bluuebunny/crossref_metadata_2025 huggingface dataset:
Construction of Seven Contiguous Chiral Centers by Two Methods: Quadruple Michael Addition vs Stepwise Double‐Double Michael Addition Controlled by Adding Speed of Michael Acceptor
Authors: Ozeki Minoru , Hayama Noboru , Fukutome Shintaro , Egawa Honoka , Arimitsu Kenji , Kajimoto Tetsuya , Hosoi Shinzo , Iwasaki Hiroki , Kojima Naoto , Node Manabu , Yamashita Masayuki
Published: July 2016

A tandem “quadruple” Michael addition reaction of (+)‐bornylamide with two equivalents of a Michael acceptor having two α,β‐unsaturated ester moieties spontaneously proceeded to afford one diastereomer with seven contiguous chiral centers in 27 % yield. Meanwhile, a stepwise “double‐double” Michael addition, in which the very slow addition of the first one equivalent of the acceptor substrate to the bornylamide was followed by a further addition of another Michael acceptor bearing two α,β‐unsaturated ester moieties, provided a compound with a similar set of seven contiguous chiral centers on a different carbon skeleton in 48 % yield. Both quadruple and double‐double Michael adducts were one of 128 possible diastereomers, namely, each Michael addition in those two reactions proceeded in 72 % and 83 % yields on average, respectively. We showed the importance of adding speed of the Michael acceptor to the bornylamide in controlling the quadruple and double‐double Michael addition reactions.
Assessment of Cesarean hysterotomy scar before pregnancy and at 11–14 weeks of gestation: a prospective cohort study
Authors: Baranov A. , Salvesen K. Å. , Vikhareva O.
Published: July 2016

Objective

To compare the appearance and measurement of Cesarean hysterotomy scar before pregnancy and at 11–14 weeks in a subsequent pregnancy.

Methods

This was a prospective cohort study of women aged 18–35 years who had one previous Cesarean delivery (CD) at ≥ 37 weeks. Women were examined with saline contrast sonohysterography 6–9 months after CD. A scar defect was defined as large if scar thickness was ≤ 2.5 mm. Women were followed up and those who became pregnant were examined by transvaginal ultrasound at 11–14 weeks. Scar thickness was measured and scars were classified subjectively as a scar with or without a large defect. A receiver–operating characteristics curve was constructed to determine the best cut‐off value for scar thickness to define a large scar defect at the 11–14‐week scan.

Results

A total of 111 women with a previous CD were scanned in the non‐pregnant state and at 11–14 weeks in a subsequent pregnancy. The best cut‐off value for scar thickness to define a large scar defect at 11–14 weeks was 2.85 mm, which had 90% sensitivity (18/20), 97% specificity (88/91) and 95% accuracy (106/111). In the non‐pregnant state, large scar defects were found in 18 (16%) women and all were confirmed at the 11–14‐week scan. In addition, a large defect was found in three women at 11–14 weeks that was not identified in the non‐pregnant state.

Conclusion

The appearance of the Cesarean hysterotomy scar was similar in the non‐pregnant state and at 11–14 weeks in a subsequent pregnancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
The XYG3 type of doubly hybrid density functionals
Authors: Su Neil Qiang , Xu Xin
Published: July 2016

Doubly hybrid (DH) functionals have emerged as a new class of density functional approximations (DFAs), which not only have a nonlocal orbital‐dependent component in the exchange part, but also incorporate the information of unoccupied orbitals in the correlation part, being at the top rung of Perdew's view of Jacob's ladder in DFAs. This review article focuses on the XYG3 type of DH (xDH) functionals, which use a low rung functional to perform the self‐consistent‐field calculation to generate orbitals and densities, with which a top rung DH functional is used for final energy evaluation. We will discuss the theoretical background of the xDH functionals, briefly reviewing the adiabatic connection formalism, coordinate scaling relations, and Görling–Levy perturbation theory. General performance of the xDH functionals will be presented for both energies and structures. In particular, we will present the fractional charge behaviors of the xDH functionals, examining the self‐interaction errors, the delocalization errors and the deviation from the linearity condition, as well as their effects on the predicted ionization potentials, electron affinities and fundamental gaps. This provides a theoretical rationale for the observed good performance of the xDH functionals. WIREs Comput Mol Sci 2016, 6:721–747. doi: 10.1002/wcms.1274

This article is categorized under:

Electronic Structure Theory > Density Functional Theory
Intracellular imaging of quantum dots, gold, and iron oxide nanoparticles with associated endocytic pathways
Authors: Chen Dandan , Monteiro‐Riviere Nancy A. , Zhang Leshuai W.
Published: July 2016

Metallic nanoparticles (NP) have been used for biomedical applications especially for imaging. Compared to nonmetallicNP, metallicNPprovide high contrast images because of their optical light scattering, magnetic resonance, X‐ray absorption, or other physicochemical properties. In this review, a series ofin vitroimaging techniques for metallicNPwill be introduced, meanwhile their strengths and weaknesses will be discussed. By utilizing these imaging methods, the cellular uptake of metallicNPcan be easily visualized to better understand the endocytic mechanisms ofNPintracellular delivery. Several types of metallicNPthat are used for imaging or as contrast agents such as quantum dots, gold, iron oxide, and other metallicNPwill be presented. Cellular uptake of metallicNPand associated endocytic mechanisms highly depends upon theNPsize, charge, surface coating, shape, or other factors such as cell type, cell differentiation status, cell surface status, external forces, protein binding, temperature, and the biological milieu. Classical endocytic routes such as lipid raft‐mediated pathways, clathrin or caveolae‐mediated pathways, macropinocytosis, and phagocytosis have been investigated, yet there is still a demand to determine other endocytic pathways. Knowing the different methodologies used to determine the endocytic pathways will increase the understanding ofNPtoxicity, cancer cell targeting, and imaging, so that surface coatings can be created for efficient cell uptake of metallicNPwith minimal cytotoxicityWIREs Nanomed Nanobiotechnol2017, 9:e1419. doi: 10.1002/wnan.1419

This article is categorized under:

Toxicology and Regulatory Issues in Nanomedicine > Toxicology of Nanomaterials
Transformation of spatial and perturbation derivatives of travel time at a curved interface between two arbitrary media
Authors: Klimeš Luděk
Published: July 2016

We consider the partial derivatives of travel time with respect to both spatial coordinates and perturbation parameters. These derivatives are very important in studying wave propagation and have already found various applications in smooth media without interfaces. In order to extend the applications to media composed of layers and blocks, we derive the explicit equations for transforming these travel–time derivatives of arbitrary orders at a general smooth curved interface between two arbitrary media. The equations are applicable to both real–valued and complex–valued travel time. The equations are expressed in terms of a general Hamiltonian function and are applicable to the transformation of travel–time derivatives in both isotropic and anisotropic media. The interface is specified by an implicit equation. No local coordinates are needed for the transformation.
4‐Methylzymosterone and Other Intermediates of Sterol Biosynthesis from Yeast Mutants Engineered in the ERG27 Gene Encoding 3‐Ketosteroid Reductase
Authors: Ferrante Terenzio , Barge Alessandro , Taramino Silvia , Oliaro‐Bosso Simonetta , Balliano Gianni
Published: July 2016

Studies in the post‐squalene section of sterol biosynthesis may be hampered by the poor availability of authentic standards. The present study used different yeast strains engineered in 3‐ketosteroid reductase (Erg27p) to obtain radioactive and non‐radioactive intermediates of sterol biosynthesis hardly or not available commercially. Non‐radioactive 3‐keto 4‐monomethyl sterones were purified from non‐saponifiable lipids extracted from cells bearing point‐mutated 3‐ketosteroid reductase. Two strategies were adopted to prepare the radioactive compounds: (1) incubation of cell homogenates of an ERG27‐deletant strain with radioactive lanosterol, (2) incubation of growing cells of a strain expressing point‐mutated 3‐ketosteroid reductase with radioactive acetate. Chemical reduction of both radioactive and non‐radioactive 3‐keto sterones gave the physiological 3‐β OH sterols, as well as the non‐physiological 3‐α OH isomers. This combined biological and chemical preparation procedure provided otherwise unavailable or hardly available 4‐mono‐methyl intermediates of sterol biosynthesis, paving the way for research into their roles in physiological and pathological conditions.
Perceptions of ostomized persons due to colorectal cancer on their quality of life
Authors: Kimura Cristilene Akiko , Kamada Ivone , Guilhem Dirce Bellezi , Ribeiro Modesto Karina , Silva de Abreu Breno
Published: July 2016

Introduction The significance of the change in the physical body and suffering as the new condition of life of stoma oncological person affect the physical, psychological, social relationships and environment.

Objective To know the perception of quality of life and the interpretation of the biopsychosocial reality of intestinal ostomy due to colorectal cancer clinics of the Ambulatory Care Program ostomy patients of the Health Secretariat of the Federal District, Brazil.

Methods Epidemiological based study, analytical character, with cross-sectional descriptive design with quantitative and qualitative approach in the light of the content analysis. Sample consisted of convenience, included 120 participants. They used the questionnaires sociodemographic, clinical, and WHOQOL-BREF and an individual interview. Data were analyzed by Microsoft Office Excel 2010 and SPSS 20.0 software. Statistical significance was accepted at 5%.

Results Physical Domains, Social Affairs and Environment are correlated with the mean score, statistically significant (p < 0.0001), the content analysis resulted in four categories: Wellness Physical, Psychological Wellness, Wellness and Spiritual Well living Social.

Conclusion Ostomy and colorectal cancer may represent suffered mutilation, loss of productive capacity resulting in the loss of quality of life.
Can Ultrasound Accurately Assess Ischiofemoral Space Dimensions? A Validation Study
Authors: Finnoff Jonathan T. , Johnson Adam C. , Hollman John H.
Published: July 2016

Background

Ischiofemoral impingement is a potential cause of hip and buttock pain. It is evaluated commonly with magnetic resonance imaging (MRI). To our knowledge, no study previously has evaluated the ability of ultrasound to measure the ischiofemoral space (IFS) dimensions reliably.

Objective

To determine whether ultrasound could accurately measure the IFS dimensions when compared with the gold standard imaging modality of MRI.

Design

A methods comparison study.

Setting

Sports medicine center within a tertiary‐care institution.

Participants

A total of 5 male and 5 female asymptomatic adult subjects (age mean = 29.2 years, range = 23‐35 years; body mass index mean = 23.5, range = 19.5‐26.6) were recruited to participate in the study.

Methods

Subjects were secured in a prone position on a MRI table with their hips in a neutral position. Their IFS dimensions were then acquired in a randomized order using diagnostic ultrasound and MRI.

Main Outcome Measurements

The main outcome measurements were the IFS dimensions acquired with ultrasound and MRI.

Results

The mean IFS dimensions measured with ultrasound was 29.5 mm (standard deviation [SD] 4.99 mm, standard error mean 1.12 mm), whereas those obtained with MRI were 28.25 mm (SD 5.91 mm, standard error mean 1.32 mm). The mean difference between the ultrasound and MRI measurements was 1.25 mm, which was not statistically significant (SD 3.71 mm, standard error mean 3.71 mm, 95% confidence interval −0.49 mm to 2.98 mm, t19 = 1.506, P = .15). The Bland‐Altman analysis indicated that the 95% limits of agreement between the 2 measurement was −6.0 to 8.5 mm, indicating that there was no systematic bias between the ultrasound and MRI measurements.

Conclusions

Our findings suggest that the IFS measurements obtained with ultrasound are very similar to those obtained with MRI. Therefore, when evaluating individuals with suspected ischiofemoral impingement, one could consider using ultrasound to measure their IFS dimensions.

Level of Evidence

III
Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management
Authors: Sturesson Lars , Falk Ann-Charlotte , Castrén Maaret , Niemi-Murola Leila , Lindström Veronica
Published: July 2016

Background

Pain is one of the most common symptoms treated in emergency department (ED). Pain may cause suffering and disability for the patient. Inadequate pain management may be associated with increased risk of complications such as sleep disturbance, delirium and depression. Previous studies conclude that pain management in ED is insufficient and inadequate. Yet, little is known about patients’ own experience regarding pain management in ED.

Objective

The aim of this study was to explore the satisfaction of pain management in patients having acute musculoskeletal injuries before and after implementation of mandatory documentation regarding pain assessment in the ED.

Method

An observational pre-post intervention study design was used. The study was conducted on patients having acute musculoskeletal injuries such as soft tissue injury, back pain or wrist/arm/leg/foot fractures in a 24-h adult (>15 years) ED at a public urban teaching hospital in Stockholm, Sweden. Data was collected by an interview based on a questionnaire.

Results

A total of 160 patients answered the questionnaire. In the pre- (n = 80) and post-intervention (n = 80) groups, 91/95% experienced pain in the ED. A significant difference (p < 0.003) was found during the post-intervention period, with more patients receiving analgesics compared to the pre-intervention group. A significant decline (p < 0.03) in patients’ own reported pain intensity at discharge was found between the groups. Patients’ reported satisfaction on pain management in the ED increased in the post-intervention group, but the difference was not statistically significantly.

Conclusion

Patients’ satisfaction with pain management increased, but not statistically significantly. However, both percentages of patients receiving analgesic drugs increased and pain intensity decrease at discharge were statistically significant after the intervention that made nurses obliged to register pain.

Implication

According to the findings of this study, mandatory pain documentation facilitates pain management in the ED, but there is still room for improvement. Additional actions are needed to improve patients’ satisfaction on pain management in the ED. Mandatory pain documentation in combination with person-centred care could be a way of improving patients’ satisfaction on pain management. Effective pain management is an important quality measure, and should be focused on in acute care in the ED. By routinely asking patients to report the pain intensity at discharge, the ED personnel can have direct feedback about the factual pain management. RNs may also be encouraged to use intravenous analgesics in higher extent when the patients have very severe pain.
Identification of the chitinase genes from the diamondback moth,Plutella xylostella
Authors: Liao Z.H. , Kuo T.C. , Kao C.H. , Chou T.M. , Kao Y.H. , Huang R.N.
Published: July 2016

Chitinases have an indispensable function in chitin metabolism and are well characterized in numerous insect species. Although the diamondback moth (DBM)Plutella xylostella, which has a high reproductive potential, short generation time, and characteristic adaptation to adverse environments, has become one of the most serious pests of cruciferous plants worldwide, the information on the chitinases of the moth is presently limited. In the present study, using degenerated polymerase chain reaction (PCR) and rapid amplification of cDNA ends-PCR strategies, four chitinase genes ofP. xylostellawere cloned, and an exhaustive search was conducted for chitinase-like sequences from theP. xylostellagenome and transcriptomic database. Based on the domain analysis of the deduced amino acid sequences and the phylogenetic analysis of the catalytic domain sequences, we identified 15 chitinase genes fromP. xylostella. Two of the gut-specific chitinases did not cluster with any of the known phylogenetic groups of chitinases and might be in a new group of the chitinase family. Moreover, in our study, group VIII chitinase was not identified. The structures, classifications and expression patterns of the chitinases ofP. xylostellawere further delineated, and with this information, further investigations on the functions of chitinase genes in DBM could be facilitated.
COLLABORATORS, COLLABORATION, AND THE PROBLEMS OF EMPIRE IN NAPOLEONIC ITALY, THE OPPIZZONI AFFAIR, 1805–1807
Authors: CAIANI AMBROGIO A.
Published: July 2016

The recent bicentennial commemorations of the Napoleonic empire have witnessed a proliferation of new studies. Scholars now possess much more sophisticated conceptual tools than in past decades with which to gauge the problems faced by French imperial administrators throughout Europe. Well-trodden concepts, like centre/periphery or collaboration/resistance, have been reinvigorated by more sophisticated understandings of how rulers and ruled interacted in the early nineteenth century. This article argues that, while much progress has been made in understanding problems of ‘resistance’, there is more to be said about the other side of the same coin, namely: ‘collaboration’. Using the micro/local history of a scandal in Napoleonic Bologna, this article wishes to reaffirm that collaboration was an active agent that shaped, and often shook, the French imperial project. The biggest problem remained that, despite ‘good intentions’, collaborators sometimes simply did not collaborate with each other. After all, imperial clients were determined to benefit from the experience of empire. The centre was often submerged by local petty squabbles. This article will use a specific micro-history in Bologna to highlight the extent to which Napoleonic empire builders had to thread a fine line between the impracticalities of direct control and the dangers of ‘going native’.
Irreducible characters of even degree and normal Sylow 2-subgroups
Authors: HUNG NGUYEN NGOC , TIEP PHAM HUU
Published: July 2016

The classical Itô-Michler theorem on character degrees of finite groups asserts that if the degree of every complex irreducible character of a finite group G is coprime to a given prime p, then G has a normal Sylow p-subgroup. We propose a new direction to generalize this theorem by introducing an invariant concerning character degrees. We show that if the average degree of linear and even-degree irreducible characters of G is less than 4/3 then G has a normal Sylow 2-subgroup, as well as corresponding analogues for real-valued characters and strongly real characters. These results improve on several earlier results concerning the Itô-Michler theorem.
Distinct Distances on Algebraic Curves in the Plane
Authors: PACH JÁNOS , DE ZEEUW FRANK
Published: July 2016

LetSbe a set ofnpoints in${\mathbb R}^{2}$contained in an algebraic curveCof degreed. We prove that the number of distinct distances determined bySis at leastcdn4/3, unlessCcontains a line or a circle.

We also prove the lower boundcd′ min{m2/3n2/3,m2,n2} for the number of distinct distances betweenmpoints on one irreducible plane algebraic curve andnpoints on another, unless the two curves are parallel lines, orthogonal lines, or concentric circles. This generalizes a result on distances between lines of Sharir, Sheffer and Solymosi in [19].
Standard Operating Procedures: A Safety Net for Pre-Analysis Plans
Authors: Lin Winston , Green Donald P.
Published: July 2016

Across the social sciences, growing concerns about research transparency have led to calls for pre-analysis plans (PAPs) that specify in advance how researchers intend to analyze the data they are about to gather. PAPs promote transparency and credibility by helping readers distinguish between exploratory and confirmatory analyses. However, PAPs are time-consuming to write and may fail to anticipate contingencies that arise in the course of data collection. This article proposes the use of “standard operating procedures” (SOPs)—default practices to guide decisions when issues arise that were not anticipated in the PAP. We offer an example of an SOP that can be adapted by other researchers seeking a safety net to support their PAPs.
Pediatric musculoskeletal pain in the emergency department: a medical record review of practice variation
Authors: Kircher Janeva , Drendel Amy L. , Newton Amanda S. , Dulai Sukhdeep , Vandermeer Ben , Samina Ali
Published: July 2016

Objective:

Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to the emergency department (ED). The primary objective of this study was to describe current analgesic administration practices for the outpatient management of children’s MSK pain, both in the ED and postdischarge.

Methods:

We reviewed the medical records of consecutive pediatric patients evaluated in either a pediatric or a general ED (Edmonton, Alberta) during four evenly distributed calendar months, with a diagnosis of fracture, dislocation, strain, or sprain of a limb. Abstracted data included demographics, administered analgesics, pain scores, discharge medication advice, and timing of clinical care.

Results:

A total of 543 medical records were reviewed (n 5 468 pediatric ED, n 5 75 general ED). Nineteen percent had documented prehospital analgesics, 34% had documented in-ED analgesics, 13% reported procedural sedation, and 24% documented discharge analgesia advice. Of those children receiving analgesics in the ED, 59% (126 of 214) received ibuprofen. Pain scores were recorded for 6% of patients. At discharge, ibuprofen was recommended to 47% and codeine-containing compounds to 21% of children. The average time from triage to first analgesic in the ED was 121 6 84 minutes.

Conclusions:

Documentation of the assessment and management of children’s pain in the ED is poor, and pain management appears to be suboptimal. When provided, ibuprofen is the most common analgesic used for children with MSK pain. Pediatric patients with MSK pain do not receive timely medication, and interventions must be developed to improve the ‘‘door to analgesia’’ time for children in pain.
Radiation doses to emergency department patients undergoing computed tomography
Authors: Worrall James C. , Jama Sadia , Stiell Ian G.
Published: July 2016

Objectives:

Computed tomography (CT) use is increasing in the emergency department (ED). Many physicians are concerned about exposing patients to radiation from CT scanning, but estimates of radiation doses vary. This study’s objective was to determine the radiation doses from CT scanning for common indications in a Canadian ED using modern multidetector CT scanners.

Methods:

We conducted a health records review of consecutive adult patients seen at two busy tertiary care EDs over a 2-month period who underwent CT scanning ordered by emergency physicians. Cases were identified by searching an imaging database. Data collected included patient age and sex, study indication, scanner model, body area, and reported dose-length product. Effective dose per scan was calculated from reported dose-length product. Data were collected on a standardized form, entered into an electronic database, and analyzed with descriptive statistics and 95% CIs. Results: During the study period, emergency physicians assessed 19,880 patients. Overall, 2,720 (13.7%) underwent CT scanning, and of these, 144 (5.3%) patients had more than one scan. Patients had a mean age of 59.0 years, and 45.3% were men. Mean doses for the most common indications were as follows: simple head, 2.9 mSv; cervical spine, 5.7 mSv; complex head, 9.3 mSv; CT pulmonary angiogram, 11.2 mSv; abdomen (nontraumatic abdominal pain), 15.4 mSv; and abdomen (renal colic), 9.8 mSv.

Conclusions:

Approximately one in seven ED patients had a CT scan. Emergency physicians should be aware of typical radiation doses for the studies they order and how the dose varies by protocol and indication.
Lumbar Puncture First? An old test and a new approach to lone acute sudden headaches
Authors: Schull Michael J.
Published: July 2016

On évoque souvent le diagnostic de l’hémorragie sous-arachnoïdienne chez les patients qui se présentent à l’urgence pour un mal de tête violent et soudain, mais dont l’examen physique est normal. La norme de soins de nos jours consiste à soumettre ces patients à une tomodensitométrie (TDM) sans substance de contraste suivie d’une ponction lombaire pour les TDM négatives. Cependant, comme la plupart des céphalées évaluées sont bénignes, la plupart des résultats de la TDM et de la ponction lombaire sont normaux.

Le présent article a pour but d’analyser l’impact d’un protocole diagnostique de rechange, où la ponction lombaire serait la première (et dans la plupart des cas, la seule) épreuve diagnostique effectuée chez les patients chez qui l’on soupçonne une hémorragie sous-arachnoïdienne et qui présentent ce symptôme isolé de mal de tête violent. Selon une hypothèse raisonnable, pour chaque 100 patients évalués, le protocole de «ponction lombaire en premier» nécessiterait 81 TDM de moins et seulement 9 ponctions lombaires additionnelles, comparativement à la stratégie diagnostique traditionnelle. Ces avantages demeurent stables même en variant les hypothèses à l’intérieur des limites cliniquement plausibles.

Nous croyons que ce protocole pourrait entraîner une utilisation beaucoup plus efficace des ressources en limitant le taux de morbidité additionnel, tout en offrant une précision diagnostique équivalente pour l’hémorragie sous-arachnoïdienne chez le patient à l’urgence qui répond au critère de mal de tête isolé violent et soudain.
Confined-space accidents on the farm: the manure pit and the silo
Authors: Shepherd Lisa G.
Published: July 2016

Manure pits and silos are potentially dangerous, gas-containing confined spaces on the farm that may generate hazardous levels of hydrogen sulphide and nitrogen dioxide respectively. Although these inhalation injuries are uncommon, emergency physicians who work within transport distance of rural areas should be aware of the toxic agents involved and their acute management. This article reviews the toxicology, clinical manifestations and treatment of acute, farm-related hydrogen sulphide and nitrogen dioxide exposures.
Malignant superior vena cava syndrome presenting after trauma
Authors: Price Laura A. , Gilkinson Trevor L.
Published: July 2016

A 41-year-old man was brought to the ED after a motor vehicle crash. On presentation, he demonstrated symptoms compatible with superior vena cava (SVC) syndrome, including extreme dyspnea, face and neck cyanosis and facial swelling. A chest tube was inserted and drained large amounts of sanguineous fluid. An exploratory thoracotomy revealed an extensive tumour encasing the SVC and the hilum. Biopsy confirmed the diagnosis of T-cell lymphoma.

The most common cause of SVC syndrome is malignant disease, with bronchogenic carcinoma and lymphoma being most frequent. Review of the literature uncovered only a few anecdotal reports of traumatic SVC syndrome. There are no previous reported cases of malignant SVC syndrome presenting in association with trauma.
Ultrasound in emergency medicine
Authors: Ducharme James
Published: July 2016

Although diagnostic imaging is, for the most part, the domain of radiologists, exceptions to this rule have developed. Cardiologists perform cardiac catheterization and echocardiography. Obstetricians have developed expertise in transvaginal ultrasound and fetal assessment. Why have some specialties embraced areas of imaging as theirs, while others — such as orthopedics and medicine — continue to rely on radiology? One reason is that radiologic expertise in these latter specialities is rarely required on a 24-hour basis and it can be provided without taking on an overwhelming workload. ED bedside ultrasonography, on the other hand, must be available 24 hours a day. Conditions requiring immediate (within 15 to 20 minutes) ultrasound (U/S) include expanding or leaking abdominal aneurysm, suspected ectopic pregnancy, and traumatic hemoperitoneum. When patients with these conditions are unstable they require even more rapid imaging — “real imaging” in the operating room.
The ultrasound controversy
Authors: Campana Bruce
Published: July 2016

Ah, the ultrasound controversy. Every emergency department (ED) that I’m aware of goes through this struggle. The radiology department resists the introduction of ultrasound (U/S) because, and I don’t want to oversimplify a complex issue, they are worried they will lose money.
A radiologist’s perspective
Authors: McPhee Derrick
Published: July 2016

Focused abdominal sonography in trauma (FAST) has in many centres replaced the diagnostic peritoneal lavage (DPL) for the early assessment of acute blunt abdominal trauma. In many cases a negative FAST obviates the need for further imaging and intervention. In well-trained hands, it is a very specific and relatively sensitive test for the detection of hemoperitoneum and has the advantage over DPL of being noninvasive. However, the introduction of this exam has raised many contentious issues around indications for the study, as well as who should perform and interpret the study. Ironically, the question of who should perform the test has in many ways overshadowed the issue of whether it should be performed at all.
Meditating on what we do
Authors: Zeit Harry
Published: July 2016

You’ll start in the ER!” the Chief of Staff informs his prize new surgical fellow, Robert Yeats, played by Hollywood heartthrob Eric Stoltz. This is TV land, Chicago Hope to be exact, and a great set-up for a hard-hitting personality clash.

“I don’t want him,” the ER director and trauma surgeon, Dr. Keith Wilks, complains ineffectually. “I’m ‘way too busy today.”
An emergency medical services controversy in Nova Scotia: What is expanded-scope EMS?
Authors: Petrie David
Published: July 2016

Les services médicaux d’urgence d’application élargie (SMU) est un sujet d’actualité qui demeure une énigme pour plusieurs. Une vue d’ensemble des SMU d’application élargie prendrait en considération quatre variations.

La première, les SMU aigus, non planifiés (d’application élargie) inclurait des protocoles de «traitement et de congé» pour des problèmes comme l’hypoglycémie, les traumatismes mineurs et les blessures. Cette variation intégrerait également le concept de SMU à «choix multiples», où les préposés aux SMU évalueraient l’état du patient et auraient le choix de le transporter vers un département d’urgence, vers une clinique ou un autre établissement de soins, ou de le traiter et de lui donner son congé. Dans un tel système, le protocole offrirait la flexibilité aux répartiteurs médicaux d’orienter les appels vers une ligne Info-Santé ou d’organiser un transport non ambulancier. Ce type de SMU pourrait aussi permettre l’application des fonctions traditionnelles des SMU dans de nouveaux environnements, comme par exemple donner aux préposés aux services médicaux d’urgence la responsabilité d’équipes d’arrêt cardiaque dans les hôpitaux..

Les SMU non aigus, planifiés (d’application élargie) incluraient des initiatives dirigées par les SMU qui établiraient un pont entre la médecine d’urgence et la santé publique. Celles-ci comprendraient, par exemple, des programmes communautaires de vaccination, des programmes d’évaluation de l’état de santé à domicile, des soins prénatals et des visites de suivi pour la vérification de plaies, l’administration intraveineuse d’antibiotiques ou de médicaments après une visite à l’urgence, et des programmes d’observance de traitement.

Le «service» d’application élargie fait référence aux initiatives de prévention et d’éducation dirigées par les SMU, comme la prévention des blessures (p. ex. le port du casque de bicyclette, les programmes de contrôle de l’alcool au volant) et l’éducation des citoyens (p. ex. la RCR et l’abandon de la cigarette).

Les SMU cliniques, hospitaliers ou en région éloignée (d’application élargie) intégreraient une nouvelle classe de préposés aux SMU ou dispensateurs de soins intermédiaires qui travailleraient avec les médecins, possiblement par le biais de la télémédecine. Ces préposés s’acquitteraient principalement de tâches spécifiques, comme poser des plâtres, faire des points de suture et extraire des corps étrangers oculaires. Avec une certaine formation post-secondaire, ils pourraient avoir la possibilité de poser des diagnostics et de prescrire des médicaments, un peu comme un «assistant médecin».

Préparez-vous! Les SMU d’application élargie s’en viennent.
The NARC (Nonsteroidal Anti-inflammatory in Renal Colic) Trial. Single-dose intravenous ketorolac versus titrated intravenous meperidine in acute renal colic: a randomized clinical trial
Authors: Wood Victor M. , Christenson James M. , Innes Grant D. , Lesperance Mary , McKnight R. Douglas
Published: July 2016

Objectives:

Intravenous (IV) opioid titration is an accepted method of relieving acute renal colic. Studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective in this setting. Our objective was to compare single-dose ketorolac and titrated meperidine, both administered intravenously, with respect to speed and degree of analgesia, adverse effects and functional status. Our primary hypothesis was that these agents provide equivalent analgesia within 60 minutes. Our secondary hypotheses were that ketorolac-treated patients would experience fewer adverse effects and would be better able to resume usual activity.

Methods:

This was a multicentre, double-blind randomized equivalence trial in a convenience sample of patients age 18–65 with moderate or severe renal colic, documented by intravenous pyelogram, ultrasound or stone passage. Meperidine-treated patients received 50 mg IV meperidine at 0 minutes, then 25–50 mg every 15 minutes as needed for ongoing pain. Ketorolac-treated patients received 30 mg IV ketorolac at 0 minutes and placebo injections every 15 minutes as needed. Pain levels and adverse effects were assessed every 15 minutes, and functional status was evaluated at 60 minutes. Our primary outcome was the proportion of patients with mild or no pain at 60 minutes.

Results:

Overall, 49 of 77 meperidine-treated patients (64%; 95% confidence interval [CI], 53%–75%) and 47 of 65 ketorolac-treated patients (72%; 95% CI, 61%–83%) achieved successful pain relief at 60 minutes (pvalue for equivalence = 0.002). Ten percent of meperidine-treated patients and 44% of ketorolac-treated patients were able to resume usual activity at 60 minutes (p= 0.001).

Conclusions:

In the doses studied, single-dose IV ketorolac is as effective as titrated IV meperidine for the relief of acute renal colic and causes less functional impairment.
Bias in a prehospital esophageal detector device trial: lessons learned
Authors: Verbeek P. Richard , Bandiera Glen , Morris Brian , Pierre Dennis St.
Published: July 2016

Objectives:

Our goals were to determine whether selection bias occurred in a prehospital study comparing an esophageal detector device (EDD) to a disposable capnometer for detecting esophageal intubation, and to determine whether such a bias would have changed the study’s conclusions about EDD effectiveness.

Methods:

In a study of patients requiring prehospital intubation, we determined the sensitivity, specificity and predictive values of the EDD for detecting esophageal intubation. We then compared intubation success rate in patients who were enrolled in the study (n= 129) to that in eligible patients who were excluded from it (n= 107). After finding that the incidence of failed intubation was higher in the “excluded” group, we used sensitivity and specificity parameters derived from the study population to assess whether EDD test characteristics would differ in studied vs. excluded patients.

Results:

The first intubation attempt was successful in 125 of 129 study patients and 76 of 107 excluded patients (97% vs. 71%,p= 0.03), confirming the presence of selection bias. The negative predictive value of the EDD for esophageal intubation was 98% in the study cohort and would have been 77% in patients like those excluded (i.e., difficult intubation cases).

Conclusions:

Conclusion: The high “first attempt” intubation success rate seen in this study was due to selective exclusion of failed intubations. This selection bias led to a clinically important overestimation of the EDD’s negative predictive value. Bias may substantially alter the estimations of test accuracy reported in scientific studies. To reduce the chance of unrecognized selection bias in studies of diagnostic tests, investigators must determine whether recruited subjects resemble patients in whom the test will ultimately be used.
Thrombolytic therapy for acute ischemic stroke
Authors:   Canadian Association of Emergency Physicians Committee on Thrombolytic Therapy for Acute Ischemic Stroke
Published: July 2016

Current evidence suggests that, in a small subset of acute stroke patients who can be treated within 3 hours of symptom onset, the administration of tissue plasminogen activator (tPA) confers a modest outcome benefit, but that this benefit is associated with an increased risk of intracranial hemorrhage that can be severe or fatal. The data show that tPA therapy must be limited to carefully selected patients within established protocols. Further evidence is necessary to support the widespread application of stroke thrombolysis outside research settings. Until it is clear that the benefits of this therapy outweigh the risks, thrombolytic therapy for acute stroke should be restricted to use within formal research protocols or in monitored practice protocols that adhere to the NINDS (the rt-PA Stroke Study Group trial of the National Institute of Neurological Disorders and Stroke) eligibility criteria. All data on protocol compliance and patient outcomes should be collated in a central Canadian registry for the purposes of tracking safety and efficacy.

Stroke thrombolysis should be limited to centers with appropriate neurological and neuro-imaging resources that are capable of administering treatment within 3 hours. In such centres, emergency physicians should identify eligible patients, initiate low risk interventions and facilitate prompt computed tomography. Only physicians with demonstrated expertise in neuroradiology should interpret head CT scans used to determine whether to administer thrombolytic agents to stroke patients. Neurologists should be directly involved prior to the thrombolytic administration.
Clinical diagnosis of clavicle fractures: a pilot study
Authors: Landine Jim , McGraw Robert , Pickett William
Published: July 2016

Objective:

Clavicle fractures are commonly encountered in the emergency department (ED). Our objective was to determine whether emergency physicians can clinically predict the presence and location of a clavicle fracture prior to obtaining x-rays.

Methods:

Over a 16-month period we prospectively studied ED patients who had injuries compatible with a clavicle fracture. Following clinical examination and prior to obtaining radiographs, ED physicians or senior emergency medicine (EM) residents were asked to predict whether the clavicle was fractured and, if fractured, the location of the fracture. Clinical predictions were later compared to the radiologist’s report.

Results:

Between April 1999 and August 2000, 184 patients with possible clavicle fracture were seen and 106 (58%) were enrolled. Of these, 94 had an acute fracture, and all 94 fractures were predicted on clinical grounds prior to x-ray. In 6 cases, physicians predicted a fracture but the radiograph was negative. In 6 additional cases, physicians were clinically unsure and the radiograph was negative. Physicians correctly predicted fracture location in 83 of 94 cases (88%; 95% confidence interval [CI], 82%–95%). In the 64 cases where physicians predicted a middle third fracture, they were 100% accurate (95% CI, 95%–100%). Errors made by physicians were conservative; that is, they occasionally predicted fractures in patients with only soft tissue injury, but they did not “miss” existing fractures.

Conclusions:

The results of this pilot study suggest that ED physicians can clinically predict the presence and location of clavicle fractures with a high degree of accuracy. It may be that x-rays are not always necessary in patients suspected of having a clavicle fracture. Future studies should define the indications for diagnostic radiography in patients with suspected clavicle fractures.
A survey of emergency medicine in 36 countries
Authors: Arnold Jeffrey L. , Dickinson Garth , Tsai Ming-Che , Han David
Published: July 2016

Objective:

To assess the current level of development of emergency medicine (EM) systems in the world.

Design:

Survey of EM professionals from 36 countries during a 90-day period from Aug. 25 to Nov. 24, 1998.

Participants:

Thirty-six EM professionals from 36 countries and 6 continents completed the survey. Thirty-five (97%) were physicians, of whom 25 (69%) gave presentations at 1 of 4 international EM conferences during the study period. Three potential participants from 3 countries were excluded because of language barriers. Five additional participants from 5 other countries did not respond within the study period and were excluded.

Measurements:

Respondents completed a 103-question questionnaire about the presence of EM specialty, academic, patient care, information and management systems and the factors influencing the future of EM in their countries.

Results:

The overall response rate was 88%. Nearly all respondents (97%) stated that their countries had hospital-based emergency departments (EDs). More than 80% of respondents reported that their countries have emergency medical services (EMS), national EMS activation phone numbers and ED systems for pediatric emergency care. More than 70% stated that their countries had national EM organizations, EM research, ED systems for patient transfer and peer review and emergency physician (EP) training in Advanced Cardiac Life Support (ACLS) and the ability to perform rapid sequence intubation. More than 60% reported ED systems for trauma care and triage and EP training in Advanced Trauma Life Support (ATLS) and the ability to perform thrombolysis for acute myocardial infarction. Fifty percent reported EM residency training programs, official recognition of EM as an independent specialty, and EM journals.

Conclusions:

Basic emergency medicine components now exist in the majority of countries surveyed. These include many specialty, academic, patient care and administrative systems. The foundation for further EM development is widely established throughout the world.
Tissue plasminogen activator for acute ischemic stroke: Is the CAEP Position Statement too negative?
Authors: Hoffman Jerome R.
Published: July 2016

Adapting information from research to clinical practice can be difficult, and we are often forced to decide whether benefits reported in selected trials are adequate to justify widespread application of the intervention studied. This is particularly problematic when the “evidence” is scanty, the degree of benefit apparently small (ifreal), and the treatment potentially dangerous. In addition, it is always important to consider whether community physicians can replicate the success described in research studies, which are typically performed by experts working in the controlled setting of a well-funded study.
Factors affecting survival after prehospital asystolic cardiac arrest in a Basic Life Support-Defibrillation system
Authors: Petrie David A. , De Maio Valerie , Stiell Ian G. , Dreyer Jonathan , Martin Michael , O’Brien Jo-Anne ,   OPALS Study Group
Published: July 2016

Objectives:

Previous studies have shown a low but meaningful survival rate in cases of prehospital cardiac arrest with an initial rhythm of asystole. There may be, however, an identifiable subgroup in which resuscitation efforts are futile. This study identified potential field criteria for predicting 100% nonsurvival when the presenting rhythm is asystole in a Basic Life Support-Defibrillation (BLS-D) system.

Methods:

This prospective cohort study, a component of Phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study, was conducted in 21 Ontario communities with BLS-D level of care, and included all adult arrests of presumed cardiac etiology according to the Utstein Style Guidelines. Analyses included descriptive and appropriate univariate tests, as well as multivariate stepwise logistic regression to determine predictors of survival.

Results:

From 1991 to 1997, 9899 consecutive cardiac arrest cases with the following characteristics: male (67.2%), bystander-witnessed (44.7%), bystander CPR (14.2%), call–response interval (CRI) ≤ 8 minutes (82%) and overall survival (4.3%) were enrolled. Of 9529 cases with available rhythm strip recordings, initial arrest rhythms were asystole in 40.8%, pulseless electrical activity in 21.2% and ventricular fibrillation or ventricular tachycardia in 38%. Of 3888 asystolic patients, 9 (0.2%) survived to discharge; 3 of these cases were unwitnessed arrests with no bystander CPR. There were no survivors if the CRI exceeded 8 minutes. Logistic regression analysis demonstrated that independent predictors of survival to admission were “CRI in minutes” (odds ratio [OR] = 0.87; 95% confidence interval [CI], 0.77–0.98) and “bystander-witnessed” (OR = 2.6; 95% CI, 1.5–4.4).

Conclusions:

In a BLS-D system, there is a very low but measurable survival rate for prehospital asystolic cardiac arrest. CRIs of over 8 minutes were associated with 100% nonsurvival, whereas unwitnessed arrests with no bystander CPR were not. These data add to the growing literature that will help guide ethical decision-making for protocol development in emergency medical services systems.
Lack of efficacy of humidification in the treatment of croup: Why do physicians persist in using an unproven modality?
Authors: Lavine Elana , Scolnik Dennis
Published: July 2016

Background:

Humidification is a time-honoured therapy for childhood croup (acute laryngotracheobronchitis). Despite a paucity of evidence supporting its use, many physicians, nurses and parents still apply this treatment. Our objective was to summarize available evidence and assess the rationale for the ongoing use of humidity to treat childhood croup.

Methods:

Searches of both MEDLINE and the Cochrane Database were conducted for English-language original or review literature on the treatment of croup with humidity, for the years 1966-1999.

Results:

Only 2 published studies have attempted to evaluate humidification therapy for croup, and none has been published since 1984. There is no published evidence to support the commonly held empirical view that humidity helps alleviate the symptoms of childhood croup, and no understanding of which factors of moisture or temperature affect patient outcomes. Risks may include scalding and unnecessary discomfort.

Interpretation:

There is no strong evidence supporting the use of humidity in the treatment of croup. Although such treatment is still widely used, it is not without risk, and further trials are required to address its efficacy.