bluuebunny/crossref_metadata_2025 huggingface dataset:
LO024: Time to perform ultrasound guided femoral nerve block in older hip fractures patients by emergency physicians
Authors: Lee J.S. , Bhandari T. , Simard R. , Kiss A. , Chenkin J.
Published: June 2016

Introduction: Ultrasound-guided femoral nerve block (USFNB) is optimal for providing analgesia for patients with hip fractures, but is rarely performed. Time of the procedure was cited as a barrier in our previous survey. Methods: We conducted a knowledge-to-practice intervention that included a two-hour training session on USFNB, use of a block kit, and reminders to improve uptake of USFNB. We measured the time it took for trained EPs to complete the block during a 20 month period. Results: Of 36 EPs, 34 (94.4%) were not routinely performing USFNB at the beginning of the study, and 4 declined to participate, leaving 30 participants who received training. The 30 trained EPs performed 100 USFNB over the next 20 months (range 1 to 20 blocks per EP). The mean reduction in pain was -4.47 on a 10 point numeric rating scale. The median time to perform the blocks was 15.0 minutes (IQR, 10 to 20 minutes), and 90 % of blocks took less than 30 minutes. The most common reason given for not performing a block was excessive clinical load. Conclusion: Given that we included 88.2% of eligible EP’s and included the first time EP’s performed a USFNB, our estimates of time to perform USFNB block should generalize to other Canadian academic ED’s. Time to complete USFNB is in keeping with other commonly performed ED procedures and should not be a barrier to optimizing analgesia.
LO025: In support of Choosing Wisely: variation in CT ordering for patients presenting to emergency with minor head injury
Authors: Grigat D. , Innes G. , Andruchow J. , McRae A. , Sevick R. , Emery D. , Lang E.
Published: June 2016

Introduction: Individual and institutional disparities in CT imaging rates for patients with head injuries have long been recognized, leading to the development of well-validated clinical decision rules designed to standardize clinical practice. To assess their impact on current practice, we sought to evaluate variation in CT imaging by emergency physicians for patients presenting with head injury across the province of Alberta. Methods: A unique data warehouse merging administrative, clinical, and imaging platforms for 11 Alberta emergency departments (EDs) was created. Unique identifiers were obtained for all emergency physicians who were included in this analysis if they evaluated in excess of ten ED patients presenting with a chief complaint of “head injury”. Patients with high triage acuity (CTAS 1) were excluded, as were patients who were admitted to hospital. Descriptive statistics were employed to describe variation between physicians and sites for a 24 month period from 2013-2015. Results: 311 emergency physicians treating 20,797 patient encounters for head injury were included. Overall a total of 8,245 head injury patients (40%) received one or more CT scans. Physician variation across the 11 sites ranged from 4% -100% of head injury patients receiving a CT. Within sites CT ordering between physicians varied from 9-fold (4% - 36%) at the lowest variation site, to more than 20-fold (4% - 90%) at the highest variation site. After removing the 5% lowest and highest ordering physicians, variation in ordering continued to range from 10% - 72%. No trends were observed across the two years examined. Conclusion: This is the largest study to date examining physician level variation in CT ordering practices for ED head injury patients. We have identified marked persistent practice variation despite the presence of well-validated clinical decision rules and a relatively low risk medicolegal environment. Variable risk tolerance and limited use of validated clinical decision rules are likely contributors making this area an ideal focus for targeted interventions to improve imaging appropriateness and reduce practice variation.
LO027: Cervical spine injury in trauma patients 65 years and older immobilised in the prehospital setting
Authors: Lamy L. , Chauny J. , Ross D.
Published: June 2016

Introduction: Following a protocol derived from the Canadian C-spine Rule (CCR), patients 65 years and older transported by ambulance after trauma require full spinal immobilisation. Immobilisation complicates the transport and the evaluation; potential side effects have been recognized. The aim of this study was to evaluate the effect of mechanism of trauma and age on the rate of cervical injury in a geriatric population. Methods: We conducted a retrospective observational study on patients 65 years and older transported by ambulance to a level-one trauma center from March 2008 to October 2013. The outcome was the rate of clinically important cervical spine injury (CICSI), defined as any fracture, dislocation or ligamentous injury needing treatment or specialised follow up. The rate was calculated in the geriatric population and in the subgroup of patients with minor trauma, defined as a fall from a standing height, a chair or a bed. We then looked at the rate of CICSI based on age to define a subgroup at lower risk of lesion. Results: We included 1221 patients with a mean age of 80 y.o. (SD = 8), 739 women (61%). CICSI was found in 53 patients (4.3%, 95% CI 3.2-5.4). This is similar to the rate found in patients 65 years and older in the NEXUS population (4.6%) and the CCR population (6.0%). The mechanism of injury was a minor trauma for 716 patients (59%). Of those, 24 patients (3.4%, 95% CI 2.1-4.7) had CICSI. The rate increased after 85 y.o in both the overall population (3.4% vs 6.4%) and the minor trauma subgroup (2.6% vs 4.4%). Conclusion: The subgroup of patients 65-84 y.o. with a minor trauma had the lower rate of cervical spine injury (2.6%). In a lot of prehospital systems, those patients are not systematically immobilised for transport. It will be interesting to review the files of all patients with CICSI to identify any possible case that would have been missed without the age criteria.
LO035: The prevalence of alcohol-related trauma recidivism: a systematic review
Authors: Green R. , Nunn J. , Erdogan M.
Published: June 2016

Introduction: Recurrent admission to a hospital or trauma centre for separate incidents of traumatic injury is known as trauma recidivism. Although use of alcohol is a known risk factor for injury and associated with trauma recidivism, the scale of alcohol-related trauma recidivism has not been well described. The purpose of this review was to search the published literature for studies that evaluated the prevalence of alcohol use among trauma recidivists. Our primary objective was to determine the proportion of trauma recidivism related to alcohol use. The association between alcohol and trauma recidivism was evaluated as a secondary objective. Methods: Four electronic databases (MEDLINE, Embase, CINAHL, Web of Science) were searched from inception until December 2015 for all articles that might provide evidence on the proportion of trauma recidivism related to use of alcohol. After removal of duplicates, the search strategy yielded 2470 records for screening. Only primary studies that reported on repeated admissions to a hospital or trauma center for traumatic injuries specifically related to alcohol use were included. Descriptive statistics were used to assess study characteristics and the prevalence of trauma recidivism related to alcohol use. An aggregate weighted estimate of alcohol-related trauma recidivism was calculated. Results: A total of 12 studies met all inclusion criteria. Studies were published between 1989 and 2014. Overall, there were 3386 trauma recidivists among included studies. The proportion of trauma recidivists with evidence of alcohol use on admission ranged from 26.7% to 76.9% (median 46.4%). The aggregated sample produced a weighted estimate of 41.0% (1388/3386) for alcohol-related trauma recidivism. In four studies, the association between alcohol and trauma recidivism was examined; all four found a positive association between alcohol use and repeated admission for traumatic injury. Studies varied considerably in design, trauma populations, periods for evaluating recidivism, definitions for positive alcohol on admission, and methods used to determine alcohol use. Conclusion: Evidence from current literature suggests that 41.0% of trauma recidivism is related to use of alcohol. Due to methodological limitations among the studies included for review, this may underestimate the actual prevalence of alcohol-related trauma recidivism.
LO036: The influence of cognitive rest and graduated return to usual activities emergency department discharge instructions on symptoms of minor traumatic brain injury
Authors: Varner C. , McLeod S.L. , Nahiddi N. , Lougheed R. , Borgundvaag B.
Published: June 2016

Introduction: It is estimated 15-50% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop post-concussive syndrome (PCS). Although expert consensus recommends cognitive rest and graduated return to usual activities, these interventions are not based on prospective clinical evidence. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions. Methods: This was a pragmatic, randomized trial of adult (18-64 years) patients presenting to an academic ED (annual census 65,000) with chief complaint ‘head injury’ occurring within 24 hours of ED visit. Patients were contacted by text message or phone 2 weeks post ED discharge and again at 4 weeks and asked to complete a validated, 22 item questionnaire to determine if there was a change in their PCSS. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school. Results: 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). Mean (SD) age was 35.2 (13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs 12.8; Δ 2.3, 95% CI: 7.0, 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; Δ 2.8, 95% CI: 6.9, 12.7) for the intervention and control groups, respectively. The number follow-up physician visits and time off work/school was similar when the groups were compared. Conclusion: Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given patients continue to experience low to moderate symptoms 2 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with post-concussive symptoms.
LO037: A randomized double-blind trial comparing the effect on pain of an oral sucrose solution versus placebo in children 1 to 3 months old needing urethral catheterization
Authors: Desjardins M. , Gouin S. , Gaucher N. , Lebel D. , Gravel J.
Published: June 2016

Introduction: Oral sweet solutions have been accepted as effective analgesics for procedures in the neonatal population. However, there have been a limited number of trials in older infants. These studies have conflicting results. The objective of the study was to compare the efficacy of an oral sucrose solution versus placebo in reducing pain during urethral catheterization in infants 1 to 3 months old in the Emergency Department (ED). Methods: A randomized, double-blind clinical trial was conducted in a pediatric university-affiliated hospital ED. Infants, 1 to 3 months of age, were recruited and randomly allocated to receive 2 ml of 88% sucrose solution (SUC) or 2 ml of placebo solution (PLA) orally, 2 minutes before planned urethral catheterization. The primary outcome measure was the difference in pain scores as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale at 1 min post procedure. Secondary outcome measures were the difference in pain scores using the Neonatal Infant Pain Scale (NIPS), crying time and variations in heart rate. Results: Seventy-six participants were recruited and completed the study, 37 (group SUC) and 39 (group PLA) respectively. The mean difference in FLACC scores compared to baseline was 5.62 ± 1.32 (SUC) vs. 6.21 ± 1.15 (PLA) (p=.51) during catheterization, 2.70 ± 1.21 (SUC) vs. 2.26 ± 1.41 (PLA) at 1 min (p=.64) and 0.66 ± 1.32 (SUC) vs. 1.26 ± 1.00 (PLA) at 3 mins (p=.38). For the NIPS scores, it was 4.27 ± 1.06 (SUC) vs. 4.69 ± 0.92 (PLA) (p=.56) during procedure, 2.05 ± 0.91 (SUC) vs. 1.97 ± 1.19 (PLA) (p=.92) at 1 min and 0.49 ± 0.89 (SUC) vs. 0.89 ± 0.97 (PLA) (p=.54) at 3 mins. The difference in the mean crying time was not different between both groups: 99 ± 34 secs (SUC) vs. 100 ± 25 (PLA) (p=.99). No significant difference was found in participants’ heart rate variations during procedure 23 ± 8 BPM (SUC) vs. 26 ± 7 (PLA) (p=.60), after 1 min 19 ± 12 BPM (SUC) vs. 17 ± 7 (PLA) (p=.76) and after 3 mins -1 ± 12 BPM (SUC) vs. 3 ± 6 (PLA) (p=.53). Conclusion: In infants 1 to 3 months of age undergoing urethral catheterization in the ED, administration of an oral sweet solution did not statistically decrease pain scores as measured by the FLACC and NIPS scales. Participants’ heart rate variations and crying time were not significantly decreased when sucrose was provided.
LO039: The effect of desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis
Authors: Principi T. , Coates A. , Parkin P. , Stephens D. , DaSilva Z. , Schuh S.
Published: June 2016

Introduction: Bronchiolitis is the most common lower respiratory tract infection among infants, characterized by wheeze and respiratory distress. Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay and escalation of care. The objectives were to determine if there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who desaturate to <90% for at least one minute during home oximetry monitoring versus those without desaturations. Methods: This is a prospective cohort study from 2008 to 2013 enrolling 118 otherwise healthy infant aged 6 weeks to 12 months discharged home from a tertiary care pediatric emergency department with a diagnosis of acute bronchiolitis. The primary outcome was unscheduled medical visits for bronchiolitis, a visit to any health care provider due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge and the effect of activity on desaturations. Results: During a mean monitoring period of 19 hours, 75/118 (64%) infants had at least one desaturation event (median continuous duration 3.4 minutes). 59/118 infants (50%) had at least 3 desaturations, 12 (10%) desaturated for >10% monitored time and 51(43%) had desaturations lasting ≥ 3 minutes continuously. 59/118 (50%) infants desaturated to ≤ 80% and 29 (24%) to ≤ 70% for ≥ 1 minute. A total 18/75 infants with desaturations (24.0%) had an unscheduled visit for bronchiolitis versus 11/43 of their non-desaturating counterparts (25.6%) [Difference - 1.6%; 95%CI -0.15 to ∞, p=0.66]. One of 75 desaturating infants (1.3%) and 2/43 (4.6%) of those without desaturations were hospitalized within 72 hours [Difference of -3.3%; 95% CI -0.04 to 0.10, p = 0.27]. Seventy seven percent of infants with desaturations experienced them during sleep or while feeding. Conclusion: The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.
LO040: Do combined electrocardiogram rhythm and point of care ultrasound findings predict outcome during cardiac arrest? The second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 2) Study
Authors: Beckett N. , Atkinson P.R. , Fraser J. , French J. , Lewis D.
Published: June 2016

Introduction: Survival to hospital discharge is better for PEA than asystole in out-of-hospital cardiac arrest. Point of care ultrasound (PoCUS) is widely used in cardiac arrest, although not mandated by ACLS guidelines. This study examines if initial PoCUS findings combined with cardiac rhythm are predictive of outcomes including return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and hospital discharge (SHD). Methods: A database review was completed for patients arriving to a tertiary ED in asystole or PEA arrest from 2010 to 2014. Patients under 19y or with a previous DNR were excluded. Patients were grouped into those with cardiac activity on PoCUS and PEA on ECG (Positive group); those with no cardiac activity recorded on PoCUS and asystole on ECG (Negative group); and those with a mix of positive and negative findings (Indeterminate group). Data was analyzed for the frequency of ROSC, SHA, and SHD. Results: 186 patients met the study criteria, with 14 (8%) in the positive group, 134 (72%) in the negative group, and 38 (20%) in the indeterminate group. The positive group had significantly better initial outcomes than the negative group: ROSC: 78% (95% CI 49-95%) vs 17% (11-25%); OR 17.70 (4.57-168.5; p < 0.0001) and SHA: 29% (8-58%) vs 7% (3-12%); OR 5.56 (1.45-21.28; p = 0.022), and then the combined negative and indeterminate groups: ROSC: 22% (16-29%), OR 12.93 (3.43-48.73; p < 0.0001; SHA: 8% (5-13%); OR 4.51 (1.25-16.27; p = 0.033). There was no difference between the positive group and either the negative or combined groups for final outcome of SHD: 0% (0-23%) vs 1% (0-5%); OR 1.83 (0.08-39.97; p = 1.00; and vs 1% (0-5%); OR 1.67 (0.08-33.96; p = 1.00). The negative group had worse initial outcomes than the combined positive and indeterminate groups: ROSC 17% (11-25%) vs. 50% (36-64%) OR 0.21 (0.10-0.42; p < 0.0001); SHA 6% (3-12%) vs. 8% (5-13%) OR 0.34 (0.13-0.92; p = 0.0490). There was no difference in SHD: 1% (0-5%) vs. 1% (0-5%) OR 0.77 (0.07-8.71; p = 1.00). Conclusion: Our results suggest that although finding positive cardiac activity on ECG (PEA) and also on PoCUS is associated with greater ROSC and SHA, it does not identify patients with a final outcome of SHD.
LO041: Predicting the return of spontaneous circulation using near-infrared spectroscopy monitoring: a systematic review and meta-analysis
Authors: Cournoyer A. , Chauny J. , Iseppon M. , Denault A. , Cossette S. , Notebaert E.
Published: June 2016

Introduction: Tissue oximetry using near-infrared spectroscopy (NIRS) is a non-invasive monitor of cerebral oxygenation. This new technology has been used during cardiac arrest because of its ability to give measures in low blood flow situations. The aim of this systematic review was to assess the evidence regarding the association between NIRS values and resuscitation outcomes in patients undergoing cardiopulmonary resuscitation. We hypothesized that higher NIRS values would be associated with better outcomes and that the strength of that association would differ depending on the timing of the NIRS measurements. Methods: This review was registered (Prospero CRD42015017380) and is reported as per the PRISMA guidelines. Medline, Embase and CENTRAL were searched from their inception to September 18th, 2015 using a specifically designed search strategy. Grey literature was also searched using Web of Science and Google Scholar. NIRS manufacturers and authors of included citations were contacted to inquire on unpublished results. Finally, the references of all retained articles were reviewed in search of additional relevant studies. Studies reporting NIRS monitoring in adults during cardiac arrest were eligible for inclusion. Case reports and case series of fewer than five patients were automatically excluded. Two reviewers assessed the quality of included articles and extracted the data. Results: Out of 3275 unique citations, 19 non-randomized observational studies (15 articles and four conference abstracts) were included in this review, for a total of 2436 patients. Six studies were evaluated at low risk of bias, nine at intermediate risk and four at high risk. We found a stronger association between the return of spontaneous circulation (ROSC) and the highest NIRS value measured during resuscitation (standard mean deviation (SMD) 3.46 (95%CI 2.31-4.62)) than between ROSC and the mean NIRS measures (SMD 1.33 (95%CI 0.92-1.74)) which was superior to the one between ROSC and initial measures (SMD 0.45 (95%CI 0.02-0.88)). Conclusion: Patients with good outcomes have significantly higher NIRS value during resuscitation than their counterparts. The association between ROSC and NIRS measurements was influenced the timing of measurements during resuscitation.
LO043: Is there an association between resuscitation effort and the use of cardiac ultrasound in patients arriving to the emergency department in cardiac arrest? The second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 2) Study
Authors: Beckett N. , Atkinson P.R. , Fraser J. , French J. , Lewis D.
Published: June 2016

Introduction: The use of cardiac point of care ultrasound (PoCUS) to assess cardiac arrest patients is widespread, although not mandated by advanced cardiac life support (ACLS) guidelines. This study aims to examine if the use of ultrasound is associated with a difference in the length of resuscitation and the frequency of interventions during ACLS in the emergency department (ED). Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19, or with a previous DNR order. Patients were grouped based on whether PoCUS was used during ACLS (PoCUS group) and those without PoCUS (control group). Multiple data were abstracted from charts using a standardized form. Data was analyzed for the length of resuscitation, frequency of common ACLS interventions such as endotracheal intubation, administration of epinephrine, and defibrillation, as well as initial cardiac activity findings on PoCUS. Results: 263 patients met the study inclusion criteria, with 51 (19%) in the control group, and 212 (81%) in the PoCUS group. In the PoCUS group 23 (11%) had cardiac activity (Positive PoCUS) and 189 (89%) had no cardiac activity recorded. Positive PoCUS patients had longer mean resuscitation times (26.13 min, 95% CI 17.80-34.46 min) compared to patients with no PoCUS cardiac activity (12.63 min, 95% CI 11.07-14.19 min, p < 0.05) as well as to the control group (14.20 min, 95% CI 10.30-18.09 min, p < 0.05). Positive PoCUS patients were more likely to receive endotracheal intubation (91%, 95% CI 72-99%), and epinephrine (100%, 95% CI 85-100%) than patients with no PoCUS cardiac activity (ET: 47%, 95% CI 40-54%, p < 0.0001; Epi: 81%, 95% CI 75-86%, p < 0.0172) and than the control group (ET: 65%, 95% CI 50-78%, p < 0.0227; Epi: 80%, 95% CI 67-90%, p < 0.0258). There was no difference in numbers receiving defibrillation between groups. Conclusion: Our results suggest emergency physicians may be making increased resuscitative effort for patients with positive cardiac activity findings on PoCUS compared to those with negative findings or when no PoCUS was performed.
LO049: Ibuprofen or oxycodone? An observational cohort study of post-emergency department discharge management of children’s fracture pain
Authors: Ali S. , Drendel A.L. , Rosychuk R.J. , Le May S. , McGrath P. , Carleton B. , Johnson D.W.
Published: June 2016

Introduction: Pediatric fracture pain is under-treated both in the emergency department (ED) and after discharge. Oral opioids and ibuprofen are amongst the top medications used to treat this pain. This study describes the post ED discharge effectiveness and safety of ibuprofen and oxycodone. Methods: A prospective cohort observational study was conducted at the Stollery Children’s Hospital (Edmonton, Alberta) from June 2010 to July 2014. Children aged 4-16 years, with an acute fracture, who were being discharged home with either ibuprofen (Ibu) or oxycodone (Oxy) for pain management were eligible for recruitment. Patients were contacted daily for three days, and at 2 and 6 weeks post-injury. Information regarding medication use, pain levels (with the Faces Pain Scale, Revised), adjuvant therapies, adverse events, and side effects and follow up was collected. Results: A total of 329 children (n=112 Oxy, n= 217 Ibu) were included. Mean age was 10.4 years (Ibu), and 12.3 years (Oxy); 68% (n=223) were male. Fracture types included forearm/wrist (47%,n=154), lower leg/ankle (14%,n=46), shoulder/clavicle (13%,n=42), and upper arm/elbow (12%,n=39). Reductions were performed in 34% of cases (n=113), while 9% (n=29) had buckle fractures. Children receiving Oxy had their eating, sleeping, play, and school attendance affected more than those receiving Ibu. More children receiving Oxy (81%, 91/112) experienced an adverse effect than those receiving Ibu (61%, 129/213) (p=0.0002); abdominal pain, dizziness, drowsiness, nausea, and vomiting were most prominent. The change in pain score (maximum pain - post-treatment pain) for Day 1 was 3.79 for Oxy and 3.61 Ibu; Day 2 was 3.68 Oxy and 3.55 Ibu; Day 3 was 3.34 Oxy and 3.66 Ibu. On Day 1, 59% (66/112) of Oxy cohort patients used other medication(s) for their pain treatment; 19% (41/213) did the same in the Ibu cohort. Conclusion: Ibuprofen and oxycodone provide similar pain relief for children with post-Ed discharge fracture pain. Oxycodone has greater impact on activities of daily living, side effects, and use of other medications to relieve pain. Oxycodone does not appear to confer any benefit over ibuprofen for pain relief, and given its negative side effect profile, this study suggests that ibuprofen is the better option. Further research is needed to determine the best combination treatment for fracture pain for children.
LO052: Sticks and stones may break your bones, but does having a car crash in a rural location affect your access to EMS care and surgical intervention? The initial analysis of a unique EMS and Trauma Dataset
Authors: Kenney M.B. , French J. , Fraser J. , Phelan B. , Watson I. , Benjamin S. , Chisholm A. , Pishe T. , Middleton J. , Atkinson P.R.
Published: June 2016

Introduction: In Canada, major trauma is a healthcare priority and in 2014 was responsible for over 15866 deaths, with a total economic burden of 26.8 billion dollars. Numerous factors influence the likelihood of occurrence and outcome from major trauma, including incident factors, host, EMS response, emergency, surgical and critical care. Traditionally trauma registers contained information that mainly concerning hospital treatment and host factors. This collaborative analysis uses matched data from a Provincial Trauma Research Register and records from a Provincial Ambulance Service. Methods: A retrospective observational (registry) study comparing rural and urban adult and pediatric major trauma patients (Injury Severity Score >15) who were injured in a motor vehicle crash (ICD V20-V99) and presented to a level 1 or level 2 trauma centre by EMS by primary or secondary transfer, between April 2011 and March 2013 in a selected province in Canada. Comparisons of the process care times, and patient disposition, were made in an inclusive trauma system. Results: 108 cases meet the inclusion criteria with 78 considered rural and 30 urban using published definitions. The median response times were 16.2 minutes for rural (95% CI: 13.2 -19.8) and 7.8 minutes for urban (95% CI: 7.2 - 10.5) with 60% and 61% meeting response targets respectively. A greater proportion of urban patients are taken initially to level 3-5 centers and require secondary transfer (45% urban vs 24% rural p=<0.01). Median times intervals to surgical care were double for the urban patients (14 rural vs 32 hrs urban p=<0.01). Conclusion: The majority of serious road traffic collisions occur in rural areas. Although rural patients wait longer for an initial EMS response, more rural patients are taken directly to a level 1 or 2 trauma center. Unexpectedly then rural patients have much shorter times to surgical care. The benefits of an inclusive trauma system should be weighed against the benefits of bypass processes in urban environments where the nearest Emergency Department is not a Level 1 or 2 Trauma Center.
LO053: Follow-up head CT scan after mild traumatic brain injury: is it really necessary?
Authors: Gariepy C. , Émond M. , Le Sage N. , Lavergne P. , Malo C.
Published: June 2016

Introduction: Injured seniors visits are on the rise in the emergency department (ED) and up to 30 % are traumatic brain injury (TBI). Many patients suffer from comorbidities that require the use of anticoagulant drugs. The use of these drugs usually modify the trajectory patients will undergo in the ED. In the last decade, some authors suggested a systematic follow-up CT head scan 8 hours after the initial, while others didn’t see the need to scan, referring only to the clinical features. We sought to evaluate the presence of delayed intracranial bleeding, evolution and investigation at the ED of elderly patients presenting for a mild TBI, with or without anticoagulotherapy. Methods: A retrospective cohort was built with hospital administrative clinical data for year 2014 at a Canadian Level 1 trauma center. Patients 65 years and older with traumatic brain injury and residing in the trauma center catching area were included. Data were extracted from medical files using a standardized collection tool in a consecutive pattern. Patients were classified in three groups: use of anticoagulant drug, use of antiplatelet drug and no anticoagulotherapy. Clinico-administrative data, intervention delay, investigations, comorbidities, medication and physiological status were collected. Intra and extra-hospital data were collected for a period of 90 days and the use of imaging and trajectories were analysed. Univariate and multivariate analysis were conducted. Results: 93 of the 189 TBI injury were mild TBI. The 93 patients were divided in patients using anticoagulotherapy (n = 9, 10 %), using antiplatelet drug (n = 58, 62.4 %) and no use of drug (n = 29, 31.2 %). Each group respectively undergo an initial head CT scan in a proportion of 88.9 %, 93 % and 76 %. Follow-up head CT scan were seen in 43 %, 16 % and 10 %. Delayed intra-cranial hemorrhage were identified in respectively 0 %, 2 % and 0 %. Conclusion: With the increase in patients presenting at Canadian ED for head trauma, our study suggests that anticoagulated elderly patients suffering from a mild traumatic brain injury do not systematically require a follow up CT head scan or longer observation time at the ED. A future clinical decision rule to determine the need of follow-up CT could be of benefit to emergency physicians.
LO058: Reducing unnecessary coagulation studies in suspected cardiac chest pain patients
Authors: Dowling S. , Rich T. , Wang D. , Mageau A. , Hair H. , McRae A. , Lang E.
Published: June 2016

Introduction: In light of escalating health care costs, initiatives such as Choosing Wisely have been advocating the need to “reduce unnecessary or wasteful medical tests, treatments and procedures”. We have identified coagulation studies as one of those low cost, but frequently ordered items, where we can decrease unnecessary testing and costs by leveraging our Computerized Practitioner Order Entry (CPOE). Considerable evidence exists to suggest a low yield of doing coagulation studies (herein defined as PTT AND INR’s) in suspected cardiac chest pain patients (SCCP). Methods: Using administrative data merged with CPOE we extracted data 90 days pre- and 90 post-intervention (Pre-intervention: May 20, 2015 to August 19th 2015, Post-intervention: August 20th, 2015 to November 18th 2015). The setting for the study is a large urban center (4 adult ED’s with an annual census of over 320,000 visits per year). Our CPOE system is fully integrated into the ED patient care. The intervention involved modifying the nursing CPOE to remove the pre-selected coagulation studies in SCCP and providing education around appropriate usage of coagulation studies. Patients were included in the study if the bedside nurse or physician felt 1. the chest pain may be cardiac in nature and 2. Labs were ordered. The primary outcome was to compare the number of coagulation studies ordered pre and post-intervention. Results: Our analysis included 10,776 patients that were included in an SCCP pathway as determined by the CPOE database. Total number of visits in these two phases were similar (73,551 pre and 72, 769 post). In the pre-intervention phase, 5255 coagulation studies were done (4246 ordered by nursing staff and 1009 studies ordered by ED physicians). In the post-intervention phase, 1464 coagulation studies were ordered (1211 by nursing staff and 253 additional tests were ordered by ED physicians). With our intervention, we identified a net reduction of 3791 coagulation studies in our post-intervention phase for a reduction of 72.14% reduction (p=<0.0001) At a cost of 15.00$ (CDN$ at our center), we would realize an estimated cost -savings of 56,865$ for this intervention over a 90 day period. Conclusion: We have implemented a simple, sustainable, evidence based intervention that significantly minimizes the use of unnecessary coagulation studies in patients presenting with SCCP.
LO060: Diagnostic and prognostic value of hydronephrosis in emergency department patients with acute renal colic
Authors: Innes G. , Grafstein E. , McRae A. , Wang D. , Lang E. , Andruchow J.
Published: June 2016

Introduction: Hydronephrosis is a marker of stone-related ureteral obstruction. Our objective was to assess the diagnostic and prognostic value of hydronephrosis in ED patients with renal colic. Methods: We used an administrative database to identify all renal colic patients seen in Calgary’s four EDs in 2014. Research assistants reviewed imaging reports to identify proven ureteral stones, and to document hydronephrosis and stone size. Surgical interventions, ED and hospital visits within 60-days were collated from all regional hospitals. The primary outcome was sensitivity and specificity of hydronephrosis (moderate or severe) for detecting stones >5mm. We also assessed the association of hydronephrosis with index admission-intervention, and with outcomes at 7 and 60 days. Results: In 2014, 1828 patients had a confirmed ureteral stone plus assessment of hydronephrosis and stone size (1714 CT, 114 US). Hydronephrosis was absent, mild, moderate or severe in 15%, 47%, 34% and 4% of patients respectively. Median stone size was 4.0, 4.0, 5.0 and 7.0mm for patients in these categories. Mild, moderate and severe hydronephrosis were highly associated with admission (OR=2.0, 4.6, 9.8; p<0.001) and index visit surgical intervention (OR=2.1, 3.7, 6.0; p<0.001). The presence of moderate-severe hydronephrosis was 54.7% sensitive and 65.4% specific for stones > 5mm, with positive and negative predictive values of 51% and 74.2%. Of 1828 patients, 748 had an index visit surgical procedure and 1080 were discharged with medical management. In the latter group, hydronephrosis was absent, mild, moderate or severe in 20%, 50%, 27% and 3%. Corresponding median (IQR) stone size was 3.0, 4.0, 4.0 and 5.0mm. Of 1080 medically managed patients, 19% and 25% had an unscheduled ED revisit by 14 and 60 days, 9% and 10% were hospitalized by 7 and 60 days, and 13% had a rescue procedure within 60 days. In the medically managed group, degree of hydronephrosis had no statistical association with any outcomes at 7 or 60 days. Conclusion: Hydronephrosis has poor sensitivity, specificity and predictive value for stones >5mm. Degree of hydronephrosis is highly associated with MD decisions for admission and intervention, but not associated with patient outcomes in the absence of these decisions. Despite poor diagnostic and prognostic performance, hydronephrosis is likely guiding critical early management decisions.
A NEW EXAMPLE OF A DETERMINISTIC CHAOS GAME
Authors: SARIZADEH ALIASGHAR
Published: June 2016

We give a new necessary and sufficient condition for an iterated function system to satisfy the deterministic chaos game. As a consequence, we give a new example of an iterated function system which satisfies the deterministic chaos game.
An Imperial Image: The Bath Gorgon in Context
Authors: Cousins Eleri H.
Published: June 2016

This paper attempts to put the Gorgon from the pediment of the Temple of Sulis Minerva at Bath into a wider provincial context, by arguing for links between the Gorgon and first- and early second-century imitations in Gaul and Spain of the iconography of the Forum of Augustus in Rome. These imitations, part of what might be called a ‘visual language of empire’, served to connect the urban spaces of the provinces to Rome; by linking the Gorgon to this trend and setting aside interpretations of the Gorgon which have focused on his perceived status as a ‘Romano-Celtic’ masterpiece, we can justify more satisfactorily his position as the centrepiece of a pediment dominated by imperial imagery.
Clinical and immunological analysis of measles patients admitted to a Beijing hospital in 2014 during an outbreak in China
Authors: TU B. , ZHAO J.-J. , HU Y. , FU J.-L. , HUANG H-H. , XIE Y.-X. , ZHANG X. , SHI L. , ZHAO P. , ZHANG X.-W. , WU D. , XU Z. , ZHOU Z.-P. , QIN E.-Q. , WANG F.-S.
Published: June 2016

At the end of 2013, China reported a countrywide outbreak of measles. From January to May 2014, we investigated the clinical and immunological features of the cases of the outbreak admitted to our hospital. In this study, all 112 inpatients with clinically diagnosed measles were recruited from the 302 Military Hospital of China. The virus was isolated from throat swabs from these patients, and cytokine profiles were examined. By detecting the measles virus of 30 of the 112 patients, we found that this measles outbreak was of the H1 genotype, which is the major strain in China. The rates of complications, specifically pneumonia and liver injury, differed significantly in patients aged <8 months, 8 months to 18 years, and >18 years: pneumonia was more common in children, while liver injury was more common in adults. Pneumonia was a significant independent risk factor affecting measles duration. Compared to healthy subjects, measles patients had fewer CD4+IL-17+, CD4+IFN-γ+, and CD8+IFN-γ+ cells in both the acute and recovery phases. In contrast, measles patients in the acute phase had more CD8+IL-22+ cells than those in recovery or healthy subjects. We recommend that future studies focus on the age-related distribution of pneumonia and liver injury as measles-related complications as well as the association between immunological markers and measles prognosis.
Synergetic electrode architecture for efficient graphene-based flexible organic light-emitting diodes
Authors: Lee Jaeho , Han Tae-Hee , Park Min-Ho , Jung Dae Yool , Seo Jeongmin , Seo Hong-Kyu , Cho Hyunsu , Kim Eunhye , Chung Jin , Choi Sung-Yool , Kim Taek-Soo , Lee Tae-Woo , Yoo Seunghyup
Published: June 2016

Graphene-based organic light-emitting diodes (OLEDs) have recently emerged as a key element essential in next-generation displays and lighting, mainly due to their promise for highly flexible light sources. However, their efficiency has been, at best, similar to that of conventional, indium tin oxide-based counterparts. We here propose an ideal electrode structure based on a synergetic interplay of high-index TiO2 layers and low-index hole-injection layers sandwiching graphene electrodes, which results in an ideal situation where enhancement by cavity resonance is maximized yet loss to surface plasmon polariton is mitigated. The proposed approach leads to OLEDs exhibiting ultrahigh external quantum efficiency of 40.8 and 62.1% (64.7 and 103% with a half-ball lens) for single- and multi-junction devices, respectively. The OLEDs made on plastics with those electrodes are repeatedly bendable at a radius of 2.3 mm, partly due to the TiO2 layers withstanding flexural strain up to 4% via crack-deflection toughening.
Active diffusion and microtubule-based transport oppose myosin forces to position organelles in cells
Authors: Lin Congping , Schuster Martin , Guimaraes Sofia Cunha , Ashwin Peter , Schrader Michael , Metz Jeremy , Hacker Christian , Gurr Sarah Jane , Steinberg Gero
Published: June 2016

Even distribution of peroxisomes (POs) and lipid droplets (LDs) is critical to their role in lipid and reactive oxygen species homeostasis. How even distribution is achieved remains elusive, but diffusive motion and directed motility may play a role. Here we show that in the fungus Ustilago maydis ∼95% of POs and LDs undergo diffusive motions. These movements require ATP and involve bidirectional early endosome motility, indicating that microtubule-associated membrane trafficking enhances diffusion of organelles. When early endosome transport is abolished, POs and LDs drift slowly towards the growing cell end. This pole-ward drift is facilitated by anterograde delivery of secretory cargo to the cell tip by myosin-5. Modelling reveals that microtubule-based directed transport and active diffusion support distribution, mobility and mixing of POs. In mammalian COS-7 cells, microtubules and F-actin also counteract each other to distribute POs. This highlights the importance of opposing cytoskeletal forces in organelle positioning in eukaryotes.
Identification of Changes in Gene expression of rats after Sensory and Motor Nerves Injury
Authors: Wang Yu , Guo Zhi-Yuan , Sun Xun , Lu Shi-bi , Xu Wen-Jing , Zhao Qing , Peng Jiang
Published: June 2016

Wallerian degeneration is a sequence of events in the distal stump of axotomized nerves. Despite large numbers of researches concentrating on WD, the biological mechanism still remains unclear. Hence we constructed a rat model with both motor and sensory nerves injury and then conducted a RNA-seq analysis. Here the rats were divided into the 4 following groups: normal motor nerves (NMN), injured motor nerves (IMN), normal sensory nerves (NSN) and injured sensory nerves (ISN). The transcriptomes of rats were sequenced by the Illumina HiSeq. The differentially expressed genes (DEGs) of 4 combinations including NMN vs. IMN, NSN vs. ISN, NMN vs. NSN and IMN vs. ISN were identified respectively. For the above 4 combinations, we identified 1666, 1514, 95 and 17 DEGs. We found that NMN vs. IMN shared the most common genes with NSN vs. ISN indicating common mechanisms between motor nerves injury and sensory nerves injury. At last, we performed an enrichment analysis and observed that the DEGs of NMN vs IMN and NSN vs. ISN were significantly associated with binding and activity, immune response, biosynthesis, metabolism and development. We hope our study may shed light on the molecular mechanisms of nerves degeneration and regeneration during WD.
Erratum: Reduced Graphene Oxide Thin Film on Conductive Substrates by Bipolar Electrochemistry
Authors: Allagui Anis , Abdelkareem Mohammad Ali , Alawadhi Hussain , Elwakil Ahmed S.
Published: June 2016

Scientific Reports 6: Article number: 21282; Published online: 17 February 2016; Updated: 02 June 2016 The original version of this Article contained errors in the spelling of the authors Anis Allagui, Mohammad Ali Abdelkareem, Hussain Alawadhi and Ahmed S. Elwakil which were incorrectly given as Allagui Anis, Ali Abdelkareem Mohammad, Alawadhi Hussain and S.
Bone scaffolds loaded with siRNA-Semaphorin4d for the treatment of osteoporosis related bone defects
Authors: Zhang Yufeng , Wei Lingfei , Miron Richard J. , Shi Bin , Bian Zhuan
Published: June 2016

Osteoporosis is a prominent disorder affecting over 200 million people worldwide. Recently, semaphorins have been implicated in the cell-cell communication between osteoclasts and osteoblasts and have been associated with the progression of osteoporosis. Previously, we demonstrated that knockdown of semaphorin4d (Sema4d) using siRNA delivered with a bone-targeting system prevented bone loss in an osteoporotic animal model. Here, we used this bone-specific technology containing siRNA-Sema4d and fabricated a PLLA scaffold capable of enhancing bone repair following fracture. We investigated the ability of the implant to release siRNA-Sema4d into the surrounding tissues over time and to influence new bone formation in a 3 mm femur osteoporotic defect model in ovariectomized rats. Delivery of the bone-targeting system released from PLLA scaffolds began 2 hours post-implantation, peaked at 1 day and was sustained over a 21 day period. μCT analysis demonstrated a significantly higher bone volume/total volume bone mineral density and number of osteoblasts in the rats that were transplanted with scaffolds loaded with siRNA-Sema4d. These results confirm the specific role of Sema4d in bone remodeling and demonstrate that significant increases in the speed and quality of new bone formation occur when siRNA-Sema4d is delivered via a PLLA scaffold.
Superconductivity and Charge Density Wave in ZrTe3−xSex
Authors: Zhu Xiangde , Ning Wei , Li Lijun , Ling Langsheng , Zhang Ranran , Zhang Jinglei , Wang Kefeng , Liu Yu , Pi Li , Ma Yongchang , Du Haifeng , Tian Minglian , Sun Yuping , Petrovic Cedomir , Zhang Yuheng
Published: June 2016

Charge density wave (CDW), the periodic modulation of the electronic charge density, will open a gap on the Fermi surface that commonly leads to decreased or vanishing conductivity. On the other hand superconductivity, a commonly believed competing order, features a Fermi surface gap that results in infinite conductivity. Here we report that superconductivity emerges upon Se doping in CDW conductor ZrTe3 when the long range CDW order is gradually suppressed. Superconducting critical temperature Tc(x) in ZrTe3−xSex (0 ≤ x ≤ 0.1) increases up to 4 K plateau for 0.04 ≤ x ≤ 0.07. Further increase in Se content results in diminishing Tc and filametary superconductivity. The CDW modes from Raman spectra are observed in x = 0.04 and 0.1 crystals, where signature of ZrTe3 CDW order in resistivity vanishes. The electronic-scattering for high Tc crystals is dominated by local CDW fluctuations at high temperatures, the resistivity is linear up to highest measured T = 300 K and contributes to substantial in-plane anisotropy.
Transmission and pathogenicity of novel reassortants derived from Eurasian avian-like and 2009 pandemic H1N1 influenza viruses in mice and guinea pigs
Authors: Kong Weili , Liu Qinfang , Sun Yipeng , Wang Yu , Gao Huijie , Liu Lirong , Qin Zhihua , He Qiming , Sun Honglei , Pu Juan , Wang Dayan , Guo Xin , Yang Hanchun , Chang Kin-Chow , Shu Yuelong , Liu Jinhua
Published: June 2016

Given the present extensive co-circulation in pigs of Eurasian avian-like (EA) swine H1N1 and 2009 pandemic (pdm/09) H1N1 viruses, reassortment between them is highly plausible but largely uncharacterized. Here, experimentally co-infected pigs with a representative EA virus and a pdm/09 virus yielded 55 novel reassortant viruses that could be categorized into 17 genotypes from Gt1 to Gt17 based on segment segregation. Majority of novel reassortants were isolated from the lower respiratory tract. Most of reassortant viruses were more pathogenic and contagious than the parental EA viruses in mice and guinea pigs. The most transmissible reassortant genotypes demonstrated in guinea pigs (Gt2, Gt3, Gt7, Gt10 and Gt13) were also the most lethal in mice. Notably, nearly all these highly virulent reassortants (all except Gt13) were characterized with possession of EA H1 and full complement of pdm/09 ribonucleoprotein genes. Compositionally, we demonstrated that EA H1-222G contributed to virulence by its ability to bind avian-type sialic acid receptors, and that pdm/09 RNP conferred the most robust polymerase activity to reassortants. The present study revealed high reassortment compatibility between EA and pdm/09 viruses in pigs, which could give rise to progeny reassortant viruses with enhanced virulence and transmissibility in mice and guinea pig models.