bluuebunny/crossref_metadata_2025 huggingface dataset:
Land Use and Hydrogeological Characteristics Influence Groundwater Invertebrate Communities
Authors: Tione María Laura , Bedano José Camilo , Blarasin Mónica
Published: July 2016

We examine the influence of land use and hydrogeological characteristics on the abundance, composition and structure of groundwater invertebrate communities in a loessic aquifer from Argentina. Seven wells, selected according to surrounding land use and hydrogeological characteristics, were sampled twice. Groundwater was characterized as sodium bicarbonate, bicarbonate sulfate or sulfate type. was detected in all samples. Land use in the area surrounding the well, unsaturated zone thickness and geochemical characteristics of groundwater influenced the abundance, composition and community structure of groundwater invertebrates. Copepoda, Oligochaeta, Cladocera, Ostracoda and Amphipoda were highly influenced by land use, particularly by point pollution sources that produced higher abundance and changes in taxonomic composition. The lowest invertebrate abundance was observed at the wells situated in areas with the thickest unsaturated zone. Groundwater salinity and geochemical type influenced the presence of certain species, particularly Stygonitocrella sp.
Preparation of Three‐Dimensional Chitosan–Graphene Oxide Aerogel for Residue Oil Removal
Authors: Guo Xiaoqing , Qu Lijun , Zhu Shifeng , Tian Mingwei , Zhang Xiansheng , Sun Kaikai , Tang Xiaoning
Published: July 2016

Graphene oxide has been used as an adsorbent in wastewater treatment. However, the hydrophily and dispersibility in aqueous solution limit its practical application in environmental protection. In this paper, a novel, environmentally friendly adsorbent, chitosan and chitosan–graphene oxide aerogels with a diverse shape, large specific surface area, and unique porous structure were prepared by a freeze‐drying method. The structure of the adsorbents was investigated using scanning electron microscopy, Fourier transform‐infrared spectroscopy, and X‐ray diffraction (XRD); the specific surface area and swelling capability were also characterized. In addition, removal of diesel oil from seawater by chitosan aerogel (CSAG) and chitosan–graphene oxide aerogel (AGGO‐1 and AGGO‐2) was studied and batch adsorption experiments were carried out as a function of different adsorbent dosages (0–6 g), contact time (0–120 minutes), pH (3–9), and initial concentrations of oil residue (3–30 g/L) to determine the optimum condition for the adsorption of residue oil from seawater. The results showed that the chitosan–graphene oxide aerogels were more effective to remove diesel oil from seawater compared with pure chitosan aerogel. A removal efficiency ≥ 95% of the chitosan–graphene oxide aerogels could be achieved easily at the initial concentrations of 20 g/L, which indicated that the chitosan–graphene oxide aerogels can be used to treat the industrial oil leakage or effluent in the natural water.
Bioprospecting Cryptogams as Potential Source of Unique Biodynamic Phytochemicals with Diverse Pharmaceutical Applications
Authors: Singh Brahma N. , Pandey Garima , - Prateeksha , Kumar J.
Published: July 2016

With the advent of green pharmaceuticals, the secondary metabolites derived from plants have provided numerous leads for the development of a wide range of therapeutic drugs; however the discovery of new drugs with novel structures has declined in the past few years. Cryptogams including lichens, bryophytes, and pteridophytes represent a group of small terrestrial plants that remain relatively untouched in the drug discovery process though some have been used as ethnomedicines by various tribes worldwide. Studies of their secondary metabolites are recent but reveal unique secondary metabolites which are not synthesized by higher plants. These compounds can have the potential to develop more potential herbal drugs for prevention and treatment of diseases The present article . deals with the secondary metabolites and pharmacological activities of cryptogams with an objective to bring them forth as potential source of biodynamic compounds of therapeutic value.
Az Európai Unió liberalizált energiapiaca
Authors: Sztankó Éva
Published: July 2016

Az egységes európai energiapiac – az elmúlt években tapasztalható előrelépések ellenére – még nem valósult meg. Az energiahálózatok teljes körű integrációja és a nemzeti piacok teljes megnyitása érdekében további alapvető változtatásokra van szükség, hogy az energiaellátás biztonságos, alacsony költségű és fenntartható lehessen. Ehhez a meglévő hálózatok korszerűsítése mellett ki kell építeni a keresleti és a kínálat oldal rugalmasságát is biztosító integrált infrastruktúrát; ez alapvető feltétele annak, hogy új technológiák, új szereplők és komplementer szolgáltatók jelenjenek meg a piacon. A következő elemzés áttekinti a piaci integráció eredményeit, a liberalizációt még hátráltató korlátokat és a lehetséges kezelési módokat. A változásokat kiváltó okok ismertetése mellett kísérletet tesz az európai energiaszektorban végbemenő jelentős átalakulások és a legfontosabb feladatok bemutatására is.

Journal of Economic Literature (JEL) kódok: Q40, Q41, Q49
A HR gyakorlatok alakulásának összehasonlító vizsgálata a világ négy régiójában, közép-kelet-európai sajátosságokat keresve
Authors: Karoliny Mártonné , Poór József
Published: July 2016

A közép- és kelet-európai országok emberi erőforrás menedzselési (Human Resource Management – HRM, vagy röviden HR) gyakorlatának alakulásáról készülő tanulmányokat a régió országaiban működő szakemberek, vezetők és a kutatók egyaránt érdeklődéssel fogadják. E tanulmányban ezt az igényt újszerű módon, a regionális sajátosságok bemutatásával igyekszünk kielégíteni. Az összehasonlító HRM főbb fejlődési fázisainak szakirodalmi áttekintése után, az ezek megállapításaira építő régióképzési elvek alkalmazásával, összehasonlító elemzés segítségével mutatjuk be a világ Cranet hálózati tagországaibólképzett négy régiójának HR sajátosságait. Figyelmünk középpontjában a közép- és kelet-európai országok HR jellegzetességeinek feltárása áll. Ennek érdekében ezeket először HR kulcsfunkciónként, majd összegzően is összevetjük Európa volt szocialista országok nélküli régiójának, illetve a nem európai angolszász és a délkelet-ázsiai országok HR jellegzetességeivel, a 2008/10-es Cranet-felmérés adatai alapján. Journal of Economic Literature (JEL) kódok: M12, M50,M51, M52,M53 és M54
Huszonegy közgazdasági érv a feltétel nélküli alapjövedelemmel szemben
Authors: Csillag István , Mihályi Péter
Published: July 2016

Összeurópai szinten és Magyarországon is élénk társadalmi vita folyt 2013/2014 fordulóján a feltétel nélküli alapjövedelem (FNA) intézményének megvalósíthatóságáról. Ennek a diskurzusnak fontos állomása volt egy, a magyar viszonyokra adaptált 100 oldalas koncepció megjelenése. A Bánfalvi István nevével fémjelzett tanulmány alapgondolata, hogy 2015-től alanyi jogon minden gyermek 25 ezer, minden felnőtt 50 ezer, illetve minden várandós nő 75 ezer forintot kapjon. A jelen tanulmány egyfelől konkrét bírálatát adja ennek a 25–50–75 javaslatnak, másfelől igyekszik szélesebb statisztikai keretek között vizsgálni a jövedelmi szegénység magyarországi adatait. A tanulmány végkövetkeztetése az, hogy a szegénység csökkentése szempontjából a kistelepülésekre bezsúfolódott roma népesség újramobilizálása a jövő kulcskérdése.

Journal of Economic Literature (JEL) kódok: H21, I38, J15
A tudásintenzív üzleti szolgáltatások innovációs jellemzői
Authors: Nagy Sándor
Published: July 2016

A cikk a szolgáltatások innovációs megközelítéséből kiindulva lehatárolja a tudásintenzív üzleti szolgáltatásokat, összefoglalja azok innovációs jellemzőit. Megállapítja, hogy az egyes szolgáltatási tevékenységeknél más szektorokhoz viszonyítva hiányoznak az ösztönzéshez szükséges intézményi és egyéb formális támogató rendszerek, amelyek nemcsak tudásközpontokként szolgálhatnának a vállalkozások számára, hanem hozzájárulhatnának az innovációk védelméhez és terjedéséhez is. A szellemi tulajdonnak a szolgáltatások körében hiányzó hatékony védelme (a termelő szektorral ellentétben) nagy kockázatot jelent, ami gátolja az optimális tudástranszfert, és pazarló, duplikált innovációs erőfeszítéseket okoz.

Journal of Economic Literature (JEL) kódok: O31, O32, L84
A határon átnyúló fúziók piaci és pénzügyi jellemzői Magyarországon, a külföldi közvetlen befektetések tükrében
Authors: Kucséber László Zoltán
Published: July 2016

A külföldi társaságok befektetéseinek egyik eszközét a határon átnyúló fúziók és felvásárlások (CrossBorder Mergers and Acquisitions – CBM&A) alkotják. Ennek számszerű bizonyítéka az, hogy amíg az 1990-es évek közepéig ezek értéke az összes külföldi közvetlen befektetés (Foreign Direct Investment – FDI) körülbelül felét tette ki, addig az 1990-es évek egészében a 84 százalékát, 2000-ben pedig már a 100 százalékát adta. Magyarországon ez a trend nem érvényesült ennyire markánsan, ám a szóban forgó arány 2009-ben mégis megközelítette a 100 százalékot. Ebben a tanulmányban nem csupán a CBM&A ésaz FDI kapcsolatát vizsgálom, hanem tekintetbe veszem a külföldi portfólió befektetéseket is. A Gazdasági Versenyhivatal által engedélyezett 343 CBM&A határozatainak elemzése azt mutatja, hogy összességében több a hasonlóság ezek és az FDI-k között, viszont létezik néhány olyan markáns különbség is, amelyet alátámasztok és kiegészítek a statisztikai eljárásokkal kapott eredményekkel. Journal of Economic Literature (JEL) kód: F21
Az állami újraelosztás és a gazdasági növekedés hosszú távú összefüggései
Authors: Nádasi Levente
Published: July 2016

Jelen tanulmány célja, hogy intézményi, történeti, modellszerű és statisztikai megközelítésben tanulmányozza az állami újraelosztás mértékének változását, és azt, egyes országokban az újraelosztás változásamilyen hatással van a hosszú távú gazdasági növekedésre. Általánosan kijelenthető, hogy Európában az 1870-es évek óta napjainkig folyamatosan (trendjét tekintve) nő a kormányzati kiadások GDP-hezviszonyított aránya. Megvizsgálom, milyen csatornákon keresztül hat az állam mérete a gazdasági növekedésre, illetve milyen egyéb tényezők befolyásolják a két változó hosszú távú kapcsolatának természetét. Hipotézisem szerint a fejlett államokban a magas állami újraelosztás hosszú távon már gátolja a gazdasági növekedést. Ezt igyekszem belátni 30 európai ország statisztikai elemzéséből is.

Journal of Economic Literature (JEL) kódok: E66, H62, C10
Galbraith néhány elfeledett mozaikja
Authors: Pásztor Szabolcs
Published: July 2016

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Billiards in confocal quadrics as a Pluri-Lagrangian system
Authors: Suris Yuri
Published: July 2016

We illustrate the theory of one-dimensional pluri-Lagrangian systems with the example of commuting billiard maps in confocal quadrics.
Surgical treatment of secondary hip osteoarthritis using cementless total hip endoprosthesis with Fitmore® Hip Stem: A case report
Authors: Golubovic Ivan , Bascarevic Zoran , Stojiljkovic Predrag , Radovanovic Zoran , Golubovic Ivana , Radojkovic Milan , Djordjevic Dusan , Mitic Aleksandar , Milijic Svetlana , Golubovic Zoran
Published: July 2016

Introduction. Hip dysplasia with subluxation represents insufficient coverage of the femur's head placed in the dysplastic acetabulum. This lack of coverage ranges from barely noticeable to condition where half of femur head is uncovered by acetabulum. The caput-collum-diaphyseal angle of the proximal femur and anteversion angle of collum are increased, Wiberg?s angle is less than 15? and M?nard-Shenton line is interrupted. Hip joint degeneration occurs very early. When radiological signs of hip joint degenerative changes are discovered in elderly they are associated with pain, limited movements and leg shortening. Case report. We present a 53-year old female treated conservatively in childhood because of hip diyplasia with subluxation. After pregnancy, right hip pain emerged. Clinical and radiological examinations revealed hip subluxation with the signs of degenerative osteoarthritis. Initial treatment was conservative and included drugs and balneophysical procedures. Since pain and movement impairment progressed and became constant, a hip replacement using cementless total endoprosthesis with Fitmore? Hip Stem was done. In the pre-operative preparation, anteroposterior x-ray of the hip(with third of the proximal femur) was made. This X-ray enabled precise planning of implantation endoprosthesis component. The early postoperative course was uneventful with very good therapeutic effect. Following successful physical rehabilitation, the patient returned to work and full life activity. Conclusion. Implantation of the cementless endoprosthesis with Fitmore? Hip Stem in the treatment of secondary hip osteoarthritis is a good choice in the treatment of young patients with good bone quality. Future clinical and radiological follow-up and comparative studies are needed to show the advantages of this type of stem compared to the classical cementless long stem.
Dispatches from the front: emergency medicine teachers' perceptions of competency-based education
Authors: Bandiera Glen , Lendrum David
Published: July 2016

Objectives:

Controversy exists regarding the applicability of competency-based education during clinical rotations in emergencymedicine (EM). Little has been written about the perceptions of front-line teachers regarding one such competencybased education paradigm, the CanMEDS framework. We undertook to determine 1) what perceptions exist among frontline teachers at two academic health science emergency departments (EDs) regarding the use of the CanMEDS roles to frame what residents should learn on ED rotations and 2) how those same teachers envision practically incorporating the CanMEDS roles into feedback provided to residents.

Methods:

Teachers at two sites volunteered for a semistructured focus group study. Focus groups were moderated by an experienced qualitative researcher, and verbatim transcriptions were coded by two independent reviewers. The codes were merged into final themes. The final focus group was used to further explore issues raised and test assumptions made in the preceding groups.

Results:

In five focus groups involving 21 participants, the Medical Expert and Professional roles were seen as most relevant to an EM rotation, whereas the Health Advocate, Manager, Scholar, and Collaborator roles were least relevant. On further exploration, however, faculty identified highly relevant components of each role that they could envision teaching in an ED. Participants also felt that the framework helped highlight the breadth of physician competencies and provided structure for teaching and feedback.

Conclusions:

EM faculty find the CanMEDS framework helpful for structuring teaching and learning and that many elements of the roles, when defined, are feasible to integrate into a clinical rotation.
An unusual case of pediatric abdominal pain
Authors: Bjoernsen Lars P. , Lindsay M. Bruce
Published: July 2016

Chronic and recurrent abdominal pains are common complaints in children and adolescents, but the evaluation in the emergency department (ED) can be challenging. We present a rare yet serious case of a 17-year-old white female who presented to the ED with a 2-day history of diffuse abdominal pain, nausea, and intractable vomiting. Abdominal examination and imaging, including computed tomography (CT), were negative during an episode 6 weeks previously. This was her fifth similar episode in a 2-month period, and she had been seen at three different hospitals and admitted on each occasion. Three days prior to presentation to our ED, she was seen at a gastroenterology clinic and diagnosed with irritable bowel syndrome and an ovarian cyst. Symptomatic therapy during the current presentation, with intravenous fluids, antiemetics, and parenteral narcotics, failed to alleviate her abdominal pain and vomiting. Emergent CT evaluation revealed a high-grade colonic obstruction with focal circumferential narrowing in the transverse colon and a lower gastrointestinal follow-through radiograph with Gastrografin enema showed a classic “apple-core” lesion. Colonic adenocarcinoma with positive regional lymph nodes was found during emergent exploratory laparotomy. Pediatric patients with recurrent, episodic abdominal pain should undergo systematic evaluation and symptomatic treatment. A previous negative workup should not dissuade emergency physicians from proceeding with a systematic and thorough evaluation of the pediatric patient presenting with abdominal pain and vomiting.
Examination of staphylococcal stethoscope contamination in the emergency department (pilot) study (EXSSCITED pilot study)
Authors: Tang Patrick H.P. , Worster Andrew , Srigley Jocelyn A. , Main Cheryl L.
Published: July 2016

Introduction:

The objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA).

Methods:

We conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members' stethoscopes at three EDs. Study participants were asked to complete a questionnaire.

Results:

Fifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED.

Conclusions:

This study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low.
Impact of a teaching attending physician on medical student, resident, and faculty perceptions and satisfaction
Authors: Cassidy-Smith Tara N. , Kilgannon J. Hope , Nyce Andrew L. , Chansky Michael E. , Baumann Brigitte M.
Published: July 2016

Objectives:

To determine if a dedicated teaching attending for medical student education improves medical student, attending physician, and resident perceptions and satisfaction.

Methods:

Two dedicated teaching attending physician shifts were added to the clinical schedule each week. A before-after trial compared medical student evaluations from 2000 to 2004 (preteaching attending physician) to medical student evaluations from 2005 to 2006 (teaching attending physician). Attending physician and resident perceptions and satisfaction with the teaching attending physician shifts using a 5-point Likert-type scale (1 = poor to 5 = excellent) were also assessed.

Results:

Eighty-nine (100%) medical students participated, with 63 preteaching attending physician and 26 teaching attending physician rotation evaluations. The addition of teaching attending physician shifts improved mean medical student satisfaction with bedside teaching (4.1 to 4.5), lecture satisfaction (4.2 to 4.8), preceptor scores (4.3 to 4.8), and perceived usefulness of the rotation (4.5 to 5.0) (allp< 0.05). Thirteen attending physicians (93%) participated in the crosssectional questionnaire. The addition of teaching attending physician shifts improved faculty ratings of their medical student interactions by ≥ 1.5 points for all items (p≤ 0.001). Faculty perceptions of their resident interactions improved for quality of bedside teaching (3.1 to 4.0), their availability to hear resident presentations (3.4 to 4.2), and their supervision of residents (3.4 to 4.1) (p≤ 0.01). Residents (n= 35) noted minor improvements with the timeliness of patient dispositions, faculty bedside teaching, and attending physician availability.

Conclusions:

The addition of select teaching attending physician shifts had the greatest effect on medical student and faculty perceptions and satisfaction, with some improvements for residents.
Iatrogenic bacterial meningitis: an unmasked threat
Authors: Barnwell Robert , Ball Vincent
Published: July 2016

Iatrogenic bacterial meningitis (IBM) is a rare but serious complication of neuraxial procedures, such as spinal and epidural anesthesia or lumbar puncture. We report a case of a 46-year-old female who presented to the emergency department with bacterial meningitis after spinal anesthesia. We reviewthe existing literature outlining the pathogenesis, vector hypothesis, diagnosis, treatment, and prevention as they relate to IBM. We highlight the role of the emergency physician in the rapid diagnosis of this disease, and underscore the need for sterile technique when performing lumbar punctures.
Residents-as-teachers: a survey of Canadian specialty programs
Authors: Patocka Catherine , Meyers Christine , Delaney J. Scott
Published: July 2016

Introduction:

The ability to teach is a critical component of residency and future practice. This is recognized by the Royal College of Physicians and Surgeons of Canada, which incorporates teaching functions into the CanMEDS competencies. The aim of our study was to identify how emergency medicine specialty programs across Canada prepare their residents for roles as teachers and to compare these results to those of other Royal College specialty programs.

Methods:

A 40-item English questionnaire was developed and translated into French. It was e-mailed to the program directors of all Royal College Emergency Medicine (EM), Anesthesia, Diagnostic Radiology, General Surgery, Internal Medicine, Obstetrics and Gynecology, Pediatrics, and Psychiatry residency programs. The survey asked what modalities were in use to teach residents how to teach and allowed respondents to comment on recent changes.

Results:

Twelve of 13 (92%) EM programs and 78 of 113 (69%) other specialty programs responded. All responding programs incorporated some kind ofmandatory teaching responsibilities. Four of 12 (33%) EM programs reserved formal teaching functions for postgraduate year 3 and above, whereas only 7 of 78 (9%) other specialty programsdid so. The remaining 71 of 78 (91%) non-EM specialty programs incorporated formal teaching functions in all years of residency. Six of 12 (50%) EM programs offered rotations in clinical medical education compared to only 11 of 78 (14%) other specialty programs.

Conclusions:

Canadian EM programs appear to differ from other specialty programs in the way that they develop residents-as-teachers. Half of EM programs offer rotations in clinical medical education, and many introduce formal teaching functions later in residency.
International Federation for Emergency Medicine model curriculum for emergency medicine specialists
Authors:   The Core Curriculum and Education Committee for the International Federation for Emergency Medicine
Published: July 2016

To meet a critical and growing need for emergency physicians and emergency medicine resources worldwide, physicians must be trained to deliver time-sensitive interventions and lifesaving emergency care. Currently, there is no globally recognized, standard curriculum that defines the basic minimum standards for specialist trainees in emergency medicine. To address this deficit, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals, and other experts in emergency medicine and international emergency medicine development to outline a curriculum for training of specialists in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed to provide a framework for educational programs in emergency medicine. The focus is on the basic minimum emergency medicine educational content that any emergency medicine physician specialist should be prepared to deliver on completion of a training program. It is designed not to be prescriptive but to assist educators and emergency medicine leadership to advance physician education in basic emergency medicine no matter the training venue. The content of this curriculum is relevant not just for communities with mature emergency medicine systems but in particular for developing nations or for nations seeking to expand emergency medicine within the current educational structure. We anticipate that there will be wide variability in how this curriculum is implemented and taught. This variability will reflect the existing educational milieu, the resources available, and the goals of the institutions' educational leadership with regard to the training of emergency medicine specialists.
How do I find a point-of-care answer to my clinical question?
Authors: Worster Andrew , Haynes R. Brian
Published: July 2016

Emergency physicians often need point-of-care access to current, valid information to guide patient management. Most emergency physicians do not work in a hospital with a computerized decision support system that prompts and provides them with information to answer their clinical questions. Searching for answers to clinical questions online, especially those related to diagnosis and treatment, can be challenging, in part because determining the validity and clinical applicability of the results of individual studies is beyond the time constraints of most emergency physicians. This article describes currently available point-of-care sources of evidence-based information to answer clinical questions and provides the access information for each.
Survey of emergency physicians’ requirements for a clinical decision rule for acute respiratory illnesses in three countries
Authors: Perry Jeffrey J. , Goindi Reena , Symington Cheryl , Brehaut Jamie , Taljaard Monica , Schneider Sandra , Stiell Ian G.
Published: July 2016

Objective:

There are currently no widely used guidelines to determine which older patients with acute respiratory conditions require hospital admission. This study assessed the need for clinical decision rules to help determine whether hospital admission is required for patients over 50 years for three common respiratory conditions: chronic obstructive pulmonary disease (COPD), heart failure (HF), and community-acquired pneumonia (CAP).

Design:

Postal survey.

Setting:

Emergency physicians (EPs) from the United States, Canada, and Australasia.

Participants:

A random sample of EPs from the United States, Canada, and Australasia.

Interventions:

A modified Dillman technique with a prenotification letter and up to three postal surveys.

Main Outcomes:

EP opinions regarding the need for and willingness to use clinical decision rules for emergency department (ED) patients over 50 years with COPD, HF, or CAP to predict hospital admission. We assessed the required sensitivity of each rule for return ED visit or death within 14 days.

Results:

A total of 801 responses from 1,493 surveys were received, with response rates of 55%, 60%, and 46% for Australasia, Canada, and the United States, respectively. Over 90% of EPs reported that they would consider using clinical decision rules for HF, CAP, and COPD. The median required sensitivity for death within 14 days was 97 to 98% for all conditions.

Conclusions:

EPs are likely to adopt highly sensitive clinical decision rules to predict the need for hospital admission for patients over 50 years with COPD, HF, or CAP.
Patients' satisfaction and wait times at Guelph General Hospital Emergency Department before and after implementation of a process improvement project
Authors: Preyde Michèle , Crawford Kim , Mullins Laura
Published: July 2016

Objective:

A process improvement program (PIP) was implemented in the emergency department (ED) at Guelph General Hospital in July 2009. The purpose of this study was to examine patients' satisfaction and wait times by level of Canadian Triage and Acuity Scale (CTAS) score before and 6 months after implementation of this program.

Methods:

Two samples were recruited: one was recruited before implementation of the PIP, January to June 2009 (T1), and one was recruited 6 months after implementation, January to June 2010 (T2). Patients were contacted by telephone to administer a survey including patient satisfaction with quality of care. Time to physician initial assessment, numbers left without being seen, and length of stay (LOS) were obtained from hospital records to compare wait times before and 6 months after implementation of the PIP.

Results:

Patients (n = 301) reported shorter wait times after implementation (e.g., 12% reported seeing a physician right away at T1 compared to 29% at T2). Time to physician initial assessment improved for patients with CTAS scores of III, IV, and V (average decrease from 2.1 to 1.7 hours), fewer patients (n = 425) left without being seen after implementation, and the mean and 90th percentile of LOS decreased for all patients except the mean LOS for discharged patients with a CTAS score of I. Total time spent in the ED for admitted patients decreased from 11.11 hours in the 2009 period to 9.95 in the 2010 period, and for nonadmitted patients, the total time decreased from 3.94 to 3.29 hours. The overall satisfaction score improved from a mean of 3.17 to 3.4 (of 4; p < 0.001).

Conclusion:

Implementation of the ED PIP corresponded with decreased wait times, increased patient satisfaction, and improved patient flow for patients with CTAS scores of III, IV, and V.
Are patients willing to remove, and capable of removing, their own nonabsorbable sutures?
Authors: Macdonald Peter , Primiani Nadia , Lund Adam
Published: July 2016

Objectives:

Providing patients with instructions and equipment regarding self-removal of nonabsorbable sutures could represent a new efficiency in emergency department (ED) practice. The primary outcome was to compare the proportion of patients successfully removing their own sutures when provided with suture removal instructions and equipment versus the standard advice and follow-up care. Secondary outcomes included complication rates, number of physician visits, and patient comfort level.

Methods:

This prospective, controlled, single-blinded, pseudorandomized trial enrolled consecutive ED patients who met the eligibility criteria (age > 19 years, simple lacerations, nonabsorbable sutures, immunocompetent). The study group was provided with wound care instructions, a suture removal kit, and instructions regarding suture self-removal. The control group received wound care instructions alone. Outcomes were assessed by telephone contact at least 14 days after suturing using a standardized questionnaire.

Results:

Overall, 183 patients were enrolled (93 in the intervention group; 90 in the control group). Significantly more patients performed suture self-removal in the intervention group (91.5%; 95% CI 85.4–97.5) compared to the control group (62.8%; 95% CI 52.1–73.6) (p< 0.001). Patients visited their physician less often in the intervention group (9.8%; 95% CI 3.3–16.2) compared to the control group (34.6%; 95% CI 24.1–45.2%) (p< 0.001). Complication rates were similar in both groups.

Conclusion:

Most patients are willing to remove, and capable of removing, their own sutures. Providing appropriate suture removal instructions and equipment to patients with simple lacerations in the ED appears to be both safe and acceptable.
Avulsion fracture of the lesser trochanter: an unusual cause of hip pain in an adolescent
Authors: Vazquez Eugenio , Kim Tommy Y. , Young Timothy P.
Published: July 2016

Sports injuries involving the hip and groin are common. Special consideration must be given to musculoskeletal injuries in children and adolescents as their immature skeletons have growth plates that are relatively weaker than the tendons and ossified bone to which they connect. We present a case of an adolescent athlete with acute-onset groin pain who was found to have an avulsion fracture of the lesser trochanter.
Variability in the emergency department use of discretionary radiographs in children with common respiratory conditions: the mixed effect of access to pediatrician care
Authors: Guttmann Astrid , Weinstein Michael , Austin Peter C. , Bhamani Azim , Anderson Geoffrey
Published: July 2016

Objectives:

The objective of this study was to investigate whether different staffing models are associated with variation in radiograph use for children seen for bronchiolitis, croup, and asthma and discharged home from emergency departments (EDs) in Ontario.

Methods:

We surveyed all Ontario EDs regarding physician staffing models and use of clinical protocols. We used a population-based ED database to determine radiograph rates and patient characteristics. Regression techniques that controlled for patient factors and clustering within EDs were applied.

Results:

From April 2004 to March 2006, 5,186, 10,408, and 35,150 children were discharged home from an ED with bronchiolitis, croup, and asthma, respectively. Radiograph rates were 42.7% for bronchiolitis, 10.1% for croup, and 25.9% for asthma. Over 50% of children were treated in EDs with nonpediatric front-line care but with consultant pediatricians available. Compared to children in these settings, those seen in EDs with front-line pediatric staff were less likely to have radiographs for all three conditions (adjusted odds ratios [ORs] 0.47 [95% CI 0.24–0.95], 0.47 [95% CI 0.27–0.82], 0.13 [95% CI 0.02–0.66] for bronchiolitis, croup, and asthma, respectively). Children in community hospitals with pediatricians were significantly more likely to have a radiograph if seen by a consultant pediatrician (OR 1.40, 95% CI 1.20–1.63 [bronchiolitis]; OR 2.76, 95% CI 2.16–3.53 [croup]; and OR 1.97, 95% CI 1.64–2.36 [asthma]). We found no association between clinical protocol use and radiograph rates.

Conclusions:

High rates of discretionary radiograph use exist for common respiratory problems of children seen across ED settings. Quality improvement efforts should be focused in this area, and radiograph use in EDs staffed by front-line pediatrics-trained staff could serve as an initial benchmark target for other institutions.
Impaired driving charges in injured impaired drivers requiring treatment in an emergency department
Authors: Fieldus Warren , Cain Ed
Published: July 2016

Objective:

To determine the percentage of injured impaired drivers brought to the only trauma centre in Nova Scotia who were charged with impaired driving.

Methods:

This retrospective observational study identified alcohol impaired drivers involved in a motor vehicle crash (MVC) brought to the emergency department (ED). Patients were selected based on blood alcohol concentrations (BACs) found to be above the legal limit. Medical records were examined to determine if the patient was the driver in an MVC. Patient records were then cross-referenced with a police database to determine the percentage of injured impaired drivers who were charged with impaired driving.

Results:

Between April 1, 2006, and April 1, 2008, 1,102 patients brought to the QEII Health Sciences Centre (QEII HSC) ED were found to have BACs over the legal limit. Of these patients, only 57 (5.2%) were found to have been the driver in an MVC. The majority of patients were male (49; 86%), with an average age of 32 years. Most injuries (51; 89.5%) were the result of a single-vehicle crash. The mean Glasgow Coma Scale score was 12.6, and the mean Injury Severity Score was 14.4. Cross-referencing with police records showed that only 22.8% (13 of 57) of injured drivers were charged with impaired driving. Those drivers not charged with impaired driving had a significantly lower median BAC and median age.

Conclusion:

During the study, the majority of alcoholimpaired drivers injured in an MVC who were brought to the QEII HSC ED for assessment of their injuries were not charged with impaired driving.
Predictors of admission to hospital of patients triaged as nonurgent using the Canadian Triage and Acuity Scale
Authors: Lin Daren , Worster Andrew
Published: July 2016

Objectives:

To identify factors known prior to triage that might have predicted hospital admission for patients triaged by the Canadian Triage Acuity Scale (CTAS) as level 5 (CTAS 5, nonurgent) and to determine whether inappropriate triage occurred in the admitted CTAS 5 patients.

Methods:

We reviewed the triage records of patients triaged as CTAS 5 at the emergency departments (EDs) of three tertiary care hospitals between April 2002 and September 2009. Two triage nurses unaware of the study objective independently assigned the CTAS level in 20% of randomly selected CTAS 5 patients who were admitted. We used the kappa statistic (κ) to measure the agreement among the raters in CTAS level between the assessment of the research nurses and the original triage assessment and regression analysis to identify independent predictors of admission to hospital.

Results:

Of the 37,416 CTAS 5 patients included in this study, 587 (1.6%) were admitted. Agreement on CTAS assignment in CTAS 5 patients who were admitted was κ −0.9, (95% confidence interval [CI] 20.96 to 20.84). Age over 65 (odds ratio [OR] 5.46, 95% CI 4.57 to 6.53) and arrival by ambulance (OR 7.42, 95% CI 6.15 to 8.96) predicted hospital admission in CTAS 5 patients.

Conclusions:

Most of the CTAS 5 patients who were subsequently admitted to hospital may have qualified for a higher triage category. Two potential modifiers, age over 65 and arrival by ambulance, may have improved the prediction of admission in CTAS 5 patients. However, the consistent application of existing CTAS criteria may also be important to prevent incorrect triage.
Implementation of small-group reflection rounds at an emergency medicine residency program
Authors: Wen Leana S. , Baca Justin T. , O'Malley Patricia , Bhatia Kriti , Peak David , Takayesu J. Kimo
Published: July 2016

Few residency curricular interventions have focused on improving well-being and promoting humanism. We describe the implementation of a novel curriculum based on small-group reflection rounds—the Emergency Medicine Reflection Rounds (EMRR)—at a 4-year US emergency medicine (EM) residency. During the inaugural year (2010–2011), nine residents volunteered to take part in 1-hour monthly sessions with faculty facilitators. Residents were provided with a confidential environment to discuss difficult ethical and interpersonal encounters from their clinical experiences. Ongoing feedback from participants was solicited, culminating with a four-question survey in which all respondents remarked that the EMRR contributed to improving their own well-being and agreed that it provided an important forum for residents to discuss difficult issues in a safe environment. In this article, we describe our innovation as an example of a wellness initiative that has promoted reflective practice and fostered cooperative learning around the communication, professional, and ethical challenges inherent in EM practice. Our EMRR model may be useful to other EM residences looking to supplement their wellness curriculum.
Unnecessary shock from an implantable cardioverter-defibrillator following transcutaneous pacing
Authors: Somani Riyaz , DeJong Peggy , Michael Kevin , Baranchuk Adrian
Published: July 2016

As the population ages and cardiovascular disease becomes more prevalent, an increasing number of patients are receiving implantable cardioverter-defibrillators (ICDs). When these patients present to the emergency department, it is imperative that physicians are not only aware of the possible underlying medical issues that may have precipitated their admission but should also have a good understanding of the potential interactions that any medical intervention may have on the patient’s device. We discuss a case in which a patient known to have an ICD in situ was transcutaneously paced for the management of bradycardia, leading to an unnecessary shock.
Detection and correction of prescription errors by an emergency department pharmacy service
Authors: Stasiak Philip , Afilalo Marc , Castelino Tanya , Xue Xiaoqing , Colacone Antoinette , Soucy Nathalie , Dankoff Jerrald
Published: July 2016

Objectives:

Emergency departments (EDs) are recognized as a high-risk setting for prescription errors. Pharmacist involvement may be important in reviewing prescriptions to identify and correct errors. The objectives of this study were to describe the frequency and type of prescription errors detected by pharmacists in EDs, determine the proportion of errors that could be corrected, and identify factors associated with prescription errors.

Methods:

This prospective observational study was conducted in a tertiary care teaching ED on 25 consecutive weekdays. Pharmacists reviewed all documented prescriptions and flagged and corrected errors for patients in the ED. We collected information on patient demographics, details on prescription errors, and the pharmacists’ recommendations.

Results:

A total of 3,136 ED prescriptions were reviewed. The proportion of prescriptions in which a pharmacist identified an error was 3.2% (99 of 3,136; 95% confidence interval [CI] 2.5–3.8). The types of identified errors were wrong dose (28 of 99, 28.3%), incomplete prescription (27 of 99, 27.3%), wrong frequency (15 of 99, 15.2%), wrong drug (11 of 99, 11.1%), wrong route (1 of 99, 1.0%), and other (17 of 99, 17.2%). The pharmacy service intervened and corrected 78 (78 of 99, 78.8%) errors. Factors associated with prescription errors were patient age over 65 (odds ratio [OR] 2.34; 95% CI 1.32–4.13), prescriptions with more than one medication (OR 5.03; 95% CI 2.54–9.96), and those written by emergency medicine residents compared to attending emergency physicians (OR 2.21, 95% CI 1.18–4.14).

Conclusions:

Pharmacists in a tertiary ED are able to correct the majority of prescriptions in which they find errors. Errors are more likely to be identified in prescriptions written for older patients, those containing multiple medication orders, and those prescribed by emergency residents.
The reverse classroom: lectures on your own and homework with faculty
Authors: Sherbino Jonathan , Chan Teresa , Schiff Karen
Published: July 2016

With the arrival of a technologically proficient generation of learners (often described with the moniker “digital natives”) into Canadian medical schools and residency programs, there is an increasing trend toward harnessing technology to enhance education and increase teaching efficiency. We present an instructionalmethod that allows medical educators to “reverse” the traditional classroom paradigm. Imagine that prior to an academic half-day session, learners watch an e-lecture on their own time; then during class, they do “homework” with tailored consultations from a content expert. The reverse classroom uses simple, readily accessible technology to allow faculty members to engage learners in high-order learning such as information analysis and synthesis. With this instructional method, the inefficient, repetitious delivery of recurring core lectures is no longer required. The reverse classroom is an effective instructional method. Using this technique, learners engage in high-order learning and interaction with teachers, and teachers are able to optimally share their expertise.
Validity of ultrasonography to diagnosing pneumothorax: a critical appraisal of two meta-analyses
Authors: Azad Aftab , Juma Saad Al , Bhatti Junaid A. , Dankoff Jerrald
Published: July 2016

Clinical question

Can ultrasonography be used in lieu of chest radiography to diagnose pneumothorax?

Articles chosen

1. Ding W, Shen Y, Yang J, et al. Diagnosis of pneumothorax by radiography and ultrasonography: a metaanalysis. Chest 2011;140:859-66. [Epub 2011 May 5]

2. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest 2012; 141:703-8.
Implementing peer review at an emergency medicine blog: bridging the gap between educators and clinical experts
Authors: Thoma Brent , Chan Teresa , Desouza Natalie , Lin Michelle
Published: July 2016

Emergency physicians are leaders in the ‘‘free open-access meducation’’ (FOAM) movement. The mandate of FOAM is to create open-access education and knowledge translation resources for trainees and practicing physicians (e.g., blogs, podcasts, and vodcasts). Critics of FOAM have suggested that because such resources can be easily published online without quality control mechanisms, unreviewed FOAM resources may be erroneous or biased. We present a new initiative to incorporate open, expert, peer review into an established academic medical blog. Experts provided either pre- or postpublication reviews that were visible to blog readers. This article outlines the details of this initiative and discusses the potentially transformative impact of this educational innovation.
What are emergency-sensitive conditions? A survey of Canadian emergency physicians and nurses
Authors: Berthelot Simon , Lang Eddy S. , Quan Hude , Stelfox Henry T.
Published: July 2016

Objective: In a previous study, we assembled a multidisciplinary Canadian panel and identified 37 International Classification of Diseases-10-Canada Diagnosis Groups (DGs) for which emergency department (ED) management may potentially reduce mortality (emergency-sensitive conditions). Before using these 37 DGs to calculate a hospital standardized mortality ratio (HSMR) specific to emergency care, we aimed to test their face validity with ED care providers.

Methods: We conducted a self-administered web survey among Canadian emergency physicians and nurses between November 22 and December 31, 2012. All members (N=2,507) of the Canadian Association of Emergency Physicians and the National Emergency Nurses Association were surveyed. They were asked to agree or disagree (binary response) with the panel classification for each of the 37 DG emergency-sensitive conditions identified and provide free text responses to identify missing entities.

Results: A total of 719 ED providers (719 of 2,507, 29%) completed the survey, of whom 470 were physicians (470 of 1,407, 33%) and 232 were nurses (232 of 1,100, 21%). Information on professional status was not provided for 17 respondents. Of 37 DGs, 32 (e.g., A41 sepsis) were rated by more than 80% of respondents to be emergency-sensitive conditions. The remaining five DGs (e.g., E11 type 2 diabetes mellitus) were rated by 68.5 to 79.7% of the respondents to be emergency-sensitive conditions. Respondents suggested an additional 31 emergency-sensitive diagnoses.

Conclusion: We identified 37 emergency-sensitive DGs that had high face validity with emergency physicians and nurses, which will enable the calculation of an ED-HSMR.