOM) report's recommendations for stronger enforcement and stricter regulations. In doing so, the article unfortunately puts aside the abundant evidence on the importance of duty hours regulations and the significant effort and expertise which went into the report, and, instead, relies on extensive commentary of a few emergency physicians and citations of a single, poorly designed study as the basis for the piece. In doing so, this would seem to fall below the standard one would expect in an Annals of Emergency Medicine piece, even in the non-peer-reviewed News & Perspective section, and appears more perspective than news.News & Perspective Piece Fails to Acknowledge Evidence for Resident Work Hours LimitsTroy Madsen10.1016/j.annemergmed.2009.11.016Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Correspondence304305http://www.annemergmed.com/article/PIIS0196064409017405/abstract?rss=yesWhile welcoming the commentator's thoughts on the subject and appreciating his close, clear attention to both this article and the surrounding research on work hours limits, I would call attention to a genre distinction. The News & Perspective department, as the editors' introduction has pointed out, treats its topics journalistically rather than academically; it occasionally makes room for views that are frankly somewhat contrarian; presenting “more perspective than news” is not a lapse but its acknowledged mission. It often places these discussions in the context of peer-reviewed literature (including in this case the IOM report, with its thorough references), but it does not aspire to the comprehensiveness of a full, rigorous literature review. The department serves a different and more informal purpose, presenting the quoted physicians' individual perspectives, not so much “put[ting] aside” the published evidence assembled by the IOM as reflecting on its relation to their clinical experience. I hope that the separate, complementary functions of research and commentary will strike most readers as useful.In replyWilliam B. Millard10.1016/j.annemergmed.2009.11.015Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Correspondence305305http://www.annemergmed.com/article/PIIS0196064409018034/abstract?rss=yesOtolaryngologic complaints are frequently seen in the emergency department (ED). For those working in academic medical centers, in-house consultants often arrive promptly and manage the patient. However, in the real world, such in-house ED consultations are often neither indicated nor available. Unfortunately, residents training in such an environment both lose experience treating some of these ENT complaints, and at times, fail to truly learn to identify those complaints that require an emergent ED consult as opposed to those which may be followed urgently, or even routinely, in the ambulatory setting. For those who have trained in such a setting (and those who have not), 10 Minute ENT Consult by Hamid Djalilian is an excellent clinical reference. Djalilian was spot on for his target audience of emergency, medical, pediatric, and family medicine physicians. It is a concise yet balanced text that is not overly bogged down by historical perspectives and pathophysiology.Andrew C. Miller10.1016/j.annemergmed.2009.12.003Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6Book and Media Reviews306306http://www.annemergmed.com/article/PIIS0196064410000508/abstract?rss=yesExpanded Table of Contents/Expanded Contents10.1016/S0196-0644(10)00050-8Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA5A5http://www.annemergmed.com/article/PIIS0196064410000521/abstract?rss=yesMasthead10.1016/S0196-0644(10)00052-1Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA13A15http://www.annemergmed.com/article/PIIS0196064410000545/abstract?rss=yesWhat's Coming in Annals ● April 201010.1016/S0196-0644(10)00054-5Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA16A16http://www.annemergmed.com/article/PIIS0196064409018344/abstract?rss=yesAmericans have drive-through everythings: fast food, coffee, banks, weddings, prayer and now, thanks to the inventiveness of a pair of California emergency physicians, even drive-through emergency care.Flu Drive-Through: Stanford ED Tests Novel Triage Model During H1N1 SurgeEric Berger10.1016/j.annemergmed.2009.12.015Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6News and PerspectiveA19A20http://www.annemergmed.com/article/PIIS0196064410000387/abstract?rss=yesThe new 8th edition of the Advanced Trauma Life Support (ATLS) course manual contains a small but significant change. The phrase, “trauma is a surgical disease,” long a point of contention with other specialties caring for trauma patients, has been removed.A Fine Excision: ATLS Manual No Longer Defines Trauma as a Surgical DiseaseWilliam B. Millard10.1016/j.annemergmed.2010.01.015Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6News and PerspectiveA20A24http://www.annemergmed.com/article/PIIS0196064410000594/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(10)00059-4Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA25A25http://www.annemergmed.com/article/PIIS0196064410000570/abstract?rss=yesMANUSCRIPT TITLE (PLEASE TYPE OR PRINT) _________________________________________________________________Manuscript Submission Agreement10.1016/S0196-0644(10)00057-0Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA27A27http://www.annemergmed.com/article/PIIS0196064410001356/abstract?rss=yesIntroduction to Emergency Medicine Ultrasound. March 1-3, 2010. St Pete Beach, FL. Sponsor: Gulfcoast Ultrasound Institute Inc. Fee: $1,695.00 – $1,735.00. Contact: Lori Green, 4615 Gulf Blvd #205, St Pete Beach, FL 33706. Email: Lori.Green@gcus.com. 727-363-4500. (20)Calendar10.1016/S0196-0644(10)00135-6Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA29A47http://www.annemergmed.com/article/PIIS0196064410001368/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)00136-8Annals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA48A48http://www.annemergmed.com/article/PIIS019606441000137X/abstract?rss=yes MISSOURI: UMC School of Medicine-Emergency Medicine is seeking a full-time physician to join the department at the Clinical Assistant Professor level. Applicants should be BC/BP in EM or PC. UMC is the only Level 1 trauma center in mid-Missouri with 35K visits per year, dedicated CT scanner, and an active helicopter service. The position offers excellent benefits, very reasonable hours, and competitive salary, as well as an ideal location in the university town of Columbia, Missouri. The University of Missouri is an Equal Opportunity/Affirmative Action Employer. Reply to: John Yanos, MD, Department of Emergency Medicine DC029.00, One Hospital Drive, Columbia MO 65212 yanos@missouri.eduClassified10.1016/S0196-0644(10)00137-XAnnals of Emergency Medicine 55, 3 (2010)2010-03-01Annals of Emergency Medicine2010-03-01553S0196-0644(10)X0002-6FrontmatterA49A63