Emergency Center Categorization Standards

The SAEM EC Categorization Task Force was developed in response to the 1994 Macy Foundation's recommendation that emergency medicine (EM) organizations "should revise the classification of emergency departments ... to reflect the level of care available in emergency departments, and indicate whether or not facilities are adequate and whether appropriately qualified and credentialed emergency physicians are available 24 hours a day." By holding Level 1 emergency centers (ECs) to objective standards based on the quality of care delivered as well as administrative, research, and educational efforts, SAEM hopes to improve patient care. The SAEM EC Categorization Task Force is now beginning the process of reviewing ECs that provide comprehensive emergency care and serve as regional resources for education, research, and administration in EM. This standards document describes relative and critical criteria to be met in order to receive designation as a Level 1 emergency center. Such centers must meet all critical criteria, and be in sufficient compliance with most or all relative criteria, in order to achieve this designation. This process is entirely voluntary. Any EC is eligible for review. Any institution can initiate the review process by applying. Application materials and further information, including the policies and procedures of the SAEM EC Categorization Task Force, are available from SAEM.     

Cost-effectiveness of colonoscopy

This article presents a cost-effectiveness analysis of colorectal cancer screening tests that have been recommended by the United States Preventive Services Task Force, American Cancer Society US Multi-Society Task Force on Colorectal Cancer American College of Radiology, or the American College of Gastroenterology. This cost-effectiveness analysis supports a common theme of the 3 guideline groups that there are multiple acceptable colorectal cancer screening strategies (including colonoscopy). The article shows which recommended strategies are also cost-effective given a range of willingness to pay per life-year gained. The set of cost-effective strategies includes tests that primarily detect cancer early (annual sensitive fecal occult blood tests [FOBTs]; either guaiac or fecal immunochemical tests, but not Hemoccult II), as well as those that can prevent colorectal cancer (flexible sigmoidoscopy every 5 years with a frequent sensitive FOBT [but not flexible sigmoidoscopy as a standalone test], and colonoscopy). Computed tomographic colonography was not a cost-effective strategy. Stool DNA testing was not assessed in the analysis for this article.     

The role of human herpes virus 6 and 7 in the pathogenesis of pityriasis rosea

Pityriasis rosea (PR) is an acute exanthematous inflammatory skin disease in which many epidemiological studies suggest a viral infection in its pathogenesis. Several viruses such as picornaviruses, parvoviruses and herpes viruses were accused as causative agents in PR. Human herpes virus-6 (HHV-6) and HHV-7 are newly discovered members of herpesviridae family. Several diseases including roseola infantum and PR have been linked with HHV-6 and HHV-7 in dermatology. We aimed to investigate the role of HHV-6 and HHV-7 in the pathogenesis of PR. Blood samples from 35 patients with acute PR and 30 healthy volunteers were examined to obtain titres for HHV-6 and HHV-7 antibodies. Anti-HHV-6 and -HHV-7 immunoglobulin (Ig) G antibodies were detected by IFA. The high titres of anti-HHV-6 IgG were determined in four patients and anti-HHV-7 IgG in only two of four patients. In our study, we haven't found any significant relationship between HHV-6, HHV-7 and PR. Our results were supported with the data of several previous studies.     

Human herpesvirus 6

Human herpesvirus (HHV) 6 is a beta-herpes, DNA virus. This virus shows closest homology with cytomegalovirus and HHV-7. Infection usually occurs in infants 6 to 24 months of age, and primary infection may result in roseola. HHV-6 infection in infants is the commonest cause of fever-induced seizures. Infection in adults is seen primarily in immunocompromised hosts with solid organ transplants or in those with human immunodeficiency virus infection. The virus is capable of pronounced interaction in vitro with cytomegalovirus and human immunodeficiency virus and induces immunosuppression and apoptosis. The importance of these interactions in vivo necessitates further investigation. HHV-6 infection may contribute to the pathogenesis of multiple sclerosis. HHV-6 may be diagnosed by viral culture, serology, or polymerase chain reaction.     

异基因造血干细胞移植后人类疱疹病毒6型活化与急性移植物抗宿主病的相关性研究

目的研究造血干细胞移植（HSCT）后人类疱疹病毒6型（HHV．6）活化与急性移植物抗宿主病（aGVHD）的相关性。方法移植前以及移植后每周1次连续采集72例患者的外周血样本，采用筑巢式聚合酶链反应扩增HHV-6基因序列，HindⅢ酶切对HHV-6基因分型。结果72例患者移植后45例（62．5％）检出HHV-6血症，中位时间为第14（7—63）天；40例（55．6％）患者发生Ⅰ～Ⅳ度aGVHD，中位时间第26（9～73）天。HHV．6血症发生的中位时间显著早于Ⅰ～Ⅳ度aGVHD发生时间（P=0．018）。Ⅰ～Ⅳ度aGVHD累积发生率在HHV-6阳性组为68．9％（45例中31例），显著高于HHV-6阴性组的33．3％（27例中9例）（P=0．003）。Ⅱ-Ⅳ度aGVHD累积发生率HHV-6阳性组为35．6％，显著高于HHV-6阴性组的14．8％（P=0．027）。移植后Ⅰ-Ⅳ度aGVHD的发生率在巨细胞病毒（CMV）和HHV-6共感染（CMV^＋／HHV-6^＋）组、CMV阳性HHV-6阴性（CMV^＋／HHV-6^-）组、CMV阴性HHV-6阳性（CMV^-／HHV-6^-）组和CMV与HHV-6均阴性（CMV^-／HHV-6^-）组分别为78，9％，55．6％，14．3％和22．2％，差异有统计学意义（P=0．0001）。Ⅱ～Ⅳ度aGVHD累积发生率在CMV^＋／HHV-6^＋、CMV^＋／HHV-6^-、CMV^-／HHV-6^＋和CMV^-／HHV-6^-组分别为42．1％．22．2％，0％和11．1％，差异有统计学意义（P=0．008）。结论HSCT后HHV-6感染以及HHV-6和CMV共感染与aGVHD发生率存在显著相关性。     

Promoting safe and effective genetic tests in the United States: work of the task force on genetic testing

The Task Force on Genetic Testing was created to review genetic testing in the United States and, when necessary, to make recommendations to ensure the development of safe and effective genetic tests. A survey to explore the state of genetic testing was undertaken for the Task Force and completed in early 1995. The survey, as well as literature reports and other information collected for the Task Force, showed problems affecting safety and effectiveness, as defined by the Task Force: validity and utility of predictive tests, laboratory quality, and appropriate use by healthcare providers and consumers. On the basis of these findings, the Task Force made several recommendations to ensure safe and effective genetic testing. The Secretary of Health and Human Services followed up one recommendation by creating the Secretary's Advisory Committee on Genetic Testing. One of its functions will be to implement other recommendations of the Task Force.     

A systematic review of the effect of waiting for treatment for chronic pain

In many countries timely access to care is a growing problem. As medical costs escalate health care resources must be prioritized. In this context there is an increasing need for benchmarks and best practices in wait-time management. The Canadian Pain Society struck a Task Force in December 2005 to identify benchmarks for acceptable wait-times for treatment of chronic pain. As part of the mandate a systematic review of the literature regarding the relationship between waiting times, health status and health outcomes for patients awaiting treatment for chronic pain was undertaken. Twenty-four studies met the inclusion criteria for the review. The current review supports that patients experience a significant deterioration in health related quality of life and psychological well being while waiting for treatment for chronic pain during the 6 months from the time of referral to treatment. It is unknown at what point this deterioration begins as results from the 14 trials involving wait-times of 10 weeks or less yielded mixed results with wait-times amounting to as little as 5 weeks, associated with deterioration. It was concluded that wait-times for chronic pain treatment of 6 months or longer are medically unacceptable. Further study is necessary to determine at what stage the deterioration begins from the onset of pain to treatment and the impact of waiting on treatment outcomes. Most important is the need to improve access to appropriate care for patients with chronic pain, an escalating public health care problem with significant human and economic costs.     

Canadian physiotherapists' professional identity: an exploratory survey

This survey was funded and conducted by the Ontario and Canadian Physiotherapy Association Task Force on Professional Identity. Professional identity influences the image an occupation projects to its clients, the public, other occupations and governments. As an aid to planning strategy for advancing the professional image of physiotherapy, an open-ended questionnaire explored Canadian physiotherapists' professional identity. Professional identity is promoted by Canadian Physiotherapy Association (CPA) branches and districts. Most therapists identified their skills and potential benefit for patients, but only 15% identified themselves as a member of a health profession involved in a rewarding career. Physiotherapists have achieved many characteristics of an independent profession, but expressed frustration reveals that some members lack power on a personal and professional level.     

A comparison of written materials vs. materials and counselling for women with sexual dysfunction and multiple sclerosis

Aim. Evaluate whether symptoms of vaginal dryness, low libido, less intense or delayed orgasm could be improved in women with multiple sclerosis who took part in an education or education plus counselling programme. Background. Sexual dysfunction, a prevalent symptom in women with multiple sclerosis, can negatively affect quality‐of‐life. Methods. Women attending a large multiple sclerosis clinic were invited and 62 were randomized into one of two groups. Group 1 received written materials on primary, secondary and tertiary sexual dysfunction in multiple sclerosis as well as additional resources (books, websites, list of local psychologists specializing in sexual counselling). Group 2 received the same written materials as well as three counselling sessions from the clinic nurse, the latter two by telephone. The primary outcome measures were the expanded disability status scale and the multiple sclerosis intimacy and sexuality questionnaire‐19. Repeated‐measures analysis of variance was used to evaluate sexual dysfunction score over time and to compare two groups. Results. At baseline, total expanded disability status scale scores were not correlated with primary, secondary or tertiary sexual dysfunction. Total multiple sclerosis intimacy and sexuality questionnaire‐19 score was correlated with use of anti‐cholinergic medications [r (54) = 0·28, P < 0·05], but no other medications, alcohol or tobacco use. Both groups had equivalent and significant reductions in primary sexual dysfunction [F (1) = 14·79, P < 0·001] postintervention. There was a trend towards an interaction effect for tertiary sexual dysfunction [F (1) = 2·88, P = 0·096], in the direction of group 2 (education and counselling). Subjectively, women welcomed the opportunity to discuss sexual concerns and noted that the written information allowed a framework for initiating discussion with their spouses. Conclusion. Relatively straightforward interventions provided by a clinic nurse may help women cope with the symptoms of sexual dysfunction associated with multiple sclerosis. Women who do not benefit from basic interventions could then be referred to an expert sexual dysfunction practitioner. Relevance to clinical practice. Women with multiple sclerosis experience many disease‐related physical and emotional challenges of which sexuality is only one. Sensitivity to sexual dysfunction and being willing to approach the topic is appreciated by women with multiple sclerosis. Nurses do not require in‐depth expertise to offer some basic suggestions which may significantly improve life quality and assist the woman with multiple sclerosis to talk about or cope with sexuality issues.     

Human herpesvirus-6 enhances natural killer cell cytotoxicity via IL-15.

The marked tropism of human herpesvirus-6 (HHV-6) for natural killer (NK) cells and T lymphocytes has led us to investigate the effect of HHV-6 on cellular cytotoxicity. We describe here how HHV-6 infection of peripheral blood mononuclear cells (PBMC) leads to upregulation of their NK cell cytotoxicity. The induction of NK cell activity by HHV-6 was abrogated by monoclonal antibodies (mAbs) to IL-15 but not by mAbs to other cytokines (IFN-alpha, IFN-gamma, TNF-alpha, TNF-beta, IL-2, IL-12) suggesting that IL-15 secreted in response to viral infection was responsible for the observed effect. Furthermore, NK activation by HHV-6 was blocked with mAb to CD122, as well as by human anti-HHV-6 neutralizing antibodies. Using RT-PCR, we were able to detect IL-15 mRNA upregulation in purified monocyte and NK cell preparations. IL-15 protein synthesis was increased in response to HHV-6. Finally, addition of IL-15 to PBMC cultures was found to severely curtail HHV-6 expression. Taken together, our data suggest that enhanced NK activity in response to viral infection represent a natural anti-viral defense mechanism aimed at rapidly eliminating virus-infected cells.     

Occupational performance measures: a review based on the guidelines for the client-centred practice of occupational therapy

In 1987, Health and Welfare Canada and the Canadian Association of Occupational Therapists Task Force recommended that work go forward to develop an outcome measure for occupational therapy which reflects the Occupational Performance Model. The first step in this process was to review critically those outcome measures which assess occupational performance and that are currently available in the literature. This paper will present the review process, describe in more detail eight assessments that fulfilled many of the review criteria, discuss the limitations of these measures using the "Guidelines for the Client-centred Practice of Occupational Therapy as the framework, and make recommendations for the development of a new outcome measure for use in occupational therapy.     

CAM for pediatric pain: what is state-of-the-research?

Previously, we reviewed the evidence for the efficacy of CAM approaches for pediatric pain (volume 2; issue 2; 2005) using criteria developed by the American Psychological Association Division 12 Task Force. Our review focused on CAM modalities that had been tested with at least one controlled trial or multiple baseline study. In addition, only those trials in which children comprised the study sample were included. Thus, several CAM modalities were not included in our review. Key ethical and other reasons for the limited literature on CAM for pediatric pain as well as directions for future studies are discussed.     

Suicidal ideation in multiple sclerosis

OBJECTIVE: To examine risk factors for suicidal ideation among people with multiple sclerosis (MS). DESIGN: Cohort study linking computerized medical records with a mailed self-report survey. SETTING: Veteran's Health Administration (VHA) region covering the northwestern United States. PARTICIPANTS: VHA patients with MS (N=445) who returned mailed surveys. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Suicidal ideation is assessed by the Patient Health Questionnaire (PHQ) suicide item with suicidal ideation more than half the days considered persistent. RESULTS: One hundred thirty-one (29.4%) of 445 respondents (95% confidence interval [CI], 25.4%-33.9%) endorsed suicidal ideation, and 35 (7.9%; 95% CI, 5.7%-10.8%) endorsed persistent suicidal ideation over the last 2 weeks. In bivariate analyses, suicidal ideation was associated with younger age, earlier disease course, progressive disease subtype, lower income, not being married, lower social support, not driving, higher levels of physical disability (mobility, bowel, bladder), and depression. Analyses on persistent suicidal ideation yielded similar results. In fully adjusted multivariate logistic regression, only depression severity and bowel disability were independently associated with suicidal ideation. Only depression severity was independently associated with persistent suicidal ideation. By using the 2-question depression screen (U.S. Preventive Services Task Force) consisting of the depression and anhedonia items from the PHQ-9, sensitivity and specificity were marginal for suicidal ideation (65.6% and 79.9%) but acceptable for persistent suicidal ideation (88.6% and 71.2%). CONCLUSIONS: Suicidal ideation is common among VHA patients with MS, and depression severity is the best risk marker. Brief screening for depression in MS should include the assessment of suicidal ideation.     

从ARVC/D诊断标准的变迁看MPI对致心律不齐性右室型心肌病的诊断价值

致心律不齐性右室型心肌病（ARVC／D）的诊断标准于1994年首次被提出,并发表在《英国心脏杂志》。2002年Hamid等在《美国心脏病学会杂志》发表了“家族性ARVC／D诊断标准”,进一步提高了对该病病因、病理的认识。2010年4月,国际专家组在《欧洲心脏杂志》发表了修订的ARVC／D诊断标准。此标准首次明确地将MRI和超声等影像学量化标准作为诊断ARVC／D的主要条件。本文借鉴ARVC／D诊断标准的变化,结合文献,分析和总结该病的MRl表现,探讨MRI对ARVC／D的诊断价值。     

人类第6型疱疹病毒感染与特发性血小板减少性紫癜

探讨人类第６型疱疹病毒（ＨＨＶ－６）感染与特发性血小板减少性紫癜（ＩＴＰ）的关系。方法采用聚合栈 反应（ＰＣＲ）方法检测１０５例ＩＴＰ患者骨髓单个核细胞（ＢＭＭＮＣ）ＨＨＶ－６ＤＮＡ及部分患者微小病毒Ｂ１９、巨细胞病毒（ＨＣＭＶ）ＤＮＡ序列;用竞争性ＥＬＩＳＡ方法检测６６例ＩＴＰ患者血小板相关抗体（ＰＡＩｇ）,并采用间接免疫荧光法动态观察１９例ＩＴＰ患者抗ＨＨＶ－６血清抗体滴度变化。结果①ＩＴＰ患     

Determining criteria for excellence in nurse practitioner education: use of the Delphi Technique

Standards and guidelines are available to help nurse practitioner (NP) educators maintain quality in their programs. NP education is now at a juncture to develop criteria that extend beyond the basic standards to measurement of exemplary educational endeavors. In 2000, the National Organization of Nurse Practitioner Faculties Task Force for Programs of Excellence was formed and given the charge of developing criteria for recognizing exemplary nurse practitioner programs. This article reports on results and recommendations that evolved from a Delphi study to identify a set of criteria for excellence in NP programs. Thirteen expert panelists from across the United States participated in three rounds of iterations to evaluate the relevance, specificity, and comprehensiveness of 14 initial criteria and reached consensus on nine final criteria. Finally, the paper discusses ways that these criteria may be used to improve NP education through the development of a program to recognize excellence in NP education.     

Quality Indicators for Geriatric Emergency Care

Objectives:  Emergency departments (EDs), similar to other health care environments, are concerned with improving the quality of patient care. Older patients comprise a large, growing, and particularly vulnerable subset of ED users. The project objective was to develop ED-specific quality indicators for older patients to help practitioners identify quality gaps and focus quality improvement efforts.
Methods:  The Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, including members representing the American College of Emergency Physicians (ACEP), selected three conditions where there are quality gaps in the care of older patients: cognitive assessment, pain management, and transitional care in both directions between nursing homes and EDs. For each condition, a content expert created potential quality indicators based on a systematic review of the literature, supplemented with expert opinion when necessary. The original candidate quality indicators were modified in response to evaluation by four groups: the Task Force, the SAEM Geriatric Interest Group, and audiences at the 2007 SAEM Annual Meeting and the 2008 American Geriatrics Society Annual Meeting.
Results:  The authors offer 6 quality indicators for cognitive assessment, 6 for pain management, and 11 for transitions between nursing homes and EDs.
Conclusions:  These quality indicators will help researchers and clinicians target quality improvement efforts. The next steps will be to test the feasibility of capturing the quality indicators in existing medical records and to measure the extent to which each quality indicator is successfully met in current emergency practice.     

Six-minute walk test for persons with mild or moderate disability from multiple sclerosis: performance and explanatory factors

Purpose: The primary purpose of this study was to determine the extent to which health factors, functional measures, and pulmonary impairment explain performance on 6-Minute Walk Test (6MWT) distance in ambulatory persons with multiple sclerosis (MS). Another purpose was to determine the effect of disability and age on 6MWT performance and explanatory factors.Methods: A cross-sectional study design was used to evaluate factors that explain performance on the 6MWT in 64 community-dwelling persons with MS-related disability (Expanded Disability Status Scale [EDSS] 3.8±1.6). Of the 64 participants, 43 (67.2%) exhibited mild disability (EDSS <4.0) and 21 (32.8%) had moderate disability (EDSS 4.0-6.5). A regression analysis compared 6MWT performance to measures of health factors (EDSS, number of medications, number of comorbidities, resting HR, systolic and diastolic blood pressure [BP]); physical performance (functional stair test [FST], sit-to-stand test [SST], static standing balance [BAL], Fatigue Severity Scale [FSS], Activities-specific Balance Confidence [ABC] Scale); and pulmonary function (forced expiratory volume in 1 second [FEV(1)], forced vital capacity [FVC], maximal voluntary ventilation [MVV], maximal inspiratory pressure [MIP], maximal expiratory pressure [MEP]).Results: EDSS, ABC, FST, SST, BAL, MVV, MIP, and MEP were significantly associated with 6MWT distance after adjusting for age. Multiple step-wise linear regression analysis revealed that ABC, FST, and BAL were significant and independent explanatory factors of 6MWT distance. ABC and FST explained 75% of the variance in 6MWT performance (R(2)=0.75). Curvilinear regression analysis revealed that the FST is the most significant explanatory factor for 6MWT distance, explaining 79% of the variance (R(2)=0.79).Conclusions: 6MWT performance in persons with MS was explained by balance confidence (ABC) and stair-climbing ability (FST). The ABC and FST may be practical clinical measures for explaining walking ability and determining risk for disablement in persons with MS.     

Plasmodium vivax: a cause of malnutrition in young children

We studied the aetiology of malnutrition in a cohort of 1511 children < 10 years old in Espiritu Santo, Vanuatu. Malnutrition was categorized using standard anthropometric criteria as: underweight [weight-for-age (WA) Z score < -2], wasting [weight-for-height (WH) Z < -2], or stunting [height-for-age (HA) Z < -2]. On multiple logistic regression analysis, the only factors significantly associated with wasting were age < 5 years [OR (95% CI) 1.8 (1.2-2.9), p = 0.01] and having suffered one or more episodes of clinical P. vivax malaria in the 6 months preceding nutritional assessment [OR 2.4 (1.3-4.4), p = 0.006]. The incidence of P. vivax infection was significantly higher during the 6 months preceding assessment in underweight vs. non-underweight children [incidence rate ratio (IRR) 2.6 (1.5-4.4), p < or = 0.0001). These groups had similar incidences of clinical P. falciparum infection during the same period [IRR 1.1 (0.57-2.1) p = 0.8] and of either species during the 6 months following assessment [IRR P. vivax 1.3 (0.9- 2.0) p = 0.2; IRR P. falciparum 1.3 (0.9-1.9) p = 0.2]. In these children, P. vivax malaria was a major predictor of acute malnutrition; P. falciparum was not. Wasting neither predisposed to nor protected against malaria of either species. Although P. vivax malaria is generally regarded as benign, it may produce considerable global mortality through malnutrition.