bluuebunny/crossref_metadata_2025 huggingface dataset:
Guidelines for evaluation and treatment of lead poisoning of wild raptors
Authors: Fallon Jesse A. , Redig Patrick , Miller Tricia A. , Lanzone Michael , Katzner Todd
Published: May 2017

Lead poisoning is a threat to birds, particularly scavenging birds of prey. With the availability of portable lead‐testing kits, an increasing number of field researchers are testing wild‐caught birds, in situ, for lead poisoning. We describe guidelines for evaluation of lead toxicity in wild raptors by outlining field testing of blood‐lead concentrations, presenting criteria for removing a lead‐poisoned bird from the wild for treatment, and suggesting strategies for effective treatment of lead intoxicated raptors. Field testing of birds is most commonly accomplished via portable electrochemical analysis of blood; visual observation of condition alone may provide insufficient evidence upon which to make a decision about lead poisoning. Our intended audience is not only the avian research community, but also rehabilitation facilities that may receive apparently uninjured birds. Best practices suggest that birds whose blood‐lead levels are <40 μg/dL be released back to the wild as soon as possible after capture. The decision to release or treat birds with blood‐lead levels between 40 μg/dL and 60 μg/dL should be made based on the presence of clinical signs of poisoning and relevant biological characteristics (e.g., breeding status). Finally, birds with blood‐lead levels >60 μg/dL are potentially lethally poisoned and best served if removed from the wild for appropriate treatment at a licensed rehabilitation facility and later released. We present guidelines for decision‐making when treating lead poisoning of wild raptors. Future work based on experimental studies will clarify the role of lead poisoning for specific species and be important to refine these guidelines to improve effectiveness. © 2017 The Wildlife Society.
Sentinel Lymph Node Mapping with Isosulfan Blue or Indocyanine Green in Colon Cancer Shows Comparable Results and Identifies Patients with Decreased Survival: A Prospective Single‐Center Trial
Authors: Weixler Benjamin , Rickenbacher Andreas , Raptis Dimitri Aristotle , Viehl Carsten T. , Guller Ulrich , Rueff Jessica , Zettl Andreas , Zuber Markus
Published: May 2017

Background

Sentinel lymph node (SLN) mapping was reported to improve lymph node staging in colon cancer. This study compares isosulfan blue (IB) with indocyanine green (ICG)‐based SLN‐mapping and assesses the prognostic value of isolated tumor cells (ITC) and micro‐metastases in upstaged patients.

Methods

A total of 220 stage I–III colon cancer patients were included in this prospective single‐center study. In 170 patients, SLN‐mapping was performed in vivo with IB and in 50 patients ex vivo with ICG. Three levels of each SLN were stained with H&E. If negative for tumor infiltration, immunostaining for cytokeratin (AE1/3; cytokeratin‐19) was performed.

Results

SLN detection rate for IB and ICG was 100 and 98%, respectively. Accuracy and sensitivity was 88 and 75% for IB, 82 and 64% for ICG, respectively (p = 0.244). Overall, 149 (68%) patients were node negative. In these patients, ITC and micro‐metastases were detected in 26% (31/129) with IB and 17% (5/29) with ICG (p = 0.469). Patients with ITC and micro‐metastases did show decreased overall survival (hazard ratio = 1.96, p = 0.09) compared to node negative disease.

Conclusions

This study demonstrates a high diagnostic accuracy for both the IB and the ICG SLN‐mapping. SLN‐mapping upstaged a quarter of patients with node negative colon cancer, and the detected ITC and micro‐metastases were an independent negative prognostic marker in multivariate analysis.
Mediators of Weight Loss Maintenance in the Keep It Off Trial
Authors: Crain A L , Sherwood N E , Martinson B C , Jeffery R W
Published: May 2017

Background

An important step toward enhancing the efficacy of weight loss maintenance interventions is identifying the pathways through which successful interventions such as the Keep It Off trial have worked.

Purpose

This study aimed to assess the viability of mediated relationships between the Keep It Off Guided intervention, conceptually and empirically grounded potential mediators, and weight. Repeated measurement of mediators and weight enabled documentation of the temporal ordering of intervention delivery and changes in mediators and in weight among participants randomized to the Guided intervention or Self-Directed comparison group.

Methods

Total, direct, and indirect effects of the Guided intervention on weight change were calculated and tested for significance. Indirect effects were comprised of the influence of the intervention on three change scores for each mediator and the relationship between mediator changes and weight changes 6 months later.

Results

Guided intervention participants regained about 2% less weight over 24 months than Self-Directed participants. Starting daily self-weighing accounted for the largest share of this difference, followed by not stopping self-weighing.

Conclusions

Daily self-weighing mediated 24-month weight loss maintenance.

Trial Registration Number

The trial is registered withClinicalTrials.gov (Identifier: NCT00702455www.clinicaltrials.gov/ct2/show/NCT00702455).
Mañana tengo examen
Authors: Cruz Fierro Claudio Manuel
Published: May 2017

En relación con su editorial del número 6 —tema por demás apasionante, aunque aun con muchas aristas—: durante una evaluación ambos protagonistas —evaluado y evaluador— tratan de desempeñarse lo mejor posible.
Estructura interna del CVP-35: ¿tres u ocho dimensiones?
Authors: Dominguez-Lara Sergio Alexis
Published: May 2017

La estructura interna de un instrumento de autoinforme es clave para el proceso de generación de conocimiento en torno a la variable estudiada, ya que una sobrestimación o subestimación de dimensiones puede tener consecuencias directas en su interpretación y, por ende, en las conclusiones vertidas.
The BDNF Val66Met polymorphism moderates the effect of cognitive reserve on 36‐month cognitive change in healthy older adults
Authors: Ward David D. , Andel Ross , Saunders Nichole L. , Thow Megan E. , Klekociuk Shannon Z. , Bindoff Aidan D. , Vickers James C.
Published: May 2017

Introduction

Cognitive reserve (CR) and BDNF Val66Met are independently associated with the rate of cognitive decline in preclinical Alzheimer's disease. This study was designed to investigate the interactive effects of these variables on 36‐month cognitive change in cognitively intact older adults.

Methods

Data for this investigation were obtained from 445 community‐residing participants of the Tasmanian Healthy Brain Project, who underwent genetic screening and annual assessment of neuropsychological, health, and psychosocial function.

Results

Our main result was that BDNF Val66Met moderated the relationship between baseline CR and change in executive function performance, in that CR‐related differences in function decreased across the follow‐up period in BDNF Val homozygotes, but became more pronounced in BDNF Met carriers. Similar effects were not observed within the other memory‐ and language‐related cognitive domains.

Discussion

Inheritance of BDNF Met may be associated with a detrimental influence on the relationship between CR and cognitive change in cognitively intact older adults, but this effect may be restricted to the executive function domain.
What is Known About Transitional Living Services for Adults With an Acquired Brain Injury? A Scoping Review
Authors: Potter Anna , Sansonetti Danielle , D'Cruz Kate , Lannin Natasha
Published: May 2017

Transitional living service (TLS) programmes for adults with an acquired brain injury are considered an important part of rehabilitation. However, considerable variability exists in the design and structure of these services, with limited research to guide the development of a programme based on best evidence. A scoping literature review was completed to answer the question ‘What is known about TLS programmes for adults with an acquired brain injury?’ Four electronic databases were systematically searched, followed by a grey literature search (from 1996 to 2015). 3183 articles were screened and 13 articles were included in the final review. Themes that emerged from the literature include the types of residents using TLS programmes, the subjective experience of residents and staff, intervention approaches, programme staffing, and programme outcomes. The research reviewed supports the use of TLS programmes to maximise functional independence and community integration of individuals with an acquired brain injury. Clinical practise recommendations were developed to help support implementation of TLS programmes based on best evidence, these included: to use multiple outcome measures, implement collaborative goal setting, support generalisation of skills learnt in the TLS to the home environment and for eligibility criteria for these programmes to include individuals across all phases of recovery.
LO39: Healthcare costs among homeless and/or substance using adults presenting to the emergency department: a single centre study
Authors: Puri V.V. , Dong K. , Rowe B.H. , Kirkland S.W. , Vandenberghe C. , Salvalaggio G. , Cooper R. , Newton A. , Wild C. , Gupta S. , Khangura J.K. , Villa-Roel C. , McCabe C.
Published: May 2017

Introduction: Active substance use and unstable housing are both associated with increased emergency department (ED) utilization. This study examined ED health care costs among a cohort of substance using and/or homeless adults following an index ED visit, relative to a control ED population. Methods: Consecutive patients presenting to an inner-city ED between August 2010 and November 2011 who reported unstable housing and/or who had a chief presenting complaint related to acute or chronic substance use were evaluated. Controls were enrolled in a 1:4 ratio. Participants’ health care utilization was tracked via electronic medical record for six months after the index ED visit. Costing data across all EDs in the region was obtained from Alberta Health Services and calculated to include physician billing and the cost of an ED visit excluding investigations. The cost impact of ED utilization was estimated by multiplying the derived ED cost per visit by the median number of visits with interquartile ranges (IQR) for each group during follow up. Proportions were compared using non-parametric tests. Results: From 4679 patients screened, 209 patients were enrolled (41 controls, 46 substance using, 91 unstably housed, 31 both unstably housed and substance using (UHS)). Median costs (IQR) per group over the six-month period were $0 ($0-$345.42) for control, $345.42 ($0-$1139.89) for substance using, $345.42 ($0-$1381.68) for unstably housed and $1381.68 ($690.84-$4248.67) for unstably housed and substance using patients (p<0.05). Conclusion: The intensity of excess ED costs was greatest in patients who were both unstably housed and presenting with a chief complaint related to substance use. This group had a significantly larger impact on health care expenditure relative to ED users who were not unstably housed or who presented with a substance use related complaint. Further research into how care or connection to community resources in the ED can reduce these costs is warranted.
LO45: Does the use of point of care ultrasonography improve survival in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial
Authors: Atkinson P.R. , Milne J. , Diegelmann L. , Lamprecht H. , Stander M. , Lussier D. , Pham C. , Henneberry R. , Fraser J. , Howlett M. , Mekwan J. , Ramrattan B. , Middleton J. , van Hoving D.J. , Fredericks D. , Peach M. , Taylor L. , Dahn T. , Hurley S.T. , MacSween K. , Cox C. , Richardson L. , Loubani O. , Stoica G. , Hunter S. , Olszynski P. , Lewis D.
Published: May 2017

Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP<100 or shock index>1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.
LO49: Characterizing highly frequent users of a large Canadian urban emergency department
Authors: Kim J. , Kwok E.S. , Cook O. , Calder L.
Published: May 2017

Introduction: Highly frequent users (HFU) of the emergency department (ED) remain a poorly defined and complex population. This study describes patient and visit characteristics for HFU of the ED, and analyzes subgroups of patients with mental illness, substance abuse, and/or ≥30 yearly ED visits. Methods: We performed a health records review of 250 randomly selected adults with >99th percentile of ED visit frequency (≥7 visits) at a tertiary care academic hospital with two EDs in 2014. Two reviewers collected demographic variables (age, sex, and comorbidities) and visit data (ED diagnosis, ED length of stay (LOS), ED presentation time (daytime 0800-1559 h, evening 1600-2359 h, overnight 2400-0759 h), consultation services, and final disposition). Data were analyzed using descriptive and univariate analyses, student t and Mann Whitney U tests. Results: Of 897 eligible patients who experienced 9,376 ED visits we included 250 patients (2,670 visits) in our main analyses, and an additional 11 patients (494 visits) outside of the random selection with ≥30 ED visits. Mean age was 53.4±1.3 (SEM), and 55.6% were female. Most patients had a fixed address (88.9%), and a family physician (87.2%). Top comorbidities included gastrointestinal (61.6%), cardiovascular (52%), and chronic pain issues (47.2%). Top ED diagnoses included musculoskeletal pain (9.6%), abdominal pain (8.4%) and alcohol-related presentations (8.5%). Hospital admission was required for 15.6% of visits. From all possible visits (3164 visits), consultations for social workers, geriatric emergency medicine nurses, or Community Care Access Centres were made for 5.9% of visits, with 47.3% of these patients presenting during daytime hours. Among visits requiring these consultations, median ED LOS was greatest in the evening (12.7 hours, range 1.4-45.2 hours), compared to daytime (5.4, 1.2-33.6; p=0.0002) or overnight (7.9, 1.0-38.3, p=0.02). Inter-rater review of 4.5% of abstracted health records revealed a kappa score of 0.8. Conclusion: This study highlights that a remarkably low proportion of HFUs received allied health consultations at the study sites, likely corresponding to a lack of available consultants outside of daytime work hours. Our findings suggest the need to address significant gaps in order to balance the clinical needs of patients who frequent the ED with currently available resources.
LO51: Incidence of clinically relevant medication errors after implementation of an electronic medication reconciliation process
Authors: Stockton K.R. , Wickham M.E. , Lai S. , Badke K. , Villanyi D. , Ho V. , Dahri K. , Hohl C.M.
Published: May 2017

Introduction: Medication discrepancies are unintended differences between a patient’s outpatient and inpatient medication regimens, and occur in up to 60% of hospital admissions. Canadian emergency departments (EDs) have implemented medication reconciliation forms that are pre-populated with outpatient medication dispensing data in order to reduce medication discrepancies and resultant adverse drug events. However, these forms may introduce errors of commission by prompting prescribers to reorder discontinued or potentially harmful medications. Our objective was to evaluate the incidence of medication discrepancies and errors of commission after the implementation of pre-populated medication reconciliation forms. Methods: This chart review included admitted patients who were enrolled in a parent study in which a research pharmacist prospectively collected best-possible medication histories (BPMHs) in the ED using all available information sources. Following discharge, research assistants uninvolved with the parent study compared medication orders documented within 48 h of admission with the BPMH to identify medication discrepancies and errors of commission. Errors of commission were defined as inappropriate continuations of medications and reordering discontinued medications. An independent panel adjudicated the clinical significance of the errors. We used regression methods to identify factors associated with errors. The sample size was limited by enrolment into the parent study. Results: Of 151 patients, 71 (47%; 95%CI 39.2-54.9) were exposed to 112 medication errors. Of these errors, 75.9% (85/112; 95%CI 67.1-82.9) were discrepancies, of which 18.8% (16/85; 95%CI 12.0-28.4) were clinically significant. Errors of commission made up 24.1% (27/112; 95%CI 17.3-32.8) of all errors, of which 37.0% (10/27; 95%CI 18.8-55.2) were clinically significant. Taking 8 or more medications was associated with a 5-fold greater odds of experiencing a medication error after controlling for confounders (OR 5.00; 95%CI 2.45-10.17; p<0.001). Conclusion: Clinically significant medication discrepancies and errors of commission remain common despite the implementation of electronically pre-populated medication reconciliation forms. Prospective studies are needed to evaluate whether using pre-populated medication reconciliation forms increases the risk of introducing errors of commission.
LO57: Validation of the Ottawa 3DY in community seniors in the ED
Authors: Bédard C. , Voyer P. , Eagles D. , Boucher V. , Pelletier M. , Gouin E. , Berthelot S. , Daoust R. , Laguë A. , Gagné A. , Émond M.
Published: May 2017

Introduction: Cognitive dysfunction is getting more common in geriatric emergency department (ED) patients, as the number of seniors visiting our EDs is increasing. ED guidelines recommend a systematic mental status screening for seniors presenting to the ED. As the existing tools are not suitable for the busy ED environment, we need quicker and easier ways to assess altered mental status, such as the O3DY. The purpose of this study is to assess the effectiveness of the French version of the O3DY to screen for cognitive dysfunction in seniors presenting to the ED. Methods: This is a planned sub-study of the INDEED project, which was conducted between February and May 2016 in 4 hospitals across the province of Québec. Inclusion criteria were: patients aged ≥65, with an 8-hour ED stay, admitted on a care unit, independent or semi-independent in their activities of daily living. Exclusion criteria were: patient living in a long-term nursing facility, with an unstable medical condition, pre-existing psychiatric condition or severe dementia, a delirium within the 8-hour exposure to the ED. A trained research assistant collected the following data upon initial interview: socio-demographic information, cognitive assessment (TICS-m), functional assessment (OARS) and delirium screening (CAM). The O3DY was also administered at initial interview and during patient follow-ups, as well as the CAM. Results: This study population was composed of 305 participants, of which 47.7% were men. Mean age was 76 years old (SD: 10.8). Nine of these participants had a previous history of dementia. 151 of these participants (47,04%) had a negative O3DY and 154 (47,98%) a positive O3DY at the initial encounter. When compared to the CAM, the O3DY presents a sensitivity of 85.0% (95% CI [62.1, 96.8]) and a specificity of 57.7% (95% CI [51.8, 63.6]) for prevalent delirium. When compared to the TICS, the O3DY presents a sensitivity of 76.7% (95% CI [66.4, 85.2]) and a specificity of 68.1% (95% CI [61.3, 74.3]) for cognitive impairment. The
combined measure
presents a sensitivity of 76.7% (95% CI [66.6, 84.9]) and a specificity of 68.4% (95% CI [61.7, 74.5]). Conclusion: A negative result to the O3DY indicates the absence of prevalent delirium or undetected cognitive impairment. The O3DY could be a useful tool for the triage nurses in the ED.
LO59: Police use of force and subsequent emergency department assessment-mental health concerns are the driving force behind ED use and choice of transport mode
Authors: Hall C.A. , Votova K. , Eramian D. , MacDonald S. , Heyd C.G. , Sedgwick C.
Published: May 2017

Introduction: We examined persons transported to hospital after police use of force to determine whether Emergency Department (ED) assessment and/or mode of transport could be predicted. Methods: A multi-site prospective consecutive cohort study of police use of force with data on ED assessment for individuals ≥18 yrs was conducted over 36 months (Jan 2010-Dec 2012) in 4 cities in Canada. Police, EMS and hospital data were linked by study ID. Stepwise logistic regression examined the relationship between the police call for service and subject characteristics on subsequent ED assessment and mode of transport. Results: In 3310 use of force events, 86.7% of subjects were male, median age 29 yrs. ED transport occurred in 26% (n=726). Odds of ED assessment increased by 1.2 (CI 1.1, 1.3) for each force modality >1. Other predictors of ED use: if the nature of police call was for Mental Health Act (MHA) (Odds 14.3, CI 10.6, 19.2), features of excited delirium (ExD) (Odds 2.7, CI 1.9, 3.7), police-assessed emotional distress (EDP) not an MHA (Odds 2.1, CI 1.5, 3.0) and combined drugs, alcohol and EDP (Odds 1.7, CI 1.9, 3.7). Those with alcohol impairment alone were less likely to go to ED from the scene: OR 0.6 (CI 0.5, 0.7). EMS transported 55% of all patients (n=401), although police transported ~100 people who EMS attended at the scene but did not subsequently transport. For patients brought to the ED, 70% had a retrievable chart (512/726) with a discernible primary diagnosis: 25% for physical injury, 32% for psychiatric and 43% for drug and/or alcohol intoxication. For use of force events that began as MHA calls, patient transport was more often by police car than ambulance OR 1.8 (CI 1.2, 2.5), while those with drug intoxication or ≥3 ExD features were more often brought by ambulance: odds of police transport 0.5 (CI 0.3, 0.9) and 0.4 (CI 0.3, 0.7). Violence or aggression did not predict mode of transport in our study. Conclusion: About one quarter of police use of force events lead to ED assessment; 1 in 4 patients transported had a physical injury of some description. Calls including the Mental Health Act or individuals with drug intoxication or excited delirium features are most predictive of ED use following police use of force. In MHA calls with use of force, persons are nearly twice as likely to go to ED by police car than by ambulance.
LO62: Systolic blood pressure is a strong predictive marker for TIA and mild stroke in younger patients
Authors: Sedgwick C. , Bibok M. , Croteau N.S. , Lesperance M.L. , Balshaw R. , Votova K. , Blackwood K. , Coutts S.D. , Penn A.
Published: May 2017

Introduction: Age and systolic blood pressure (SBP) are important predictors of Acute Cerebrovascular Syndrome (ACVS). Yet, the effect of SBP is confounded by age, making its independent contribution to ACVS risk difficult to quantify. Here we use logistic regression to explore the role of SBP in younger and older ED patients. Methods: Data comprised 1019 ED patients (ACVS 70%, 30% non-ACVS) enrolled during a 28-month period of an ongoing prospective, observational, multi-site stroke biomarker study (SpecTRA). We used logistic regression to examine the effects of age, sex, and the age:SBP interaction as predictive markers of the diagnosis of ACVS. Results: Participants (53% male) ranged in age from 18 to 97 years (Q1=58, median=70, Q3=80). SBP ranged from 84 to 248 mmHg (Q1=137, median=154, Q3=174). In our initial regression model, age, sex, SBP and the age:SBP interaction were all significant (p<0.01). Using cubic regression splines for age, sbp and their interaction yields the same conclusion (p<0.01). To better understand the role of SBP in younger vs. older patients, we stratified the sample at the median age (70 years of age). In the younger group (n=510), participants were 55% male, 60% ACVS, and had SBP ranging from 91 to 236 mmHg (Q1=133, median=148, Q3=165). In the older group (n=509), participants were 51% male, 82% ACVS and had SBP ranging from 84 to 248 mmHg (Q1=143, median=159, Q3=179), a shift of approximately 10 mmHg between the groups. The logistic regression model was then fit separately to each group without the age:SBP interaction term. In the younger group, we found SBP to be highly significant (p<0.001), with an odds-ratio (OR) of 1.18 per 10 mmHg (95% CI: 1.10-1.29). In the older group, we found that SBP was not significant (p=0.91), with an OR of 1.00 per 10 mmHg (95% CI: 0.91-1.08). Age and sex were also significant risk factors in the younger group (each p<0.01), though not in the older group (both p>0.07). Conclusion: Our findings suggest that for ED patients suspected of ACVS, SBP is a clinically relevant predictor for younger patients, with higher SBP associated with an increased risk of ACVS, regardless of patient age and sex. SBP does not appear to be a strong predictor for patients over 70. ED physicians can leverage this finding by attributing greater importance to elevated SBP in younger patients than older patients when working toward a clinical suspicion of ACVS.
LO66: Did the Choosing Wisely Canada campaign work? A retrospective analysis of its impact on emergency department imaging utilization for head injuries
Authors: Masood S. , Chartier L.B.
Published: May 2017

Introduction: Head injuries are a commonly encountered presentation in emergency departments (ED) and the Choosing Wisely Canada (CWC) campaign was released in June 2015 in an attempt to decrease imaging utilization for patients with minor head injuries. The impact of the CWC campaign on imaging utilization for head injuries has not been explored in the ED setting. In our study, we describe the characteristics of patients with head injuries presenting to a tertiary care academic ED and the impact of the CWC campaign on CT head utilization. Methods: This retrospective cohort study used linked databases from the province of Ontario, Canada to assess emergency department visits with a primary diagnosis of head injury made between June 1, 2014 and Aug 31, 2016 at the University Health Network in Toronto, Canada. We examined the number of visits during the study period, the proportion of patients that had a CT head performed before and after the release of the CWC campaign, as well as mode of arrival, and disposition. Results: There were 4,322 qualifying visits at our site during the study period. The median presenting age was 44.12 years (IQR 27.83,67.45), the median GCS was 15 (IQR 15,15) and the majority of patients presenting had intermediate acuity (CTAS 3). Overall, 43.17% of patients arrived via ambulance, 49.24 % of patients received a CT head and 10.46% of patients were admitted. Compared to patients presenting before the CWC campaign release, there was no significant difference in the rate of CT heads after the CWC (50.41% vs 47.68%, P=0.07). There were also no significant differences between the two groups in mode of arrival (ambulance vs ambulatory) (42.94% vs 43.48%, P=0.72) or admission rates (9.85% vs 11.26%, P=0.15). However, more patients belonged to the high acuity groups (CTAS 1 or 2) in the post CWC campaign release group (12.98% vs 8.11% P<0.001). Conclusion: Visits for head injuries make up a significant proportion of total ED visits and approximately half of these patients receive CT imaging in the ED. The CWC campaign did not seem to impact imaging utilization for head injuries in the 14 months following its launch. Further efforts, including local quality improvement initiatives, are likely needed to increase adherence to its recommendation and reduce imaging utilization for head injuries.
LO68: Extracorporeal membrane oxygenation in the emergency department for resuscitation of out-of-hospital cardiac arrest patients: a systematic review
Authors: Beyea M.M. , Tillmann B.W. , Lansavichene A.E. , Randhawa V. , Van Aarsen K. , Nagpal A.
Published: May 2017

Introduction: With one person in Canada suffering an out-of-hospital cardiac arrest (OHCA) every 12 minutes and an estimated survival to hospital discharge with good neurologic function ranging from 3 to 16%, OHCA represents a major source of morbidity and mortality. An evolving adjunct for resuscitation of OHCA patients is the use of extracorporeal membrane oxygenation-assisted CPR (ECPR). The purpose of this systematic review is to investigate the survival to hospital discharge with good neurologic recovery in patients suffering from OHCA treated with ECPR compared to those who received standard advanced cardiac life support with conventional CPR (CCPR) alone. Methods: A systematic database search of both MEDLINE & EMBASE was performed up until September 2016 to identify studies with ≥5 patients reporting ECPR use in adults (age ≥16 years) with OHCA. Only studies reporting survival to hospital discharge were included. All identified studies were assessed independently using pre-determined inclusion criteria by two reviewers. Study quality and risk of bias were evaluated using the Newcastle Ottawa regulations assessment scale. Results: Of the 1065 records identified, 54 studies met all inclusion criteria. Inter-rater reliability was high with a kappa statistic of 0.85. The majority of studies were comprised of case series (n=45) of ECPR with 5 to 83 patients/study. Out of the 45 case series, 37 presented neurologic data at hospital discharge and demonstrated a broad range of patients surviving with good neurologic outcome (0 to 71.4%). Only 9 cohort studies with relevant control group (CCPR) were identified (38 to 21750 patients/study). Preliminary analysis demonstrated that 6 cohort studies were sufficient quality to compare ECPR to CCPR. All 6 studies showed significantly increased survival to hospital discharge with good neurologic recovery (ECPR 10.6 to 41.6% vs CCPR 1.5 to 7.7%, respectively). Conclusion: Given the paucity of studies using appropriate comparators to evaluate the impact of ECMO, our confidence in a clinically relevant difference in outcomes compared to current standards of care for OHCA remains weak. Interestingly, a limited number of studies with suitable controls demonstrated a potential benefit associated with ECPR in the management of OHCA in selected patients. In this state of equipoise, high quality RCT data is urgently needed.
LO70: Do automatic external defibrillators improve rates of return of spontaneous circulation, survival to hospital discharge and favourable neurological survival in Canada?
Authors: Barbic D. , Grunau B.E. , Scheuermeyer F.X. , Dick W. , Christenson J.
Published: May 2017

Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically 8-12%. Recent evidence has shown that public access automatic external defibrillators (AED) may improve survival. The objectives of this study were to determine whether AEDs improve rates of return of spontaneous circulation (ROSC), overall survival, and favourable neurological survival (FNS) in Canada. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2011-2015 within BC’s four metropolitan areas. We included all EMS-treated adult patients. Data were collected in accordance with recognized Utstein criteria. We described frequencies with counts, means and medians where appropriate, and the Z-test was used to compare population proportions. Results: We examined 7577 OHCAs from 2011-2015. AEDs were deployed on 223 patients in this period (mean age 60.4 yrs [95% CI 45.7-75.1] and 83.9% male; non-AED OHCAs mean age 66.2 yrs [48.4-83.8] and 67.3% male). Seventy seven percent of AED deployments occurred in public locations, 69.1% were witnessed by bystanders and CPR was initiated in 98.7% of these cases. Fifteen percent of non-AED OHCAs occurred in public locations, 38.3% were bystander witnessed, and 45.4% received bystander CPR. AEDs delivered shocks to 61.4% of patients, and EMS crews found an initial shockable rhythm upon scene arrival in 60.5% of AED deployments (22.9% for non-AED cases). AED OHCA patients had higher rates of ROSC at any time (67.2% vs 47.6%; difference of 19.6% [12.9-26.2 p<0.01]), and ROSC at ED arrival (61% vs 35.4%; difference of 25.6% [19.2-32.0 p<0.01]). AED OHCA patients had higher rates of survival to hospital discharge (23.8% vs 8.5%; difference 15.3% [11.5-19.1 p<0.01]). Detailed neurologic outcome data was not available for all patients, yet for those which it was available AED OHCA patients had improved outcomes (modified Rankin score<2) compared to non-AED OHCA patients (9.0% vs 5.4%; difference 3.6% [0.6-6.6 p<0.02]. Conclusion: Automatic external defibrillators markedly improve rates of ROSC at any time, sustained ROSC at ED arrival, survival to hospital discharge, and FNS in Canada. Continued support for public access AED programs is essential to improve patient outcomes.
LO71: For patients suffering from out-of-hospital cardiac arrest, is survival influenced by the capabilities of the receiving hospital?
Authors: Cournoyer A. , Notebaert E. , De Montigny L. , Iseppon M. , Cossette S. , Londei-Leduc L. , Lamarche Y. , Larose D. , de Champlain F. , Morris J. , Vadeboncoeur A. , Piette E. , Daoust R. , Chauny J. , Sokoloff C. , Ross D. , Cavayas Y. , Paquet J. , Denault A.
Published: May 2017

Introduction: Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital after return of spontaneous circulation (ROSC). Percutaneous coronary intervention (PCI) is often indicated as a diagnostic and therapeutic procedure following OHCA. This study aimed to determine the association between the type of destination hospital (PCI-capable or not) and survival to discharge for patients with OHCA and prehospital ROSC. We hypothesized that being transported to a PCI-capable hospital would be associated with a higher survival to discharge. Methods: The present study used a registry of adult OHCA between 2010 and 2015 in Montréal, Canada. We included adult patients with non-traumatic OHCA and prehospital ROSC. The association of interest was evaluated with a multivariate logistic regression model to control for demographic and clinical variables (age, gender, time of day, initial rhythm, witnessed arrest, bystander CPR, presence of first responders or advanced care paramedics, prehospital supraglottic airway placement, delay before paramedics’ arrival). Assuming a survival rate of 40% and 75% of the variability explained by other factors included in the model, more than 1200 patients needed to be included to detect an absolute difference of 10% in survival between both groups with a power of more than 90%. Results: A total of 1691 patients (1140 men and 551 women) with a mean age of 64 years (standard deviation 17) were included, of which 1071 (63%) were transported to a PCI-capable hospital. Among all patients, 704 patients (42%) survived to hospital discharge. We observed a significant independent association between survival to discharge and being transported to a PCI-capable hospital (adjusted odds ratio [AOR] 1.46 [95% confidence interval 1.09-1.96]) after controlling for confounding variables. Having an initial shockable rhythm and presence of first responders also increased survival to discharge (AORs 3.67 [95% confidence interval 2.75-4.88] and 1.53 [95% confidence interval 1.12-2.09], respectively). Conclusion: Patients experiencing ROSC after OHCA could benefit from a direct transport to a PCI-capable hospital. This benefit might also be related to unmeasured interventions other than PCI these hospitals can provide (e.g. high-level intensive care or cardiovascular surgery).
LO73: Long-term functional outcome and health-related quality of life of elderly out-of-hospital cardiac arrest survivors
Authors: Mercier E. , Andrew E. , Nehme Z. , Lijovic M. , Bernard S. , Smith K.
Published: May 2017

Introduction: This study aims to describe the long-term functional outcome and health-related quality of life of elderly (≥65 years old) out-of-hospital cardiac arrest (OHCA) survivors in Victoria, Australia. Methods: Elderly OHCA patients who arrested between January 1st, 2010 and December 31st, 2014 were identified from the Victorian Ambulance Cardiac Arrest Registry (VACAR). Living status, Glasgow Outcome Scale-Extended (GOS-E), Euro-QoL (EQ-5D) and Twelve-item Short Form (SF-12) Health Survey were collected by telephone 12 months following the OHCA. Results: Emergency medical services attended on 14,678 elderly OHCA during the study period, 6,851 (46.7%) of which received a resuscitation attempt. Of these, 668 patients (9.8%) survived to hospital discharge. The mean age of the survivors was 75 (standard deviation (SD) 7.4) years and 504 (75.4%) were male. Eighty-five patients subsequently died within 12 months of their OHCA. A total of 483 patients were interviewed (response rate 82.9%). At 12 months, 313 responders (64.9%) were living at home without care. Most responders (n=324 (67.2%)) had a good long-term functional recovery with a GOS-E ≥7. The proportion of patients with a GOS-E≥7 progressively decreased with increasing age (65-74 years: 66.1%, 75-84 years: 53.0%,≥85 years: 27.3%). On the EQ-5D, the majority of survivors reported no problem with mobility (n=266 (55.1%)), self-care (n=403 (83.4%)), activity (n=293 (60.6%)), pain (n=335 (69.3%)) and anxiety (n=358 (74.1%)). On the SF-12, the mean mental component summary was 56.3 (SD 6.6) while the mean physical component summary was 44.7 (SD 11.4) (both measures range from 0-100). Among the 1,951 patients who arrested in a supported accommodation, 849 (43.5%) had a resuscitation attempt, and of these, 21 survived to hospital discharge (2.5%). Only eight (1.0%) of these patients were still alive 12 months after the OHCA and one survivor (0.12%) had a good functional outcome (GOS-E≥7). Conclusion: Most elderly OHCA survivors have an adequate long-term functional status and health-related quality of life. However, the likelihood of having a good functional recovery decreases with increasing age, and is rare for patients arresting in a supported accommodation.
LO74: Prehospital sodium bicarbonate use was associated with worse neurological outcomes among patients with out-of-hospital non-traumatic cardiac arrest
Authors: Kawano T. , Scheuermeyer F.X. , Christenson J. , Stenstrom R. , Grunau B.E.
Published: May 2017

Introduction: Sodium bicarbonate (SB) is still widely used for resuscitation in out-of- hospital cardiac arrest (OHCA) despite limited clinical indications but the effect on neurological recovery is unclear. Methods: From 2006 to 2016, we prospectively conducted a province-wide population-based observational study of adult non-traumatic OHCA patients managed by EMS. According to provincial guidelines, paramedics administered SB to OHCA patients based on their clinical assessment. Outcome of interest was favorable neurological outcome at hospital discharge, defined as CPC of 1 and 2 or modified Rankin scale of 3 or less. We performed multivariable logistic regression, comparing the proportion of outcome between SB and non-SB groups, further stratified by the median of the length of resuscitation. We also applied propensity score matching technique adjusting for baseline characters to the same model to reduce potential selection bias. Results: Of 13,008 OHCA patients, 4,699 (36.1%) were managed with SB. In the SB treated group, 64 / 4,699 (1.3%) patients had favorable neurological outcomes, compared to 823 / 8,309 (9.9%) in the non-SB treated group (crude odds ratio [OR] 0.12, 95% CI 0.09 to 0.16). In logistic regression model, SB was associated with decreased probability of favorable outcomes (adjusted OR 0.63, 95% CI 0.45 to 0.89). Similarly, with stratification by length of resuscitation, the SB group had a lower probability of favorable outcomes (≦24 min: adjusted OR 0.68, 95% CI 0.46 to 1.02, >24 min: adjusted OR 0.47, 95% CI 0.23 to 0.97). In 1:1 propensity matched cohort including 5,126 OHCA patients, the adjusted association also persisted (adjusted OR 0.59, 95% CI 0.39 to 0.89). Conclusion: Prehospital administration of SB to OHCA patients was associated with worse neurological outcomes and the trend persisted even after stratification by resuscitation length.
LO78:
Frailty Assessments of Older Canadians Using Emergency Health Services: The FOCUS Study
Authors: Lee J.S.
Published: May 2017

Introduction: The Clinical Frailty Scale (CFS) has been validated internationally to predict adverse outcomes and mortality. Frailty assessments in the Emergency Departments (ED) are challenging to due to a lack of training and time. We studied the use of a tablet-based CFS that used graphics and short descriptors to assist choice of the 9 frailty categories. Methods: We conducted a prospective observational cohort study of people >65 years seen in the ED of 3 Canadian academic centers. We excluded critically ill patients, and those with significant visual impairment or inability to communicate in English or French. We compared agreement on the tablet-based CFS between 4 categories of assessors: Patients, ED Physicians, trained Research Assistance and Caregivers using the kappa statistic. Results: We enrolled 274/380 eligible patients who provided complete data (72.1%). Their average age was 75.8 years, and 48.9% were female. Their median MOCA score was 23/30 (IQR=17-26) and their median OARS was 26/28 (IQR 22-28). Agreement between physicians and research assistants was good (κ=0.60, 95% CI 0.50-0.70), as was physician-caregiver agreement and patient-caregiver agreement (κ=0.66, 95% CI 0.40-0.93). Agreement between physicians and patients was only moderate (κ=0.47, 95% CI 0.36-0.58). Conclusion: There was less agreement between physicians and patient self-assessments for the CFS compared to physicians-research assistant agreement and care-giver patient assessments of frailty. Future research should validate whether MD, patient, or caregiver rated CFS have higher predictive validity.
LO82: The accuracy and prognostic value of point-of-care ultrasound for renal colic: a systematic review
Authors: Wong C. , Young P. , Ross M. , Lee Robertson H. , Lang E.
Published: May 2017

Introduction: Point-of-care ultrasound (POCUS) has been suggested as an initial investigation in the management of renal colic. Our objectives were: 1) to determine the accuracy of POCUS for the diagnosis of nephrolithiasis, and 2) to assess its prognostic value in the management of renal colic (PROSPERO: 42016035331). Methods: An electronic database search of MEDLINE, EMBASE, and PubMed was conducted utilizing subject headings, keywords, and synonyms that address our research question. Bibliographies of included studies and narrative reviews were manually examined. Studies of adult emergency department patients with renal colic symptoms were included. Any degree of hydronephrosis was considered a positive POCUS finding. Accepted criterion standards were CT evidence of renal stone or hydronephrosis, direct stone visualization, or surgical findings. Screening of abstracts, quality assessment with the QUADAS-2 instrument, and data extraction were performed by two reviewers, with discrepancies resolved by conference with a third reviewer.Test performance was assessed by pooled sensitivity and specificity, calculated likelihood ratios, and a summary receiver operator curve (SROC). The secondary outcome of prognostic value was reported as a narrative summary. Results: The electronic search yielded 627 unique titles. After relevance screening, 25 papers underwent full-text review, and 8 articles met all inclusion criteria. Of these, 5 high-quality studies (N=1773) were included in the meta-analysis for diagnostic accuracy, and three yielded data on prognostic value. The pooled results for sensitivity and specificity were 70.2% (95% CI=67.1% to 73.2%) and 75.4% (95% CI=72.5% to 78.2%), respectively. The calculated positive and negative likelihood ratios were 2.85 and 0.39. The SROC generated did not show evidence of a threshold effect.Three studies examining prognostic value noted a higher likelihood of a large stone or surgical intervention with positive POCUS findings. The largest randomized trial showed lower cumulative radiation exposure and no increase in adverse events in those who received POCUS investigation as the initial renal colic investigation. Conclusion: Point-of-care ultrasound is of modest accuracy for the diagnosis of nephrolithiasis. While positive POCUS findings are associated with larger stones and greater likelihood for intervention, the clinical importance of this is unclear.