bluuebunny/crossref_metadata_2025 huggingface dataset:
Dantrolene in the treatment of MDMA-related hyperpyrexia: a systematic review
Authors: Grunau Brian E. , Wiens Matthew O. , Brubacher Jeffrey R.
Published: July 2016

Objective:

The use of dantrolene in the treatment of hyperpyrexia related to MDMA (3,4-methylenedioxymethamphetamine) is controversial, with little data available to guide clinical decision-making. Although the treatment is recommended by several poison control centres, published data are primarily in the form of case reports and animal and in vitro experiments. We conducted a systematic review to investigate the published evidence regarding the safety and benefits of dantrolene for MDMA-related hyperpyrexia in humans.

Data sources:

A systematic search of Embase and MEDLINE was conducted from the earliest possible date to November 2008.

Study selection:

All human trials and case reports of MDMA-related hyperpyrexia were considered.

Data extraction:

Data were abstracted systematically and characteristics including use of dantrolene, adverse reactions attributed to dantrolene, peak temperature, complications from MDMA-related hyperpyrexia and survival were recorded.

Data synthesis:

Our search yielded 668 articles of which 53, reporting 71 cases of MDMA-induced hyperpyrexia, met our inclusion criteria. No clinical trials, randomized controlled trials, observational studies or meta-analyses were identified. Dantrolene was used in 26 cases. Patient characteristics were similar in the dantrolene and no dantrolene groups. The proportion of survivors was higher in the dantrolene group (21/26) than in the no dantrolene group (25/45). This difference was especially pronounced in those with extreme (≥ 42°C) and severe (≥ 40°C) fever, with a survival rate of 8 of 13 and 10 of 10, respectively, in the dantrolene group compared with 0 of 4 and 15 of 27 in the no dantrolene group. There were no reports of adverse events attributable to dantrolene with the exception of a possible association with an episode of transient hypoglycemia.

Conclusion:

Our systematic review suggests that dantrolene is safe for patients with MDMA-related hyperpyrexia. Dantrolene may also be associated with improved survival and reduced complications, especially in patients with extreme (≥ 42°C) or severe (≥ 40°C) hyperpyrexia, although this conclusion must be interpreted with caution given the risk of reporting or publication bias.
Dantrolene for the treatment of MDMA toxicity
Authors: Grunau Brian E. , Wiens Matthew O. , Greidanus Marc
Published: July 2016

MDMA (3,4-methylenedioxymethamphetamine), popularly known as “Ecstasy,” was first introduced and patented by Merck & Co., Inc., in 1914 as an appetite suppressant. Currently, its primary role is as an illegal stimulant used to produce a euphoric effect during parties. This case report describes a 31-year-old man who, after taking 3 tablets of Ecstasy, presented to an emergency department with a decreased level of consciousness and became progressively hyperthermic and rigid. During the course of his acute illness, his temperature reached 42.2°C rectally. He was given mechanical ventilation. He was aggressively cooled and dantrolene was initiated. Soon after the administration of dantrolene his temperature decreased and his rigidity began to resolve. The only complication was rhabdomyolysis with a creatine kinase level increasing to over 150 μkat/L. This did not progress to acute renal failure. The patient made a full recovery and was discharged to psychiatry for assessment.
The role of clopidogrel in the emergency department
Authors: Patel Payal , Cheng Lily
Published: July 2016

Despite major advances in the management of acute coronary syndromes (ACS), 1 in 3 Canadians die from cardiovascular disease. In 1998, the total economic burden of cardiovascular illness in Canada was $159 434.5 million dollars — $83 953.9 million in direct costs and $75 479.6 in indirect costs. During the past 20 years, several pharmacologic adjuncts have been investigated with hopes of ameliorating the consequences of ACS. Notably, clopidogrel has become a common component of ACS therapeutic regimens since its introduction in 1998. Both new medications and those already accepted as standard treatment deserve critical evaluation to ensure they are safe and effective.
Atraumatic hemopericardium in a patient receiving warfarin therapy for a pulmonary embolus
Authors: Katis Peter G.
Published: July 2016

Acute pericardial tamponade is a potentially life-threatening condition that requires immediate treatment. This report describes a patient who presented to the emergency department with an acute hemopericardium and echocardiographic evidence of cardiac tamponade following the initiation of warfarin therapy for a recently diagnosed pulmonary embolism. The association between cardiac tamponade, oral anticoagulation and pulmonary thromboembolic disease is briefly discussed.
Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system
Authors: Richard Julie , Osmond Martin H. , Nesbitt Lisa , Stiell Ian G.
Published: July 2016

Objectives:

There is uncertainty around the types of interventions that are provided by emergency medical services (EMS) to children during prehospital transport. We describe the patient characteristics, events, interventions provided and outcomes of a cohort of children transported by EMS.

Methods:

This prospective cohort study was conducted in a city of 750 000 people with a 2-tiered EMS system. All children <16 years of age who were attended by EMS during a 6-month period were enrolled. Data were extracted from ambulance call reports and hospital charts, and analyzed using descriptive statistics.

Results:

During the study period there were 1377 pediatric EMS calls. Mean age was 8.2 years (standard deviation 5.4), and the most common diagnoses were trauma (44.9%), seizure (11.8%) and respiratory distress (8.8%). The ambulance return code wasUrgentin 7%,Promptin 57%,Deferrablein 8% andNot Transportedin 28%. Fifty-six percent received either an Advanced Life Support or Basic Life Support prehospital intervention. Common procedures included cardiac monitoring (20.0%), oxygen administration (19.8%), blood glucose monitoring (16.3%), spine board (12.2%), limb immobilization (11.1%) and cervical collar (10.0%). Uncommon procedures included administering medications intravenously (IV) (1.4%), bag-valve-mask ventilation (0.3%) and endotracheal intubation (0.1%). Seventy-eight percent of attempted IV lines were successful. Only 9.0% of EMS-transported children were admitted to hospital, and 2.2% were admitted to the intensive care unit.

Conclusions:

This first study of Canadian pediatric prehospital interventions shows a high rate of non-transport, and a low rate ofUrgenttransports and hospital admissions for children. Very few children receive prehospital airway management, ventilation or IV medications; consequently EMS personnel have little opportunity to maintain these pediatric skills in the field.
Potential value for new diagnostic markers in the early recognition of acute coronary syndromes
Authors: Lippi Giuseppe , Montagnana Martina , Salvagno Gian Luca , Guidi Gian Cesare
Published: July 2016

The diagnostic approach to acute coronary syndromes (ACS) remains one of the most difficult and controversial challenges facing emergency physicians. In recent years, cardiac troponins have emerged as the biochemical “gold standard” for diagnosis of patients with acute chest pain, enhancing our ability to recognize ACS. Early diagnosis and treatment of myocardial ischemia improve patient outcomes, but conventional markers are often nondiagnostic at the time of arrival at the emergency department. Promising new biomarkers, which appear earlier after the onset of ischemia, are being studied and integrated into clinical practice. Some are markers of myocyte necrosis, but others, including ischemia-modified albumin and natriuretic peptides, detect myocardial ischemia and myocardial dysfunction. The aim of the present article is to review the diagnostic approach to ACS, focusing on recent literature describing novel biochemical markers. If ongoing and future studies confirm their role in probability-based models risk assessment, a new era in the diagnostic approach to ACS may be dawning.
Orbital pseudotumour presenting as orbital cellulitis
Authors: Anderson Jack , Thomas Tamara
Published: July 2016

A 33-year-old woman presented to a community emergency department with a 4-day history of monocular orbital pain, photophobia and pain on extraocular movement. Findings included chemosis, conjunctival injection and restricted extraocular movements causing strabismus. She was diagnosed with orbital cellulitis during her initial emergency department visit and treated with intravenous antibiotics. On her second ED visit later the same day, a diagnosis of orbital pseudotumour was made after computed tomography revealed inflammation of the sclera, optic nerve, muscle and adipose tissue within the orbit. Antibiotics were discontinued and tapering steroids were initiated, with prompt resolution of symptoms.
Emergency department use by CTAS Levels IV and V patients
Authors: Field Simon , Lantz Andrea
Published: July 2016

Introduction:

Many emergency department (ED) visits are non-urgent. Postulated reasons for these visits include lack of access to family physicians, convenience and 24/7 access, perceived need for investigations or treatment not available elsewhere, and as a mechanism for expedited referral to other specialists. We conducted a patient survey to determine why non-urgent patients use our tertiary care ED. Our primary objective was to determine how often the lack of a family physician was associated with non-urgent ED use.

Methods:

The survey was administered toCanadian Emergency Department Triage and Acuity Scale(CTAS) Level IV and V patients who attended the ED of the Queen Elizabeth II Health Sciences Centre in Halifax, NS, from March 7 to March 13, 2005.

Results:

Of the 352 eligible patients, 235 completed the survey (response rate, 67%). Fifty-six percent (132/235) had an acute medical problem of less than 48 hours, including 48% (114/235) with a recent injury. Thirty-four percent (82/235) had been referred to the ED, 49% (114/235) believed they required a specific service that was unavailable elsewhere (e.g., radiology, suturing, casting) and 43% (100/235) presented because of self-perceived urgency of their condition. Eighty-four percent (198/235) had a family physician; 23% (55/235) used the ED because of limited access to theirfamily physician and 3% (6/235) used the ED because they did not have a family physician.

Conclusions:

In this setting, most non-urgent ED visits involved patients who required a specific service offered by the ED, patients who believed their condition was urgent, or patients who were referred from the community to the ED. From a patient perspective, relatively few visits would be considered inappropriate. Lack of a family physician was not associated with non-urgent ED use; however, inability to obtain timely access to the FP was a factor in one-quarter of cases.
Effect of the SARS outbreak on visits to a community hospital emergency department
Authors: Heiber Michael , Lou W.Y. Wendy
Published: July 2016

Objectives:

To examine the effect of severe acute respiratory syndrome (SARS) on visits to a community hospital emergency department (ED) during the early stage of the Toronto outbreak in 2003 and for the same period in 2004. We focused on visits for respiratory illness (SARS-like symptoms) and different age groups.

Methods:

This study is a retrospective review of ED discharge diagnoses obtained from a computerized database, examining the 4-week period starting March 28 for the years 2001-2004. We obtained the discharge diagnosis, age and visit date for each ED patient during the relevant time intervals, then compared visit data from 2003 and 2004 with a baseline derived from the average number of visits during 2001 and 2002. We constructed groupings based on age and respiratory-illness symptoms.

Results:

During the SARS outbreak in 2003, ED visits declined by 21% (95% confidence interval [CI], 18%–24%) over the 4-week study period. The greatest reduction was for combined infant and toddler visits (69%; 95% CI, 58%–79%); these did not recover the following year. However, during the SARS outbreak there was a large increase in the number of visits for respiratory illnesses in adults (61%; 95% CI, 46%–75%) and in teenagers (132%; 95% CI, 82%–182%).

Conclusions:

During the SARS outbreak, total ED visits fell. The relative decline was most notable for infants and toddlers. By contrast, there was an increase in respiratory illness–related visits for adults and teenagers. In 2004, the year following the SARS outbreak, visit patterns shifted toward baseline levels, but ED visits by infants and toddlers remained depressed.
Posterior sternoclavicular joint dislocation: case report and discussion
Authors: Kuzak Nick , Ishkanian Adrian , Abu-Laban Riyad B.
Published: July 2016

The sternoclavicular joint is the most frequently mobilized non-axial, major joint, but is the least frequently dislocated. Most sternoclavicular dislocations are anterior. When posterior sternoclavicular joint dislocations do occur, they may present with a variety of signs and symptoms, including serious intrathoracic injuries. We discuss the case of a patient with a subacute posterior sternoclavicular dislocation who presented to the emergency department 2 months after being hit in the posterior neck. We also review the signs, symptoms and management of posterior sternoclavicular dislocation and the literature on this topic.
Lamotrigine as a possible cause of QRS prolongation in a patient with known seizure disorder
Authors: Herold Thomas J.S.
Published: July 2016

Lamotrigine and felbamate are 2 newer anticonvulsant medications used to control refractory partial and generalized seizures. Although several cases of lamotrigine toxicity secondary to acute intentional or unintentional overdose have been described, there is little published information related to potential side-effects associated with the therapeutic use of these agents. Described is a case of a 22-year-old woman who presented to the emergency department after experiencing 2 seizure-like episodes. Findings on evaluation included nystagmus, ataxia, widening of the QRS complex and right-axis deviation on ECG. The patient reported only therapeutic use of her medications. The lamotrigine level was 14.8 mg/L. The mechanism of action for lamotrigine is blockade of the sodium channels; therefore, the patient was treated with intravenous sodium bicarbonate with resultant QRS narrowing following administration.
Intravenous dexamethasone to prevent the recurrence of benign headache after discharge from the emergency department: a randomized, double-blind, placebo-controlled clinical trial
Authors: Baden Eric Y. , Hunter Curtis J.
Published: July 2016

Objective:

To evaluate whether the addition of intravenous (IV) dexamethasone to standard emergency department (ED) benign headache therapy would reduce the incidence of headache recurrence at 48–72 hours.

Methods:

This randomized, double-blind, placebo-controlled clinical trial of adult patients presenting with the chief complaint of headache was conducted in the ED of 2 academic, urban Level 1 hospitals. Headache evaluation and therapy were determined by the treating physician, and, before discharge, patients were administered either 10 mg of IV dexamethasone or placebo. The treatment groups had similar baseline characteristics, abortive therapy, IV fluids and degree of pain relief achieved before discharge. Patients were contacted 48–72 hours following discharge and asked whether their headache was “better,” “worse” or “remained unchanged” when compared with their symptoms at discharge. Those whose headaches were “worse” or “unchanged,” and those who reported a return of headache after being pain free at discharge were considered to be treatment failures and classified as having had a recurrence. The patient's headache at follow-up was further categorized as severe (i.e., provoking another physician visit or interfering with daily activity) or mild (i.e., requiring self-medication or no treatment).

Results:

Fifty-seven patients met the inclusion criteria and 2 were lost to follow-up, leaving 55 for analysis. At follow-up, 9.7% (3/31) of those receiving dexamethasone had headache recurrence, versus 58.3% (14/24) of those receiving placebo (p< 0.001). Four dexamethasone recipients (12.9%) had severe headaches at follow-up compared with 8 (33.3%) in the placebo group (p= 0.14).

Conclusions:

In this study, IV dexamethasone reduced headache recurrence at 48–72-hour follow-up. Given its excellent safety profile and likely benefit, IV dexamethasone should be considered for ED headache patients after standard evaluation and therapy.
Myth: Interpretation of a single ammonia level in patients with chronic liver disease can confirm or rule out hepatic encephalopathy
Authors: Arora Sanjay , Martin Christopher L. , Herbert Mel
Published: July 2016

Although the exact pathophysiology of hepatic encephalopathy (HE) is not fully understood, for more than a century ammonia has been thought to play a critical role. However, the interpretation and utility of ammonia levels in patients with chronic liver disease (CLD) presenting with HE has been a long-standing source of confusion. It is a common belief in the emergency department and on the wards that a single elevated ammonia level in a patient with CLD can confirm the diagnosis of HE, and a normal level essentially rules it out. This confusion stems from the fact that early studies showed a correlation between degree of encephalopathy and the ammonia level, but numerous subsequent studies have shown that severely encephalopathic patients often have normal ammonia levels. This paper reviews the published literature on ammonia levels in patients with CLD in an attempt to clarify its value as a clinical decision-making tool in patients with suspected HE.
Prospective time study derivation of emergency physician workload predictors
Authors: Innes Grant D. , Stenstrom Robert , Grafstein Eric , Christenson James M.
Published: July 2016

Background:

A reliable emergency department (ED) workload measurement tool would provide a method of quantifying clinical productivity for performance evaluation and physician incentive programs; it would enable health administrators to measure ED outputs; and it could provide the basis for an equitable formula to estimate ED physician staffing requirements. Our objectives were to identify predictors that correlate with physician time needed to treat patients and to develop a multivariable model to predict physician workload.

Methods:

During 31 day, evening, night and weekend shifts, a research assistant (RA) shadowed 20 emergency physicians, documenting time spent performing clinical and non-clinical functions for 585 patient visits. The RA recorded key predictors including patient gender, age, vital signs and Glasgow Coma Scale (GCS) score, and the mode of arrival, triage level assigned, comorbidity and procedures performed. Multiple linear regression was used to describe the associations between predictor variables and total physician time per patient visit (TPPV), and to derive an equation for physician workload. Model derivation was based on 16 shifts and 314 patient visits; model validation was based on 15 shifts and 271 additional patient visits.

Results:

The strongest predictor variables were: procedure required, triage level, arrival by ambulance, GCS, age, any comorbidity, and number of prior visits. The derived regression equation is: TPPV = 29.7 + 8.6 (procedure required [Yes]) – 3.8 (triage level [1–5]) + 7.1 (ambulance arrival) – 1.1 (GCS [3–15]) + 0.1 (age in years) – 0.05 (n of previous visits) + 3.1 (any comorbidity). This model predicted 31.3% of the variance in physician TPPV (F [12, 29] = 13.2; p < 0.0001).

Conclusions:

This study clarifies important determinants of emergency physician workload. If validated in other settings, the predictive formula derived and internally validated here is a potential alternative to current simplistic models based solely on patient volume and perceived acuity. An evidence-based workload estimation tool like that described here could facilitate ED productivity measurement, benchmarking, physician performance evaluation, and provide the substrate for an equitable formula to estimate ED physician staffing requirements.
Dog bites in Canadian children: a five-year review of severity and emergency department management
Authors: Lang Mia E. , Klassen Terry
Published: July 2016

Objectives:

Dog bites are a common problem. The purpose of this study was to determine the characteristics of dog bites and their emergency department management in a Canadian pediatric population, and to provide treatment and prevention recommendations.

Methods:

The charts of all children ≤ 16 years of age presenting with a dog bite to either of the 2 tertiary emergency departments in Edmonton, Alberta, between 1998 and 2002 were retrospectively reviewed.

Results:

Overall, 287 cases were reviewed; 145 boys (50.5%) and 142 girls (49.5%). The mean age was 7.4 years. The patient's face was the most frequently bitten site (58.5%,n= 168), followed by an extremity (35.5%,n= 102). Most bites required sutures (54.5%,n= 155), and 72 (25.1%) were classified as severe, based on suture number (>10 sutures,n= 69), associated fractures (n= 4), operating room repair (n= 21) or fatality (n= 1). The mean age of children with severe bites was significantly lower than children with mild bites (6.3 v. 7.8 yr,p< 0.01). Most patients were treated solely in the emergency department (84.7%,n= 243); however 44 (15.3%) were admitted to hospital and required a total of 144 days of inpatient care. Signs of infection were described in 16 cases (5.6%); of these 8 had received 2 or more prior doses of antibiotics. Public health or police notification was documented in 56 cases (19.5%), and safety or preventive discussion was documented in 3 cases (1.0%).

Conclusions:

Dog bites in Canadian children are common, often serious or even lethal, and not always managed ideally. Preventive discussion and public health contact is infrequently documented and likely seldom occurs. In addition to medical care, emergency department staff should provide and document preventive guidance and ensure involvement of public health or police when indicated.
Spinal epidural abscess
Authors: Louis Amy , Fernandes Christopher M.B.
Published: July 2016

Spinal epidural abscess is an uncommon condition. Predisposing factors include spinal surgery, recent trauma, immunosuppression, a distal site of infection and intravenous drug use; however, these are not always present, as illustrated by this case report describing a patient who had repeated emergency department visits and delayed diagnosis that was ultimately confirmed via magnetic resonance imaging.
Minimally angulated pediatric wrist fractures: Is immobilization without manipulation enough?
Authors: Al-Ansari Khalid , Howard Andrew , Seeto Brian , Yoo Solina , Zaki Salma , Boutis Kathy
Published: July 2016

Background:

Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures.

Objectives:

The primary objective of this study was to determine the proportion of minimally angulated distal radius fractures managed in the ED with plaster immobilization that subsequently required manipulation. Our secondary objective was to document, at follow-up, changes in angulation for each wrist fracture.

Methods:

This retrospective cohort study reviewed consecutive records of all children with bi-cortical minimally angulated (≤15° of angulation in the sagittal plane and ≤0.5 cm of displacement) distal metaphyseal radius fractures, alone or in combination with distal ulnar fracture. Details of treatment, radiographic findings, and clinical outcomes during the subsequent orthopedic follow up were recorded.

Results:

Of 124 patients included in the analysis, none required manipulation after their ED visit. All but 14 (11.3%) fractures were angulated ≤20° within the follow-up period. Two (1.6%) fractures that were initially angulated ≤15° progressed to 30°–35°, but remodeled within 2 years to nearly perfect anatomic alignment. By 6 weeks post-injury, no patients had clinically apparent deformity and all had normal function.

Conclusions:

Minimally angulated fractures of the distal metaphyseal radius managed in plaster immobilization without reduction in the ED are unlikely to require future surgical intervention.
Impact of a multifaceted pediatric sedation course: self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines
Authors: Schneeweiss Suzan , Ratnapalan Savithiri
Published: July 2016

Background:

Procedural sedation guidelines were established for a tertiary care pediatric emergency department (ED). We developed a pediatric procedural sedation course to disseminate these guidelines.

Objective:

Our objective was to evaluate the effectiveness of a sedation course in improving physicians' knowledge of pediatric procedural sedation practices and guidelines, relative to individual self-directed learning.

Methods:

We recruited emergency staff physicians and fellows as well as fourth-year pediatric residents in a tertiary care pediatric ED to participate in a randomized, controlled, educational intervention. All consenting physicians received pediatric sedation educational material for individual study 2 weeks before a learning assessment. Participants were randomly assigned to one of 2 groups. The self-directed learning group (n= 24) completed a multiple-choice examination without receiving any formal teaching. The study group (n= 24) participated in a 4-hour formal multi-faceted sedation course before writing the multiple-choice examination.

Results:

The groups did not differ significantly in demographic characteristics or self-perceived knowledge of pediatric sedation. The formal teaching group's median examination score (83.3%; range 75.8%–96.5%) was significantly higher (p< 0.0001) than the median examination score of participants in the self-directed study group (73.3%, range 43.5%–86.6%).

Conclusion:

The multifaceted sedation course was more effective in improving physician knowledge and understanding of sedation guidelines and practices than unstructured, self-directed learning.
Identification and correction of guide wire malposition during internal jugular cannulation with ultrasound
Authors: Stone Michael B.
Published: July 2016

Real-time ultrasound guidance for central venous catheterization increases success and reduces procedural complications. I describe a case in which guide wire resistance was encountered and real-time ultrasound visualization of the guide wire facilitated correction of guide wire malposition. No additional passes of the introducer needle were necessary and the chances of inadvertent carotid artery puncture or pneumothorax were therefore reduced. The technique described here may prove valuable when guide wire resistance is encountered while placing a central venous catheter.
A case of Clostridium septicum spontaneous gas gangrene
Authors: Dylewski Joe , Drummond Robert , Rowen John
Published: July 2016

Severe skin and soft tissue infections (SSTIs) are often life-threatening emergencies that require a rapid diagnosis. Gas gangrene is one of the most fulminant types of SSTI and is usually caused by Clostridium perfringens' contamination of an open wound.

Although gas gangrene is usually associated with fecally contaminated wounds, “spontaneous” cases occur and are most commonly caused by Clostridium (C.) septicum. We report a case of spontaneous gas gangrene caused by C. septicum that only became manifest while the patient was being monitored in the emergency department. We also review the diagnosis and treatment aspects of this entity.
Emergency department dispositions among 4100 youth injured by violence: a population-based study
Authors: Snider Carolyn E. , Lee Jacques S.
Published: July 2016

Objective:

Concern about youth violence in Canada is growing. Because victims of violence are more likely to become future violent perpetrators, preventative interventions are often based out of inpatient units; however, the question of how often youth who have been injured due to violence are discharged from emergency departments (EDs), or whether there are opportunities for emergency healthcare workers to deliver violence prevention programs, is not known. The primary objectives of this study were to describe the frequency and patterns of violent injuries among youth, to determine how many injured youth are discharged directly from EDs and to estimate the proportion of injured youth who may benefit from ED-based intervention programs.

Methods:

We conducted an observational study using a population-based database that records information on all ED visits in Ontario. We analyzed age, sex, cause of injury and disposition for all patients aged 12–19 years who presented to Toronto EDs with violent injuries during a 2-year period (April 2002 to March 2004).

Results:

A total of 4100 patients aged 12–19 years visited Toronto EDs with violent injuries during the study period. Assault due to bodily force (in contrast to sharp objects, guns or other) was the most common injury mechanism, accounting for 48.7% of cases (95% confidence interval [CI] 47.1%–50.2%). The majority of patients (89.3%; 95% CI 88.3%–90.2%) were discharged directly from EDs, including 44% of gun-related injuries.

Conclusion:

In Toronto, a large proportion (89.3%) of youth injured in violent incidents are discharged directly from EDs. There are opportunities to develop ED-based youth violence prevention initiatives.
The effect of training on nurse agreement using an electronic triage system
Authors: Dong Sandy L. , Bullard Michael J. , Meurer David P. , Blitz Sandra , Holroyd Brian R. , Rowe Brian H.
Published: July 2016

Objectives:

Emergency department (ED) triage prioritizes patients based on urgency of care, and the Canadian Triage and Acuity Scale (CTAS) is the national standard. We describe the inter-rater agreement and manual overrides of nurses using a CTAS-compliant web-based triage tool (eTRIAGE) for 2 different intensities of staff training.

Methods:

This prospective study was conducted in an urban tertiary care ED. In phase 1, eTRIAGE was deployed after a 3-hour training course for 24 triage nurses who were asked to share this knowledge during regular triage shifts with colleagues who had not received training (n= 77). In phase 2, a targeted group of 8 triage nurses underwent further training with eTRIAGE. In each phase, patients were assessed first by the duty triage nurse and then by a blinded independent study nurse, both using eTRIAGE. Inter-rater agreement was calculated using kappa (weighted κ) statistics.

Results:

In phase 1, 569 patients were enrolled with 513 (90.2%) complete records; 577 patients were enrolled in phase 2 with 555 (96.2%) complete records. Inter-rater agreement during phase 1 was moderate (weighted κ = 0.55; 95% confidence interval [CI] 0.49–0.62); agreement improved in phase 2 (weighted κ = 0.65; 95% CI 0.60–0.70). Manual overrides of eTRIAGE scores were infrequent (approximately 10%) during both periods.

Conclusions:

Agreement between study nurses and duty triage nurses, both using eTRIAGE, was moderate to good, with a trend toward improvement with additional training. Triage overrides were infrequent. Continued attempts to refine the triage process and training appear warranted.
Prévalence de la pneumonie chez les enfants de moins de 12 ans qui ont une radiographie abdominale à l'urgence
Authors: Homier Valérie , Bellavance Colette , Xhignesse Marianne
Published: July 2016

Objectif:

La pneumonie est une cause bien connue de douleur abdominale aiguë chez les enfants. L'utilité de la radiographie pulmonaire dans ce contexte est toutefois controversée. Nous avons cherché à déterminer la prévalence de la pneumonie chez les enfants de moins de 12 ans qui souffraient de douleur abdominale et ont eu une radiographie abdominale à l'urgence. Nous voulions aussi décrire les signes et les symptômes des enfants chez lesquels on a diagnostiqué une pneumonie dans ce contexte.

Méthodes:

Nous avons procédé à une analyse rétrospective des données électroniques tirées des visites effectuées à l'urgence d'un centre de soins tertiaires par des enfants de 12 ans et moins examinés entre le 1er juin 2001 et le 30 juin 2003 et qui ont eu une radiographie abdominale et pulmonaire au cours de la même visite, ou une radiographie abdominale au cours d'une première visite et une radiographie pulmonaire dans les 10 jours suivant la visite initiale.

Résultats:

Sur les 1584 visites étudiées, on a repéré 30 cas de pneumonie, ce qui représente une prévalence de 1,89 % (intervalle de confiance à 95 %, 1,22 %–1,56 %). Si on avait limité la radiographie pulmonaire aux enfants qui avaient de la fière, toussaient et présentaient des symptômes d'infection des voies respiratoires supérieures (IVRS), on aurait raté le diagnostic de pneumonie dans seulement 2 cas sur 1584 (0,13 %).

Conclusion:

Les enfants de 12 ans et moins qui se présentent à l'urgence avec une douleur abdominale aiguë et pour lesquels on demande une radiographie abdominale n'ont besoin que d'une radiographie pulmonaire s'ils toussent, ont de la fière ou présentent d'autres symptômes d'IVRS.
Physical exam myths: listening for carotid artery bruits in stroke patients
Authors: Nemeth Joe
Published: July 2016

When a patient presents to the emergency department with a neurologic deficit and a cerebrovascular event is included in the differential diagnosis, the classic recommendation is to examine the carotid artery and assess for the presence of a bruit. The diagnostic yield and utility of this practice has seldom been called into question. This critical appraisal will review the practice of listening for a carotid artery bruit (CAB) in suspected stroke patients and analyze its clinical utility, including the sensitivity and specificity of a CAB for detecting a significant lesion and the potential impact a CAB may have on the investigation and disposition of such patients.
Ultrasound-guided central venous access: a homemade phantom for simulation
Authors: Kendall John L. , Faragher Jeffrey P.
Published: July 2016

Various medical specialty organizations and the Agency for Healthcare Research and Quality (AHRQ) have advocated using ultrasonography to guide central venous cannulation. It is surprising then, that very few instructional models have been described to teach this technique. Consequently, we developed a model to teach ultrasound-guided central venous access. This paper presents a recipe for an ultrasonographic model or “phantom” that is easily made, inexpensive and simulates vessel cannulation extremely well.
Type I Monteggia lesion and associated fracture of the distal radius and ulna metaphysis in a child
Authors: Peter Noel , Myint Sein
Published: July 2016

We report a rare case of a type I Monteggia lesion with an associated fracture of the distal radius and ulna metaphysis in a child. We discuss the mechanism of injury and the importance of thorough clinical examination in childhood injuries.
Patients presenting to the emergency department: the use of other health care services and reasons for presentation
Authors: Han Alice , Ospina Maria B. , Blitz Sandra , Strome Trevor , Rowe Brian H.
Published: July 2016

Objective:

Some low-acuity emergency department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study assessed the frequency and determinants of patients' efforts to access alternative care before ED presentation.

Methods:

Patients aged 17 years and older were randomly selected from 2 urban ED sites in Edmonton. Survey data were collected on use and characteristics of alternative care before the ED visit. Information was also collected on patient demographics and factors influencing their perception of whether the ED was the best care option.

Results:

Of the 1389 patients approached, 905 (65%) completed the survey and data from 894 participants were analyzed. Sixty-one percent reported that they sought alternative care before visiting the ED. Eighty-nine of the patients who attempted alternative access before the ED visit felt that the ED was their best care option. Results of the multivariate logistic regression analysis showed that injury presentation, living arrangements, smoking status and whether or not patients had a family practitioner were predictors for seeking alternative care before visiting the ED.

Conclusion:

Most ambulatory patients attempt to look for other sources of care before presenting to the ED. Despite this attempted access to alternative care, while patients wait for ED care, they perceive that the ED is their best care option at that point in time.
Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial
Authors: Richards Doug , Meshkat Nazanin , Chu Jaqueline , Eva Kevin , Worster Andrew
Published: July 2016

Introduction:

Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP).

Methods:

Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations.

Results:

Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (χ2= 6.69,p< 0.001) with a relative risk of 1.29 (95% confidence interval 1.18–1.40), and the results remained significant after a “worst case” sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary.

Conclusion:

When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.
Myth: Nephrolithiasis and medical expulsive therapy
Authors: Liu May , Henderson Sean O.
Published: July 2016

There is a medical myth that ureteral stones larger than 5 mm will not pass spontaneously and require urological intervention for removal. Recent findings indicate that medical expulsive therapy can facilitate spontaneous passage for stones up to 10 mm. For the management of ureteral stones, we recommend administering tamsulosin and a corticosteroid (deflazacort or prednisone) along with the standard therapy of analgesics, antibiotics and hydration.
Legitimizing Political Science or Splitting the Discipline? Reflections on DA-RT and the Policy-making Role of a Professional Association
Authors: Schwartz-Shea Peregrine , Yanow Dvora
Published: July 2016

We have been invited by Politics & Gender's editors to review the origins and current standing of the Data Access and Research Transparency (DA-RT) policy, an effort initiated by the eponymous American Political Science Association (APSA) Ad Hoc Committee and led primarily by Colin Elman, Diana Kapiszewski, and Arthur (“Skip”) Lupia. We have not been bystanders in this unfolding history, and in keeping with feminist and interpretive epistemologies that inform our work and that tie positionality to knowledge claims (e.g., Haraway 1988), we include mention of our own involvement (see Mala Htun's 2016 parallel account of her activities). Herein lies one of our main points in assessing DA-RT: from the perspective of interpretive, feminist, and some other qualitative methods, transparency as an epistemological mandate is not new. On the contrary, it is widely accepted, and expected, within certain epistemic communities (noted also in Yanow and Schwartz-Shea 2014); it needs no set of new rules imposed from above, by journal editors and others, for its instantiation. Our assessment includes questions about the relationship between APSA and DA-RT, as the association's support has colored DA-RT's reception. Part of what we seek to account for is resistance on the part of political scientists of various sorts—and not only those in the interpretive community, which we know best—to the DA-RT initiative and even to the participatory Qualitative Transparency Deliberations (QTD) process designed by Alan Jacobs and Tim Büthe (2015) at the invitation of the APSA organized section Qualitative and Multi-Method Research (QMMR; see, e.g., Isaac 2016). Even as we see changes in representations of DA-RT in response to critiques, we are concerned that those questioning the substance of DA-RT and the process of its adoption by APSA (in the Ethics Guidelines) and various journals are being represented by its architects as “either not paying attention to what we have been doing or [as] purposely misrepresenting the project,” including presenting “conspiracy theories, enemy narratives, and speculation about others' motives” (Elman and Lupia, 2106, 45, 50). These very words speak to DA-RT's potential to marginalize dissenters and even split the discipline. How has U.S. political science arrived at this pass?
Quotas and Women's Substantive Representation: Evidence from a Content Analysis of Ugandan Plenary Debates
Authors: Clayton Amanda , Josefsson Cecilia , Wang Vibeke
Published: July 2016

Despite the popularity of electoral gender quotas, the substantive impact of quotas on the plenary behavior of members of parliament (MPs) has yet to be thoroughly empirically explored, and in particular, there is a dearth of evidence from non-Western cases. Here we create a unique content analysis dataset from 14 years (1998–2011) of plenary debates, including the contents of more than 150,000 unique MP speeches recorded in some 40,000 pages of the Ugandan parliamentary Hansard to test how MP characteristics affect patterns of gender-related legislative speech. We find that female MPs speak about issues related to women's interests significantly more than male MPs. Further, we find no evidence of significant differencesbetweenfemale MPs elected with and without quotas, suggesting that, in the Ugandan case, gender is a more salient predictor of the tendency to “speak for women” than electoral pathway. To our knowledge, this is the first study that examines the effectiveness of quotas in promoting women's substantive representation in parliamentary debates across all policy domains over a significant time period. We discuss the implications of these findings in the Ugandan context, as well as how our evidence speaks to substantive representation through reserved seat quotas in semi-authoritarian regimes more broadly.
Mysteries of the Magnetosphere
Authors: Yan Wudan
Published: July 2016

Scientists investigate how dipolarization fronts in Earth's protective magnetosphere interact with the environment around them.
The ‘other’ coral symbiont: Ostreobium diversity and distribution
Authors: del Campo Javier , Pombert Jean-François , Šlapeta Jan , Larkum Anthony , Keeling Patrick J
Published: July 2016

Ostreobium is an endolithic algal genus thought to be an early-diverging lineage of the Bryopsidales (Ulvophyceae, Chlorophyta). Ostreobium can live in low-light conditions on calcium carbonate substrata in tropical conditions. It is best known as a symbiont of corals, where it lives deep within the animal skeleton and exchanges nitrogen and carbon, as well as providing nutrients and photoassimilates. In contrast to the relatively well-studied role of the photosynthetic zooxanthellae symbionts in coral (Symbiodinium), Ostreobium phylogeny, diversity and distribution are all poorly understood. Here, we describe the phylogenetic position and diversity of Ostreobium based on plastid 16S ribosomal DNA (rDNA), 18S rDNA and rbcL genes from a nuclear genome survey and complete plastid genome, and determined its environmental diversity and distribution by screening the publicly available environmental data for those genes. The results shed light on the phylogeny and the ecology of the ‘other’ coral symbiont.
Adjustable white-light emission from a photo-structured micro-OLED array
Authors: Krotkus Simonas , Kasemann Daniel , Lenk Simone , Leo Karl , Reineke Sebastian
Published: July 2016

White organic light-emitting diodes (OLEDs) are promising candidates for future solid-state lighting applications and backplane illumination in large-area displays. One very specific feature of OLEDs, which is currently gaining momentum, is that they can enable tunable white light emission. This feature is conventionally realized either through the vertical stacking of independent OLEDs emitting different colors or in lateral arrangement of OLEDs. The vertical design is optically difficult to optimize and often results in efficiency compromises between the units. In contrast, the lateral concept introduces severe area losses to dark regions between the subunits, which requires a significantly larger overall device area to achieve equal brightness. Here we demonstrate a color-tunable, two-color OLED device realized by side-by-side alignment of yellow and blue p-i-n OLEDs structured down to 20 μm by a simple and up-scalable orthogonal photolithography technique. This layout eliminates the problems of conventional lateral approaches by utilizing all area for light emission. The corresponding emission of the photo-patterned two-unit OLED can be tuned over a wide range from yellow to white to blue colors. The independent control of the different units allows the desired overall spectrum to be set at any given brightness level. Operated as a white light source, the microstructured OLED reaches a luminous efficacy of 13 lm W−1 at 1000 cd m−2 without an additional light outcoupling enhancement and reaches a color rendering index of 68 when operated near the color point E. Finally, we demonstrate an improved device lifetime by means of size variation of the subunits.