This paper is a sequel to [8] where we introduced an invariant, called canonical degree, of Cohen–Macaulay local rings that admit a canonical ideal. Here to each such ring R with a canonical ideal, we attach a different invariant, called bi-canonical degree, which in dimension 1 appears also in [12] as the residue of R. The minimal values of these functions characterize specific classes of Cohen–Macaulay rings. We give a uniform presentation of such degrees and discuss some computational opportunities offered by the bi-canonical degree.

Study objectives: Studies of patient satisfaction after an emergency department (ED) visit often focus on methods of improving willingness to return for further care or postvisit satisfaction measures. However, up to half of ED visits are by first-time visitors, and such measures are not applicable to their initial appearance in the ED. Thus, interventions targeted toward improved satisfaction may not be relevant in addressing the preferences of a large segment of the ED population. This study is undertaken to determine the factors first-time visitors value most when choosing an ED, compared with repeat visitors. In addition, demographic factors affecting ED utilization between these groups were assessed. Methods: An observational, prospective survey at an urban Level I trauma center (annual census 64,000) was undertaken. A convenience sample of 346 patients visiting the ED during July and August 2003 was surveyed. Demographics on age, sex, race, insurance status, primary care access, and income were collected. Before their ED encounter, patients quantified the importance of the following aspects of their care a priori from 1 (not important) to 5 (very important): privacy, attentive nurse, diagnosis, informed of delays, wait time, pain relief, trust in providers, and having concerns addressed. These categories have previously been linked to patient satisfaction. A subset of first-time visitors was contacted several weeks after their initial visit to reevaluate their scores on these criteria. First-time visitors and repeat visitors were compared by Wilcoxon rank-sum test, with statistical significance criteria adjusted for multiple tests. Results: First-time visitors comprised 46% of total visits. Between first-time visitors and repeat visitors, median age was 37 years, 56% were women, 84% were insured, and 77% had a primary care physician. Repeat visitors averaged 2.7 visits per year (95% confidence interval [CI] 1.5 to 3.82) and reported lower median annual income than first-time visitors ($34,000 versus $60,000, P=.002). A greater proportion of repeat visitors were black (23% versus 13%, P=.02) and Hispanic (26% versus 13%, P=.007). Both groups valued "trust in providers" most (mean 4.5, 95% CI 4.4 to 4.7). First-time visitors valued privacy less than repeat visitors (3.8 versus 4.3, P=.0001) but were otherwise similar in their preferences. At follow-up, values of first-time visitors were no longer different from those of repeat visitors. Conclusion: Despite similarities in age, sex, and markers for access to care (insurance and a primary care physician), there are significant differences in the racial and economic backgrounds of repeat visitors compared with first-time visitors, which suggests that other factors contribute to increased utilization in this population. Although first-time visitors initially value privacy less than repeat visitors, this changed after experiencing a complete ED visit, which may reflect an initial naiveté on the part of first-time visitors about what to expect during a typical ED stay. We conclude that commonly used categories to score patient satisfaction may be used in first-time visitor and repeat visitor populations. Study objectives: Studies of patient satisfaction after an emergency department (ED) visit often focus on methods of improving willingness to return for further care or postvisit satisfaction measures. However, up to half of ED visits are by first-time visitors, and such measures are not applicable to their initial appearance in the ED. Thus, interventions targeted toward improved satisfaction may not be relevant in addressing the preferences of a large segment of the ED population. This study is undertaken to determine the factors first-time visitors value most when choosing an ED, compared with repeat visitors. In addition, demographic factors affecting ED utilization between these groups were assessed. Methods: An observational, prospective survey at an urban Level I trauma center (annual census 64,000) was undertaken. A convenience sample of 346 patients visiting the ED during July and August 2003 was surveyed. Demographics on age, sex, race, insurance status, primary care access, and income were collected. Before their ED encounter, patients quantified the importance of the following aspects of their care a priori from 1 (not important) to 5 (very important): privacy, attentive nurse, diagnosis, informed of delays, wait time, pain relief, trust in providers, and having concerns addressed. These categories have previously been linked to patient satisfaction. A subset of first-time visitors was contacted several weeks after their initial visit to reevaluate their scores on these criteria. First-time visitors and repeat visitors were compared by Wilcoxon rank-sum test, with statistical significance criteria adjusted for multiple tests. Results: First-time visitors comprised 46% of total visits. Between first-time visitors and repeat visitors, median age was 37 years, 56% were women, 84% were insured, and 77% had a primary care physician. Repeat visitors averaged 2.7 visits per year (95% confidence interval [CI] 1.5 to 3.82) and reported lower median annual income than first-time visitors ($34,000 versus $60,000, P=.002). A greater proportion of repeat visitors were black (23% versus 13%, P=.02) and Hispanic (26% versus 13%, P=.007). Both groups valued "trust in providers" most (mean 4.5, 95% CI 4.4 to 4.7). First-time visitors valued privacy less than repeat visitors (3.8 versus 4.3, P=.0001) but were otherwise similar in their preferences. At follow-up, values of first-time visitors were no longer different from those of repeat visitors. Conclusion: Despite similarities in age, sex, and markers for access to care (insurance and a primary care physician), there are significant differences in the racial and economic backgrounds of repeat visitors compared with first-time visitors, which suggests that other factors contribute to increased utilization in this population. Although first-time visitors initially value privacy less than repeat visitors, this changed after experiencing a complete ED visit, which may reflect an initial naiveté on the part of first-time visitors about what to expect during a typical ED stay. We conclude that commonly used categories to score patient satisfaction may be used in first-time visitor and repeat visitor populations.

Study objectives: Hate violence is a criminal offense that is motivated by bias against race, religion, disability, sexual orientation, or ethnicity. Many hate violence victims have great psychologic sequelae for as long as 5 years after the incident has occurred. Victims of hate violence commonly present to the emergency department (ED) for evaluation of their injuries. If emergency physicians fail to evaluate the events surrounding the assault, hate violence victims may be overlooked and improperly treated. Only scant information on hate violence is available in the medical literature. This study is designed to analyze the prevalence and affected groups of hate violence in the United States during an 11-year period. Methods: This study is a descriptive epidemiologic 11-year analysis of hate violence derived from the Federal B ureau of Investigation's Uniform Crime Reports from 1992 to 2002. The yearly data were aggregated, allowing the analysis and review of hate violence offenses according to year, bias motivation group, subgroup, and offense type for crimes against persons during an 11-year period. This study focused only on crimes against people and does not include crimes against property or society. Results: During 11 years, 71,185 acts of hate violence were reported to the Uniform Crime Reports. Intimidation (54%) and assaults (46%) accounted for the bulk of reported hate violence offenses. The analysis showed that 62% of reported hate violence was motivated by race, with antiblack bias accounting for 40% of all hate violence offenses. The next largest bias motivation was sexual orientation, encompassing 15% of the total, predominantly against male homosexuals. Hate violence offenses toward ethnicity accounted for an additional 14%, with Hispanics being the primary target. Although acts of hate violence against religion composed 9%, 78% of this amount was due to anti-Semitism. Also, an alarming trend emerged after September 11, 2001, with anti-Islamic violence growing by 2,061% from 2000 to 2001. Although 156 homicides and 93 sexual assaults composed a smaller amount of the total, the heinous nature of these hate violence offenses should not be disregarded. Conclusion: Hate violence permeates every facet of society, with only a fraction of offenses being reported (estimated 1 in 9). Many of these victims present to the ED; thus emergency physicians are likely to serve as the initial foundation of safety and advocacy for hate violence victims. The scope of the problem and psychologic sequelae caused by hate victimization must be understood to effectively manage care in the ED.

There are approximately 6 million individuals with a diagnosis of mental retardation in the United States. Because of deinstitutionalization of patients with mental retardation, coupled with an increase in their life expectancy, emergency physicians are increasingly encountering and managing patients with mental retardation in the emergency department. Many emergency physicians are uncomfortable when interacting with individuals with mental retardation, which often carries over to the assessment and management of these patients in the ED. The purpose of this review is to aid the emergency physician in understanding the patient with mental retardation, their comorbid conditions, and the approach to evaluating and managing these patients in the ED. [Grossman SA, Richards CF, Anglin D, Hutson HR. Caring for the patient with mental retardation in the emergency department. Ann Emerg Med. January 2000;35:69-76.]

Recent developments, such as the bombings of the World Trade Center in 1993 and the Alfred P. Murrah Federal Building in Oklahoma City in 1995, the sarin attacks in Tokyo and Matsumoto, Japan, and US Embassy bombings in Kenya and Tanzania in 1998, have heightened fears of terrorist attacks. Future terrorist activities will continue to involve bombs and firearms, but may also include weapons of mass destruction, including biological agents. Recent US government initiatives have recognized the threats to our country from these weapons and have funded planning and response programs. These preparedness programs are being built on existing infrastructure of EMS and fire services' plans for hazardous materials response. Appropriate emergency department and hospital response, guided by public health principles, could significantly limit the morbidity and mortality of biological warfare agents. Inappropriate response by the medical community may worsen a chaotic and potentially devastating situation. This article discusses planning and response issues central to a potential bioterrorism event.

Study objective: "Suicide by cop" is a term used by law enforcement officers to describe an incident in which a suicidal individual intentionally engages in life-threatening and criminal behavior with a lethal weapon or what appears to be a lethal weapon toward law enforcement officers or civilians to specifically provoke officers to shoot the suicidal individual in self-defense or to protect civilians. The objective of this study was to investigate the phenomenon that some individuals attempt or commit suicide by intentionally provoking law enforcement officers to shoot them.Methods: We reviewed all files of officer-involved shootings investigated by the Los Angeles County Sheriff's Department from 1987 to 1997. Cases met the following criteria: (1) evidence of the individual's suicidal intent, (2) evidence they specifically wanted officers to shoot them, (3) evidence they possessed a lethal weapon or what appeared to be a lethal weapon, and (4) evidence they intentionally escalated the encounter and provoked officers to shoot them.Results: Suicide by cop accounted for 11% (n=46) of all officer-involved shootings and 13% of all officer-involved justifiable homicides. Ages of suicidal individuals ranged from 18 to 54 years; 98% were male. Forty-eight percent of weapons possessed by suicidal individuals were firearms, 17% replica firearms. The median time from arrival of officers at the scene to the time of the shooting was 15 minutes with 70% of shootings occurring within 30 minutes of arrival of officers. Thirty-nine percent of cases involved domestic violence. Fifty-four percent of suicidal individuals sustained fatal gunshot wounds. All deaths were classified by the coroner as homicides, as opposed to suicides.Conclusion: Suicide by cop is an actual form of suicide. The most appropriate term for this phenomenon is law enforcement-forced-assisted suicide. law enforcement agencies may be able to develop strategies for early recognition and handling of law enforcement-forced-assisted suicide (suicide by cop). Health care providers involved in the evaluation of potentially suicidal individuals and in the resuscitation of officer-involved shootings should be aware of law enforcement-forced-assisted suicide as a form of suicide.

In this paper we demonstrate the relationship between uniform distribution modulo 1 of the sequence $cp^{\alpha}$, $p$ prime, and the zero free regions of the Riemann zeta function.

In this paper we characterize commutative rings with finite dimensional classical ring of quotients. To illustrate the diversity of behavior of these rings we examine the case of local rings and FPF rings. Our results extend earlier work on rings with zero-dimensional rings of quotients.

The purpose of this paper is to examine the ways in which the structure of the Minimal Spectrum (Min(A )) of a commutative ring A is reflected in its maximal flat mono-epimorphism (Q,,,(A)) and its classical ring of Quotients (Q,,(A)). In the reduced case, there is an extensive literature [Ml, H & J, Mew, Q] on this subject. We focus attention on the subtleties created by non-trivial nilpotents. In general, there are homomorphisms relating Q,,,(A) and Q,,(A) to T(Min(A), 8) (0 denotes the structure sheaf of A). Examples are given to show that even in global flat dimension 1, these three objects can be distinct. With this potential in mind, we ask how such pathology can be eliminated. In particular, we show that for any commutative ring A, the following are equivalent: