bluuebunny/crossref_metadata_2025 huggingface dataset:
P111: Presentations for hypoglycemia associated with diabetes mellitus to emergency departments in a Canadian province: a database and epidemiological analysis
Authors: Alexiu C. , Jelinski S. , Chuck A. , Rowe B.H.
Published: June 2016

Introduction: Diabetes mellitus (DM) is a major chronic disease. Prevalence of diabetes was 9% globally in 2014 and 9.3% in Canada and 7.2% in Alberta in 2015. Complications of the disease are numerous and frequent. Hypoglycemia is one complication of diabetes treatment. The objective of this study was to quantify and characterize presentations by adults to Alberta emergency departments (EDs) for hypoglycemia associated with type 1 (T1DM) or type 2 (T2DM) diabetes. Methods: A retrospective cohort study was conducted using data for Alberta for a five-year period (fiscal years 2010/11-2014/15). Data were sourced from an administrative database: National Ambulatory Care Reporting System (NACRS). Records of interest were those with an ICD-10-CA diagnosis of DM-associated hypoglycemia (i.e., E10.63, E11.63, E13.63, or E14.63). A descriptive analysis was conducted. Results: Data extraction yielded 7,835 presentations by 5,884 patients. The majority of presentations were by males (56.2%) and median patient age was 62. These episodes constituted 0.08% of presentations to Alberta EDs and they occurred at an event rate of 0.67 episodes per 100 patient-years (95% CI: 0.66-0.69). The annual rate of presentations decreased by 11.8% during the five-year period. Most presentations (63.4%) involved transportation to the ED via ambulance. Relative to LOS for ED presentations for all reasons, average length-of-stay (LOS) was 3.2x longer and 1.4x longer for discharged and admitted patients, respectively. For 27.5% of presentations, an X-ray was obtained. Most hypoglycemic episodes (65.2%) were considered to be of moderate severity while 34.3% were considered to be severe. None were mild because all involved access to an ED. The condition mainly (absolute terms) afflicted people with T2DM and urban areas; however, it disproportionately afflicted people with T1DM and rural areas. Conclusion: For a condition that is largely preventable with effective blood glucose management, DM-associated hypoglycemia incurs significant healthcare resource use. People with DM would be better served with more effective and safer euglycemic agents.
P115: An analysis of current and forecasted patient visits to Ontario’s emergency departments and its effect on hospital admissions
Authors: Rawana A. , Savage D.W. , Weaver B.
Published: June 2016

Introduction: The number of emergency department (ED) visits across Ontario has increased annually over the past two decades leading to overcrowding and longer wait times. ED volume forecasting may provide insight to strategic planners regarding future patient volumes and the effects on health care resources. We investigated the pattern of ED use at the local health integration network (LHIN) level and developed forecasts using historical data. The forecasts were then used to examine the effect on acute care hospital bed requirements and the number of full time equivalent physicians needed. Methods: Aggregated data from the Canadian Institute for Health Information for the period 2003 to 2013 was obtained for each of Ontario’s LHINs. The total number of ED visits per year was first quantified by LHIN and then simple linear regression was used to forecast patient volumes in 2018 and 2023. The rate of hospital admission by LHIN was also calculated. We then used the forecasted volume, admission rate and the total number of acute care hospital beds by LHIN to predict the total number of beds needed by LHIN. Based on the forecasted patient volumes and the hours of coverage model, the total number of full-time equivalent physicians needed was calculated. Results: Over the study period, the number of patients increased from 4 to 37% among LHINs. Admission rates generally decreased from 2003 to 2013. Based on historical trends, all EDs across Ontario are expected to experience increased patient visits in the future but at different rates of growth. Depending on the rate of growth in ED visits, the number of acute care beds needed by LHIN is somewhat variable and affected by the proportion of alternate level of care patients. Given, the forecasted increase in patient volume, the hours of coverage model suggests that approximately 320 additional full-time equivalent ED physicians are needed across the province by 2023. Conclusion: Although all forecasts inherently have a degree of error associated with their estimates, strategic planners require some quantitative prediction of future events to develop initial plans. Through research, these predictions can be focused and refined. The results suggest that many hospitals will experience increased demand for services and will have to do resource allocation planning accordingly to ensure patient demand is met appropriately.
P116: An analysis of pediatric visits to a tertiary care centre in Northern Ontario, Canada
Authors: Savage D.W. , Weaver B. , Neilipovitz B. , Wood D.
Published: June 2016

Introduction: The Thunder Bay Regional Health Sciences Centre (TBRHSC) Emergency Department (ED) has experienced an all patient increase in visits ranging from 1.5 to 6% per year since 2004. As a regional referral centre with no dedicated pediatric ED, TBRHSC is the sole emergency provider. Given the rising visits, we have investigated the pattern of pediatric visits, rates of admission to hospital and for a subset of years the investigations completed. Methods: Pediatric visits from 2004 to 2014 were summarized for the TBRHSC ED. The pattern of visits was examined along with the rate of admission to hospital. We also investigated the trend in acuity over the study period. Laboratory and imaging data are purged 1 year after each visit and were not available prior to 2011 but were summarized for the remainder of the years to identify the rates of all investigations completed. Results: From 2004 to 2014 there was a total increase in visits of 7.5% with the average annual admission rate ranging from 5 to 6.3%. The month to month variability in visits over the study period was high with a minimum of 1292 in August 2004 and a maximum of 2488 in October 2009. Nearly all patients were either CTAS II, III or IV, with level III having the highest occurrence. The mean investigation rate was approximately 16, 0.8, 24, and 2.3% of patients having laboratory, CT, x-ray and ultra-sound completed, respectively. Conclusion: Pediatric patients are an important subset of all patients visiting the ED. They often require special resources and at the TBRHSC use specific treatment spaces. In addition, there is a limited number of pediatric inpatient hospital beds. Managers could use the timing of visits, number of visits and admission rates to examine resource use and the probability of exceeding capacity. This study also provides baseline information on the rates of investigations, especially imaging such as CT which can have long-term radiological consequences.
P119: B-mode point-of-care ultrasound without doppler may help include or exclude significant carotid stenosis in stroke and transient ischemic attack patients - a prospective pilot study
Authors: Simard R. , Socransky S.
Published: June 2016

Introduction: Emergency physicians can use B-mode Point-of-Care Ultrasound (POCUS) to identify a patient’s carotid vasculature including the common carotid artery (CCA), and carotid bulb (CB) as well as carotid bifurcation into the internal carotid artery (ICA) and external carotid artery (ECA). Radiology performed carotid ultrasound (RPCU) is performed using both B-mode and spectral Doppler ultrasound, a combination termed “duplex” ultrasound where first arteries are evaluated for stenosis using B-mode ultrasound, which is followed by flow measurements using Doppler. Performing flow measurements using Doppler may add a significant amount of time to the ultrasound, which makes it impractical for an emergency physician in a busy emergency department. Some institutional practices include arranging for outpatient RPCU to assess patients with Transient Ischemic Attack (TIA) and have them follow up in an outpatient TIA clinic. This study explored whether B-mode POCUS without Doppler may help identify Stroke or TIA patients in the emergency department with significant carotid stenosis (CS) by measuring the CCA, CB, and ICA lumen. Methods: Adult patients with an emergency physician diagnosis of stroke or TIA who were sent for RPCU were included in this study. An emergency medicine resident in their POCUS fellowship training performed a B-mode POCUS of the patient’s right and left CCA, CB and ICA with the patient sitting 90 degrees. Three measurements of each of the 3 sections were obtained and the mean calculated. This was then compared to the results from the RPCU as CS >50% or CS <50%. Results: 38 patients were included in the study between February and June 2013. We observed a correlation between absolute differences in comparing the right side of the carotid vasculature to the left side of the carotid vasculature with CS >50%. Also, in one case, the absolute lumen diameter with B-mode POCUS without Doppler predicted near complete CS which was confirmed on the RPCU. Conclusion: B-mode POCUS without Doppler may be useful in identifying patients with CS above and below 50% and may help identify patients who need expedited referrals for CS. However, further research is required before this method can be recommended.
P122: The use of decision support tools in the implementation of the Prehospital Canadian Triage Acuity Score (Pre-CTAS)
Authors: Smith K.E. , Lobay K. , Bullard M.
Published: June 2016

Introduction: The Prehospital Canadian Triage and Acuity Scale (Pre-CTAS) is based upon, and is consistent with, the CTAS (Canadian Triage and Acuity Scale). Paramedic-assigned Pre-CTAS scores using memory compared to Triage Nurse CTAS scores have previously demonstrated moderate inter-rater reliability. This is the first study to measure the effect of two different point-of-care decision support tools on the inter-rater reliability of paramedic assigned Pre-CTAS and Triage nurse CTAS scores. Methods: Paramedics were randomized to Pre-CTAS booklet or CTAS smartphone app during the one-year study period. Pre-CTAS scores assigned on arrival at hospital (AH) were compared with Triage Nurse CTAS scores and analyzed using Cohen’s Kappa. Paramedics were then surveyed to assess the perceived utility and satisfaction with the decision support tools. Results: For 1663 patient transports, the weighted kappa score for Paramedic AH vs. Triage Nurse CTAS was fair at 0.38 (95% CI 0.35-0.41). For patients whose initial on-scene and AH Pre-CTAS scores did not change (n= 1405, 85%), Paramedic-Triage Nurse agreement was moderate at 0.43 (95% CI 0.39-0.46). The survey revealed that tools, when employed, helped assign scores; however accessing the additional resource was cumbersome or time consuming, and scores were occasionally assigned post clinical encounter. Conclusion: Point-of-care external decision support tools did not affect Pre-CTAS and ED CTAS agreement. These tools may add complexity or be perceived to add time to documentation within the delivery of clinical care if not implemented with adequate support. Future research needs to evaluate the impact of clinical decision support embedded within an electronic patient care record consistent with many ED information systems.
P124: The Ottawa Chest Pain Rule would increase stretcher capacity if implemented for cardiac chest pain patients
Authors: Sonntag M. , Lang E.
Published: June 2016

Introduction: Reducing the number of patients requiring cardiac monitoring would increase system capacity and improve emergency department (ED) patient flow. The Ottawa Chest Pain Rule helps physicians identify chest pain patients who do not require cardiac monitoring and is based on a ‘normal or non-specific’ ECG and being pain-free on initial physician assessment. Our objective was to measure the impact that the implementation of this decision rule would have on cardiac monitoring bed utilization in adult EDs in Calgary. Methods: A convenience sample of patients was prospectively obtained at each of the four Calgary adult emergency sites. All patients presenting with the Canadian Triage Acuity Scale chief complaint of “cardiac pain”, or “chest pain with cardiac features” were captured for inclusion in the study. Real time interviews and survey assessments were conducted with the primary nurse and physician involved in each patient’s care. Results: A total of 61 patients were captured by the study. Physicians identified cardiac as the primary rule-out pathology in 51% of these patients. The average Heart Score of all study patients was 4.2, and 30% of patients were ultimately admitted. Physicians believed that 39% of the 61 patients needed cardiac monitoring, while primary nurses believed that 59% needed monitoring. Of the 61 patients, 59% were triaged to areas providing cardiac monitoring. The application of the Ottawa Rule would have allowed 47% of patients triaged to cardiac monitoring to be taken off cardiac monitoring. This would translate to a total of greater than 74 hours saved or a reduction of 30% of the total cardiac monitored patient time. Conclusion: The Ottawa rule appears to be a low-risk emergency department flow intervention that has the potential to help reduce resource utilization in emergency departments. This change may result in increased emergency department capacity and improved overall patient flow. This simple rule based only on ECG findings and absence of chest pain can easily be applied and implemented without increasing physician workload or increasing risk to patients.
P136: A quality improvement initiative to optimize appropriate testing for venous thromboembolism in the emergency department
Authors: Vaillancourt S. , Wang X.Y. , Leontowicz B. , Sholzberg M. , McIntyre K.
Published: June 2016

Introduction: Venous thromboembolism (VTE) is a common diagnostic consideration among patients presenting to the emergency department (ED) and often requires the use of diagnostic testing. A normal d-dimer (DD) blood test can exclude VTE and eliminate the need for costly imaging and the associated contrast medium and radiation exposure. The purpose of this quality improvement initiative was to increase the use of DD testing for patients with a low and intermediate clinical pretest probability of VTE, increase the use of ventilation perfusion scans (VQ) as an alternative to CT pulmonary angiogram (CTPA) and decrease the use of CTPA and venous doppler ultrasound (VDUS) at St. Michael’s hospital. Methods: A multispecialty team developed an ED specific algorithm set for appropriate VTE testing that were posted on the ED online portal along with a poster in each zone of the ED after an ED launch campaign with request for feedback. A run chart was used to track DD, CTPA, VQ and VDUS utilization. Two-sided T-test comparison was conducted to compare pre- and post-implementation utilization. Results: Physician feedback was positive regarding the use of: DD in VTE intermediate risk patients and the VTE algorithm set. Feedback was negative for DD turnaround time. We found a significant increase in DD use (77 tests per month to 93; p=0.013), but no significant change in the use of CTPA (27.3 per month to 30; p=0.38), VDUS, or VQ. Number of monthly ED visits remained constant. Conclusion: This intervention increased DD utilization, but measuring appropriateness will require prospective collection of clinical pre-test probability. Integrated risk stratification and decision aids into computer physician order entry may be necessary to track and improve appropriateness.
P138: The Family Medicine Obstetrical Ultrasound (FaMOUS) course: a model for training office-based family physicians in first trimester point of care ultrasound
Authors: Varner C. , Bearss E. , Hu S. , McLeod S.L. , Lee S.
Published: June 2016

Introduction / Innovation Concept: In Canada, family physicians (FPs) provide the majority of 1st trimester pregnancy care and are often first to evaluate complications, including threatened and spontaneous abortion and ectopic pregnancy. To receive a same day urgent US, most patients will be sent to the emergency department (ED). With increasing availability and affordability of point of care ultrasound (PoCUS), FPs are starting to use US in their offices, potentially diverting some ED visits for patients with reassuring US findings. To date, no formal certification process exists for FPs who wish to use PoCUS for 1st trimester indications. Methods: The objective of this educational initiative was to implement and evaluate a novel, 2-day didactic and hands-on certification process for FPs utilizing office-based PoCUS to identify intrauterine pregnancy and fetal cardiac activity. The FaMOUS course was modeled after the Canadian Emergency Ultrasound Society Emergency Department Echo (CEUS EDE) curriculum and adapted with permission for FPs. Curriculum, Tool, or Material: The curriculum consisted of a deliberate practice mastery model utilizing on-line materials, seminars and hands-on training. Prior to the 2-day course, FPs completed an e-learning module comprised of core competency material specific to obstetrical practice. Learners were required to score 100% on a post-module exam to participate in the 2-day course. Attendees participated in a 4-hour training session to learn US image generation and interpretation. This was followed by 10 hours of hands-on training with CEUS instructor supervision to complete the certification process (50 determinate scans). Thirteen FPs from 3 family practice units successfully completed the certification process. Cumulative knowledge and skill levels were assessed throughout the 2-day workshop through feedback from CEUS supervisors to confirm key concepts were learned. All 13 participants agreed to utilize PoCUS in their clinical assessments of patients with 1st trimester complaints using handheld PoCUS equipment provided to the sites. FPs will be surveyed at 3 month intervals for 12 months following the FaMOUS course to assess provider confidence, satisfaction and perceived impact on clinical decision-making. Conclusion: The FaMOUS certification course is a standardized curriculum by which FPs can learn PoCUS safely to improve quality and timeliness of care for patients experiencing 1st trimester complaints. If PoCUS is adopted by FPs, lengthy ED visits may be decreased for this patient population.
P141: Limited variation in diagnostic imaging use among emergency department physicians
Authors: Wong H. , Sidhu K. , Margau R. , Fam M. , Sistrom C. , Weilburg J. , Lin L.
Published: June 2016

Introduction: Use of diagnostic imaging in the emergency department (ED) has significantly increased over time. The decision to use a certain type of imaging, if any at all, is not always clear. Accordingly, concerns of appropriateness are justified. A starting point to assess imaging appropriateness is to measure variation in its use. It has been suggested that where large variation exists, there may be inappropriate use. Methods: We retrospectively studied consecutive ED visits at North York General Hospital between April 1, 2009 and March 31, 2013 (n = 316,251), and developed a two-level hierarchical logistic regression model to quantify inter-physician variation in imaging use (high-cost imaging: computed tomography (CT), magnetic resonance (MR), nuclear medicine; low-cost: plain radiography, ultrasound) in the ED after adjusting for patient-, visit- and physician-level factors. Results: Plain radiography or ultrasound examinations were performed during 36.3% of ED visits; CT, MR, or nuclear medicine examinations were performed during 10.6% of ED visits; 4.1% of ED visits had both high- and low-cost imaging. After adjusting for patient-, visit- and physician-specific factors, only 2.4% and 2.2% of the variation regarding whether or not an ED visit resulted in at least one high-cost and low-cost imaging test, respectively, was attributable to individual physician practice patterns. Physicians who had a tendency to obtain more low-cost imaging also obtained more high-cost imaging, and those who obtained less low-cost imaging also obtained less high-cost imaging. Conclusion: Only a small portion of the variation in imaging use was attributed to differences in ED physician ordering patterns, however, these findings may still help promote discussion among clinicians, and improve imaging utilization.
P145: HIV point of care testing by community paramedics in a vulnerable population: a pilot study
Authors: Yaworski H. , Hutlet P. , Grierson R. , Weldon E. , Sneath R. , Kasper K. , Becker M. , Pindera C. , Carnochan T.
Published: June 2016

Introduction: Literature suggests that up to 25% of people with HIV in North America are unaware of their status and are at risk to transmit the virus unknowingly. A high proportion of HIV patients are diagnosed when the disease is more advanced, with CD4 counts < 200. This study examined the rates of HIV testing, detection, and treatment of clients at an inner city shelter and detoxification centre after the introduction of a point of care testing (POCT) program by on-site community paramedics (CP). Methods: In 2013, in collaboration with a regional HIV program, CP received training and instituted an HIV POCT program and post-test counselling initiative. A retrospective electronic database review from October 16, 2013 to October 15, 2014 of adult patients who received testing was performed. Demographic and testing details of each patient encounter were abstracted and select variables were compared to a historic population who received POC HIV testing at an inner city emergency department (ED) in the same city. Results: 1,207 HIV POC tests were performed on 997 patients during the pilot. 57% of the patients tested were less than 40 years of age (range 18-73 years) compared to 55% in the historic ED population. A total of 9 reactive cases were identified in the study population including 3 new cases, 5 previously known cases, and 1 false reactive result. The mean age of the new cases was 47 years, vs 44 in the historical control. All 3 new cases were referred to a local HIV clinic for further care and treatment. New HIV cases represented 0.25% of total tests performed, which is less than the expected prevalence rate of 1% for this population, as well as the rate of 1.4% found in the ED population. Conclusion: Despite lower than expected reactive rates, the large scale implementation of a CP HIV POCT program in an inner city shelter and detoxification centre is feasible. All patients with new reactive tests were immediately connected to care. Future research will focus on risk factors and barriers to testing.
PL003: Impact of process improvements on measures of emergency department efficiency
Authors: Leung A. , Duic M. , Gao D. , Whatley S.
Published: June 2016

Introduction: The objective was to study the operational impact of an intervention comprised of simultaneous process improvements to triage, patient inflow, and physician scheduling patterns on emergency department (ED) patient flow. The intervention did not require any increase in ED resources or expenditures. Methods: A 36-month pre-/post-intervention retrospective chart review at an urban community emergency department from January 2010 to December 2012. The ED process improvements started on June 6, 2011 and involved streamlining triage, parallel processing, flexible nurse-patient ratios, flexible exam spaces, and flexible physician scheduling. The main outcomes were ED length-of-stay (LOS). Secondary outcomes included time to physician-initial-assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed on Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether there were changes in the trend between pre-intervention and post-intervention segments. Results: 251,899 patients attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.64 hours (p<0.001), and 90th-percentile LOS by 0.81 hours (p=0.024). When separated by acuity and disposition, there were reductions in LOS for non-admitted CTAS 2 (-0.58 hours, p <0.001), 3 (-0.75 hours, p <0.001), 4 (-0.32 hours, p=0.002), and 5 (-0.28 hours, p=0.008) patients. For secondary outcomes, there was a decrease in overall average PIA by 43.81 minutes (p<0.001), and 90th-percentile PIA by 91.39 minutes (p<0.001). LWBS and LAMA rates decreased by 35.2% (p<0.001) and 61.9% (p<0.001), respectively. Conclusion: A series of process improvements meant to optimize flow in the ED without the addition of resources was associated with clinically significant reductions in LOS, PIA, LWBS and LAMA rates for non-resuscitative patients.
LO004: Short-term risk of arrhythmias among syncope patients presenting with atrial fibrillation/flutter to Canadian emergency departments
Authors: Toarta C. , Kwong K. , Stiell I.G. , Mukarram M.A. , Taljaard M. , Sheldon R. , Wells G.A. , Thiruganasambandamoorthy V.
Published: June 2016

Introduction: Short-term risk of arrhythmia or death among emergency department (ED) syncope patients with atrial fibrillation/flutter (AFF) has not been reported in the literature. Our objectives were to assess the incidence and the independent risk of 30-day arrhythmia or death for syncope patients with AFF after ED disposition. Methods: We conducted a prospective study at 6 Canadian academic EDs to include adults with syncope. We collected demographic, clinical and ECG characteristics while our outcome assessments were completed by medical records review and by telephone follow-up of patients after 30 days. Primary outcome was arrhythmia or death within 30-days after ED disposition and secondary outcomes included non-arrhythmic cardiac and non-cardiac outcomes. We performed descriptive and logistic regression analyses. Results: We enrolled 4,266 patients: mean age 53.4 years, 55.4% females, and 8.5% with AFF. After excluding those with outcomes in the ED, lost to follow-up and those with other non-sinus rhythms, 3,417 patients in the sinus and 280 patients in the AFF groups were analyzed. The incidence of arrhythmia or death was significantly higher in the AFF group (Relative Risk 5.1; 95% CI 3.1-8.4; p<0.0001) but there were no significant differences in secondary outcomes between the groups. The unadjusted odds ratio for 30-days arrhythmia or deaths among ED syncope patients with AFF was 5.4 (95% CI 3.2- 9.2). After adjusting for important baseline risk factors by multivariable analysis, the odds ratio for arrhythmia or death in patients with AFF was 1.5 (95% CI 0.8-2.7). Conclusion: The risk of AFF for 30-day arrhythmia or death among syncope patients after ED disposition is higher but is attenuated when adjusted for important patient characteristics. Future research should assess long-term outcomes among syncope patients with AFF to guide follow-up after ED discharge.
LO013: Can you trust administrative data? Accuracy of ICD-10 codes for diagnosis of pulmonary embolism
Authors: Burles K. , Wang D. , Grigat D. , Senior K.D. , Innes G. , Andruchow J. , Lang E. , McRae A.
Published: June 2016

Introduction: Administrative data is a useful tool for research and quality improvement; however, the validity of research findings based on these data depends on their reliability. Diagnoses are recorded using diagnostic codes, as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Several groups have reported coding errors associated with ICD-10 assignments to patient diagnoses; these errors have serious implications for research, quality improvement, and policymaking. As part of a quality improvement project targeting emergency department (ED) diagnostic appropriateness for pulmonary embolism (PE), we sought to validate the accuracy of ICD-10 codes for studying ED patients diagnosed with PE. Methods: Hospital administrative data for adult patients (age ≥18 years) with an ICD-10 code for PE (I26.0 and I26.9) were obtained from the records of four urban EDs between July 2013 to January 2015. A review of medical records and imaging reports was used to confirm the diagnosis of PE. In the case of discrepancy between ICD-10 coding and chart review, the diagnosis obtained from chart review was considered correct. The physicians’ discharge notes in the administrative database were also searched using ‘pulmonary embolism’ and ‘PE’, and patients who were diagnosed with PE but not coded as PE were identified. Coding discrepancies were quantified and described. Results: 1,453 ED patients had a PE ICD-10 code during our study period. 257 (17.7%) of these patients’ diagnoses were improperly coded. 211 patients assigned an ICD-10 PE code had ED discharge diagnoses of ‘rule-out PE’ or ‘query PE’. 64 other patients were miscoded as having a PE and should have been assigned an alternate code, such as chest pain, hypoxia, or dyspnea. The physician did not include a discharge diagnosis in 4 of the 64 miscoded patients; however, triage and physician assessment notes indicated no suspicion of PE. Furthermore, 117 patients who had an ED discharge diagnosis of PE were not assigned a PE code, meaning that 8.91% of true PEs were missed by using ICD-10 codes alone. Thus, 1,313 ED patients truly had a PE. Conclusion: Our work suggests the need for more accuracy in ICD-10 coding of ED diagnoses of PE. Caution should be exercised when using administrative data for studying PE, and validation of the accuracy of ICD-10 coding prior to research use is recommended.
LO030: Inter-rater agreement of nurse and clinical expert tremor assessments for patients with alcohol withdrawal syndrome in the emergency department
Authors: Borgundvaag B. , McLeod S.L. , Dear T.E. , Carver S.M. , Norouzi N. , Kahan M. , Gray S.H. , Arabi P.
Published: June 2016

Introduction: Of the domains assessed by the CIWA-Ar, tremor is the most objective, and reliable clinical symptom of alcohol withdrawal syndrome. Even so, anecdotal evidence suggests that the ability of health care workers to reliably rate tremor severity is highly variable, and there is no high quality, readily available training to teach this competency. Improper evaluation and interpretation of tremor may result in under or over treatment, posing serious risks to patient safety, prolonging emergency department (ED) length of stay, and increasing the likelihood of complications/hospital admission. The objective of this study was to prospectively compare tremor assessment scores assigned by nurses and clinical experts for patients with alcohol withdrawal syndrome in the ED. Methods: A prospective observational study was conducted for patients ≥18 years presenting to an academic ED in alcohol withdrawal from Oct 2014 to Aug 2015. Individual tremor assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Tremor severity scores assigned in real-time by the nurses were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 31 patients with 62 tremor recordings were included. Nurse-derived tremor scores matched exactly with expert assessor scores in 11 (17.7%) cases, within 1 point for 29 (46.8%) cases and differed by ≥ 2 points in 33 (53.3%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘fair’ 0.39 (95% CI: 0.25, 0.53). Conclusion: These results confirm the high variability in the assessment of alcohol withdrawal tremor by health care workers. Future research should focus on ways to improve the accuracy of tremor in alcohol withdrawal patients, and the development and implementation of an educational program to improve the individual competencies of clinical staff in the recognition and treatment of alcohol withdrawal in the ED.
LO034: Does head injury matter? Comparison of functional outcomes in elderly who have sustained a minor trauma with or without head injury: a prospective multicenter cohort study
Authors: Brousseau A. , Emond M. , Sirois M. , Daoust R. , Griffith L.E. , Lang E. , Lee J.S. , Perry J.J. , Ouellet M. , Verreault R. , Berthelot S. , Mercier E. , Allain-Boulé N. , Boucher V. , Tardif P. , Le Sage N.
Published: June 2016

Introduction: The older adult population is growing. The consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a MT-HI on the functional and cognitive outcomes six months post injury of older adults who sustained a minor trauma. Methods: This multicenter prospective cohort study in eight sites included patients who were: aged 65 years or older, presenting to the emergency department (ED) within two weeks of injury with a chief complaint of a minor trauma, discharged within 48 hours, and independent for their basic activities of daily living prior to the ED visit. Participants underwent a baseline evaluation and a follow-up evaluation at six months post-injury. The main outcome was the functional decline measured with the Older Americans’ Resources and Services (OARS) scale six months after the trauma. Results: All 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 without head injury. After six months, the functional decline was similar in both groups, 10.8% and 11.9% respectively (RR=0.79 [95% CI: 0.55-1.14]). The proportion of participants with mild cognitive disabilities was also similar, 21.7% and 22.8% respectively (RR=0.91 [95% CI: 0.71-1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR= 1.35 [95% CI: 0.71-2.59]), or with or without the presence of a mTBI as defined by the WHO criteria (RR= 0.90 [95% CI: 0.59-1.13]). Conclusion: This study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population six months after injury.
LO050: The predictive value of pre-endoscopic risk scores to predict adverse outcomes among emergency department patients with upper gastrointestinal bleeding - a systematic review
Authors: Ramaekers R. , Mukarram M.A. , Smith C.A. , Thiruganasambandamoorthy V.
Published: June 2016

Introduction: Patients with upper gastrointestinal bleeding (UGIB) are at risk for serious adverse events (SAE) after emergency department (ED) discharge. Endoscopy can aid in risk stratification but is not easily available. Therefore, stratifying using pre-endoscopic risk scores can aid ED physicians in disposition decisions. The aim of this study was to conduct a systematic review to assess the predictive value of pre-endoscopic risk scores for risk-stratification of ED UGIB patients. Methods: We searched 4 databases from inception to March 2015 with search terms related to “UGIB” and “ED”. Inclusion criteria were: 1) adult UGIB patients presenting to the ED; 2) risk scores without endoscopic predictors developed and validated in variceal and non-variceal UGIB patients. We excluded case reports, reviews, abstracts, animal studies and commentaries. In 2 phases (screening and full-review), 2 reviewers independently screened articles for inclusion. SAE included 30-day death, recurrent bleeding and need for intervention. Two reviewers independently extracted patient level data and the consensus data was used for analysis. We report kappa for the article selection, and pooled sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratios and accuracy with 95% CI for the risk scores. Results: We identified 3,173 articles, of which 3,065 were excluded in phase I (kappa 0.88, 95% CI 0.83-0.93). In phase II, we included 16 of the 108 remaining articles (kappa 0.84, 95% CI 0.70-0.97); 3 studied Glasgow Blatchford Score (GBS), 1 clinical Rockall score (cRockall) and 2 AIMS65; 6 compared GBS and cRockall, 3 compared GBS, a modification of the GBS and cRockall and 1 compared the GBS and AIMS65. Overall, the accuracy of the GBS, cRockall and AIMS65 was 0.47 (95% CI 0.46-0.47), 0.47 (95% CI 0.46-0.49) and 0.62 (95% CI 0.61-0.62), respectively. The accuracy for the GBS with a cut-off score of 2 was 0.73 (95% CI 0.71-0.74). Conclusion: None of the risk scores identified by our systematic review were robust and hence, cannot be recommended for use in clinical practice. However, the GBS with a cut-off score of 2 was superior over other risk scores. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB.
LO062: Ultrasound-assisted distal radius fracture reduction
Authors: Socransky S. , Atkinson P.R. , Skinner A. , Bromley M. , Smith A. , Ross P.
Published: June 2016

Introduction: Closed reduction of distal radius fractures (CRDRF) is a commonly performed emergency department (ED) procedure. The use of Point-of-care ultrasound (POCUS) to diagnose fractures and guide reduction has previously been described. The primary objective for this study was to determine if the addition of PoCUS to CRDRF changed the perception of successful initial reduction. This was measured by the rate of further reduction attempts based on POCUS following the initial clinical determination of achievement of best possible reduction. Methods: We performed a multicenter prospective cohort study, using a convenience sample of adult ED patients presenting with a distal radius fracture to 5 Canadian EDs. All study physicians underwent standardized PoCUS training for fractures. Standard clinically guided best possible fracture reduction was initially performed. PoCUS was then used to assess the reduction adequacy. Repeat reduction was performed if deemed indicated. A post-reduction radiograph was then performed. Clinician impression of reduction adequacy was scored on a 5 point Likert scale following the initial clinically guided reduction, and following each POCUS scan and the post-reduction radiograph. Results: There were 131 patients with 132 distal radius fractures. Twelve cases were excluded prior to analysis. There was no significant difference in the assessment scores for reduction success by PoCUS vs. clinical assessment (Median scores 4 vs.4; p=0.370;) or in the odds ratio of successful reduction (0.89; 95% CI 0.46 to 1.72; p=0.87). Significantly fewer cases fell in the uncertain category with POCUS than with clinical assessment (12 vs 2; p=0.008). Repeat reduction was performed in 49 patients (41.2%). In this group, the odds ratio for adequate reduction assessment post-PoCUS to pre-PoCUS was 12.5 (95% CI 3.42 to 45.7; p<0.0001). There was no significant difference in the assessment of reduction by PoCUS vs. radiograph. Conclusion: PoCUS guided fracture reduction leads to repeat reduction attempts in approximately 40% of cases, and enhances certainty regarding reduction adequacy when clinical assessment is unclear.
Oxidative stress during early pregnancy and birth outcomes
Authors: Shastri Lisha , Pammal Rajkumar S , Mani Indu , Thomas Tinku , Kurpad Anura V
Published: June 2016

Objective

Routine high-dose Fe supplementation in non-anaemic pregnant women may induce oxidative stress and eventually affect birth outcomes. The aim of the present study was to measure oxidative stress markers in pregnant women with low/normal and high Hb values in trimester 1 (Hb1) and to relate these to birth weight.

Design

A cross-sectional study where selected oxidative stress markers were analysed in both maternal (trimester 1; T1) and cord blood samples and correlated with birth weight.

Setting

A tertiary hospital in urban South India.

Subjects

One hundred women were chosen based on their Hb1 values (forty women with low/normal Hb1 (<110 g/l) and sixty women with high Hb1 (≥120 g/l)).

Results

In T1, women with high Hb1 values were found to have lower paraoxonase-1 (PON-1) activity (424·7 (sd 163·7) v. 532·9 (sd 144·7) pmol p-nitrophenol formed/min per ml plasma, P=0·002) and higher lipid peroxides compared with women with low/normal Hb1. Routine supplementation of Fe to these women resulted in persistent lower PON-1 activity in cord blood (P=0·02) and directionally lower (P=0·142) birth weights. Furthermore, women with high Hb1 who delivered low-birth-weight babies were observed to have lowest PON-1 activity in T1. No changes were observed in other markers (myeloperoxidase activity and total antioxidant levels).

Conclusions

Routine Fe supplementation in pregnant women with high Hb1 associated with increased oxidative stress, as reflected by low PON-1 activity in T1, could potentially lead to deleterious effects on birth weight.
Risk of venous thromboembolism in people with lung cancer: a cohort study using linked UK healthcare data
Authors: Walker Alex J , Baldwin David R , Card Tim R , Powell Helen A , Hubbard Richard B , Grainge Matthew J
Published: June 2016

Background:

Venous thromboembolism (VTE) is a potentially preventable cause of death in people with lung cancer. Identification of those most at risk and high-risk periods may provide the opportunity for better targeted intervention.

Methods:

We conducted a cohort study using the Clinical Practice Research Datalink linked to Hospital Episode Statistics and Cancer Registry data. Our cohort comprises 10 598 people with lung cancer diagnosed between 1997 and 2006 with follow-up continuing to the end of 2010. Cox regression analysis was performed to determine which demographic, tumour and treatment-related factors (time-varying effects of chemotherapy and surgery) independently affected VTE risk. We also determined the effect of a VTE diagnosis on the survival of people with lung cancer.

Results:

People with lung cancer had an overall VTE incidence of 39.2 per 1000 person-years (95% confidence interval (CI), 35.4–43.5), though rates varied depending on the patient group and treatment course. Independent factors associated with increased VTE risk were metastatic disease (hazard ratio (HR)=1.9, CI 1.2–3.0vslocal disease); adenocarcinoma subtype (HR=2.0, CI 1.5–2.7,vssquamous cell; chemotherapy administration (HR=2.1, CI 1.4–3.0vsoutside chemotherapy courses); and diagnosis via emergency hospital admission (HR=1.7, CI 1.2–2.3vsother routes to diagnosis). Patients with VTE had an approximately 50% higher risk of mortality than those without VTE.

Conclusions:

People with lung cancer have especially high risk of VTE if they have advanced disease, adenocarcinoma or are undergoing chemotherapy. The presence of VTE is an independent risk factor for death.
Erianin induces G2/M-phase arrest, apoptosis, and autophagy via the ROS/JNK signaling pathway in human osteosarcoma cells in vitro and in vivo
Authors: Wang H , Zhang T , Sun W , Wang Z , Zuo D , Zhou Z , Li S , Xu J , Yin F , Hua Y , Cai Z
Published: June 2016

Erianin, a natural product derived from Dendrobium chrysotoxum, has exhibited potential antitumor activity in various malignancies, including hepatocarcinoma, melanoma, and promyelocytic leukemia. Here we explored the effects of erianin on osteosarcoma (OS) in vitro and in vivo and further elucidated the underlying molecule mechanisms. In this study, we found that erianin potently suppressed cell viability in various OS cell lines. Treatment with erianin induced G2/M-phase arrest, apoptosis, and autophagy in OS cells. Further studies showed that erianin-induced apoptosis and autophagy was attributed to reactive oxygen species (ROS), as N-acetyl cysteine (NAC), an ROS scavenger, attenuated them. Moreover, we found that erianin induced activation of c-Jun N-terminal kinase (JNK) signal pathway, which was also blocked by NAC. Downregulation of JNK by its specific inhibitor SP600125 could attenuate apoptosis and autophagy induced by erianin. Finally, erianin in vivo markedly reduced the growth with little organ-related toxicity. In conclusion, erianin induced cell cycle G2/M-phase arrest, apoptosis, and autophagy via the ROS/JNK signaling pathway in human OS. In light of these results, erianin may be a promising agent for anticancer therapy against OS.
TMEM2 inhibits hepatitis B virus infection in HepG2 and HepG2.2.15 cells by activating the JAK–STAT signaling pathway
Authors: Zhu X , Xie C , Li Y-m , Huang Z-l , Zhao Q-y , Hu Z-x , Wang P-p , Gu Y-r , Gao Z-l , Peng L
Published: June 2016

We have previously observed the downregulation of TMEM2 in the liver tissue of patients with chronic hepatitis B virus (HBV) infection and in HepG2.2.15 cells with HBV genomic DNA. In the present study, we investigated the role and mechanism of TMEM2 in HepG2 and HepG2.2.15 during HBV infection HepG2 and HepG2.2.15. HepG2 shTMEM2 cells with stable TMEM2 knockdown and HepG2 TMEM2 and HepG2.2.15 TMEM2 cells with stable TMEM2 overexpression were established using lentivirus vectors. We observed reduced expression of TMEM2 in HBV-infected liver tissues and HepG2.2.15 cells. HBsAg, HBcAg, HBV DNA, and HBV cccDNA levels were significantly increased in HepG2 shTMEM2 cells but decreased in HepG2 TMEM2 and HepG2.2.15 TMEM2 cells compared with naive HepG2 cells. On the basis of the western blotting results, the JAK–STAT signaling pathway was inhibited in HepG2 shTMEM2 cells but activated in HepG2 TMEM2 and HepG2.2.15 TMEM2 cells. In addition, reduced and increased expression of the antiviral proteins MxA and OAS1 was observed in TMEM2-silenced cells (HepG2 shTMEM2 cells) and TMEM2-overexpressing cells (HepG2 TMEM2 and HepG2.2.15 TMEM2 cells), respectively. The expression of Interferon regulatory factor 9 (IRF9) was not affected by TMEM2. However, we found that overexpression and knockdown of TMEM2, respectively, promoted and inhibited importation of IRF9 into nuclei. The luciferase reporter assay showed that IRF9 nuclear translocation affected interferon-stimulated response element activities. In addition, the inhibitory effects of TMEM2 on HBV infection in HepG2 shTMEM2 cells was significantly enhanced by pre-treatment with interferon but significantly inhibited in HepG2.2.15 TMEM2 cells by pre-treatment with JAK1 inhibitor. TMEM2 inhibits HBV infection in HepG2 and HepG2.2.15 by activating the JAK–STAT signaling pathway.
A ribosome-related signature in peripheral blood CLL B cells is linked to reduced survival following treatment
Authors: Sbarrato T , Horvilleur E , Pöyry T , Hill K , Chaplin L C , Spriggs R V , Stoneley M , Wilson L , Jayne S , Vulliamy T , Beck D , Dokal I , Dyer M J S , Yeomans A M , Packham G , Bushell M , Wagner S D , Willis A E
Published: June 2016

We have used polysome profiling coupled to microarray analysis to examine the translatome of a panel of peripheral blood (PB) B cells isolated from 34 chronic lymphocytic leukaemia (CLL) patients. We have identified a ‘ribosome-related’ signature in CLL patients with mRNAs encoding for ribosomal proteins and factors that modify ribosomal RNA, e.g. DKC1 (which encodes dyskerin, a pseudouridine synthase), showing reduced polysomal association and decreased expression of the corresponding proteins. Our data suggest a general impact of dyskerin dysregulation on the translational apparatus in CLL and importantly patients with low dyskerin levels have a significantly shorter period of overall survival following treatment. Thus, translational dysregulation of dyskerin could constitute a mechanism by which the CLL PB B cells acquire an aggressive phenotype and thus have a major role in oncogenesis.