bluuebunny/crossref_metadata_2025_split huggingface dataset:
Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial
Authors: Innes Grant D. , Macphail Iain , Dillon Edward C. , Metcalfe Cathy , Gao Min 
Published: July 2016

ABSTRACT:Objective:To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment.Methods:Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double-blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment). Results: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At follow-up, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69;p= 0 .005).Conclusions:Migraine recurrence is common after “successful” ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.
Development, implementation and reliability assessment of an emergency physician performance evaluation tool
Authors: Etherington Jeremy , Innes Grant , Christenson James , Berkowitz Jonathan , Chamberlain Robert , Berringer Ross , Leung Cosmas 
Published: July 2016

ABSTRACT
Evaluation of physician practice is necessary, both to provide feedback for self-improvement and to guide department heads during yearly evaluations.

Objective:
To develop and implement a peer-based performance evaluation tool and to measure reliability and physician satisfaction.

Methods:
Each emergency physician in an urban emergency department evaluated their peers by completing a survey consisting of 21 questions on effectiveness in 4 categories: clinical practice, interaction with coworkers and the public, nonclinical departmental responsibilities, and academic activities. A sample of emergency nurses evaluated each emergency physician on a subset of 5 of the questions. Factor analysis was used to assess the reliability of the questions and categories. Intra-class correlation coefficients were calculated to determine inter-rater reliability. After receiving their peer evaluations, each physician rated the process’s usefulness to the individual and the department.

Results:
225 surveys were completed on 16 physicians. Factor analysis did not distinguish the nonclinical and academic categories as distinct; therefore, the survey questions fell into 3 domains, rather than the 4 hypothesized. The overall intra-class correlation coefficient was 0.43 for emergency physicians, indicating moderate, but far from perfect, agreement. This suggests that variability exists between physician evaluators, and that multiple reviewers are probably required to provide a balanced physician evaluation. The intra-class correlation coefficient for emergency nurses was 0.11, suggesting poor reliability. Overall, 11 of 15 physicians reported the process valuable or mostly valuable, 3 of 15 were unsure and 1 of 15 reported that the process was definitely not valuable.

Conclusion:
Physician evaluation by a single individual is probably unreliable. A useful physician peer evaluation tool can be developed. Most physicians view a personalized, broad-based, confidential peer review as valuable.
Ruralizing the Canadian Triage and Acuity Scale
Authors: Thompson James M. , Dodd Graham 
Published: July 2016

SOMMAIRE:L’échelle canadienne de triage et de gravité (ÉTG) a été introduite dans les années 90 et est rapidement en voie de devenir la norme canadienne de triage. Mais depuis 1997, moment où l’Institut canadien d’information sur la santé a commencé à promouvoir l’ÉTG, certains médecins de campagne ont manifesté leurs préoccupations, signalant l’existence de d’autres systèmes de triage et mettant en doute l’efficacité de l’ÉTG dans les milieux ruraux.Les médecins des milieux ruraux soulèvent divers points: une perception de la complexité de l’ÉTG, un délai de réponse apparemment court pour l’évaluation par le médecin (et les ramifications médico-légales de la définition de ces délais), et une validation inadéquate de l’ÉTG dans les milieux ruraux. Le présent article explore l’historique de cette controverse et ébauche des solutions possibles. Les auteurs concluent que l’ÉTG est un outil malléable qui peut être «adapté» aux milieux ruraux et qu’il permettra par la suite d’améliorer les soins aux patients et les conditions de travail des infirmières et des médecins de ces milieux.
Survey of pain etiology, management practices and patient satisfaction in two urban emergency departments
Authors: Todd Knox H. , Sloan Edward P. , Chen Connie , Eder Stephen , Wamstad Kyle 
Published: July 2016

ABSTRACT:

Objective:
The underuse of analgesics, or “oligoanalgesia,” is common in emergency departments (EDs). To improve care we must understand our patients’ pain experiences as well as our clinical practice patterns. To this end, we examined pain etiology, pain management practices and patient satisfaction in 2 urban EDs.

Methods:
We conducted a cross-sectional study using structured interviews and chart reviews for patients with pain who presented to either of 2 university-affiliated EDs. We assessed pain etiologies, patient pain experiences, pain management practices, and patient satisfaction with pain management.

Results:
The 525 study subjects reported high pain intensity levels on presentation, with a median rating of 8 on a 10-point numerical rating scale (NRS). At discharge, pain severity had decreased to a median rating of 4; however, 48% of patients were discharged from the ED in moderate to severe pain (NRS 5–10). Subjects reported spending 57% of their ED stay in moderate to severe pain. Analgesics were administered to only 50% of patients. The mean time to analgesic administration was almost 2 hours. Despite high levels of reported pain at discharge and low rates of analgesic administration, subjects reported high satisfaction with pain management.

Conclusions:
In the 2 EDs studied, we found high levels of pain severity for our patients, as well as low levels of analgesic use. When used, analgesic administration was often delayed. Despite these findings, patient satisfaction remained high. Despite recent efforts to improve pain management practice; oligoanalgesia remains a problem for our specialty.
Major injury associated with all-terrain vehicle use in Nova Scotia: a 5-year review
Authors: Sibley Aaron K. , Tallon John M. 
Published: July 2016

ABSTRACT:

Background:
Riding all-terrain vehicles (ATVs) is a popular recreational activity, with approximately 1.5 million users in Canada. Despite legislation aimed at reducing injury rates, ATV-related incidents remain a major cause of trauma and death. This paper reviews the epidemiology of major injury associated with ATV use in Nova Scotia.

Methods:
The Nova Scotia Trauma Registry was used to identify all adults over age 15 who sustained major ATV-related trauma (Injury Severity Score [ISS] ≥12) within a 5-year period. Demographic variables, temporal statistics, alcohol use, helmet use, injury characteristics and injury outcome variables, including ISS, length of stay (LOS), Glasgow Coma Scale score and discharge status were evaluated.

Results:
Twenty-five patients met the inclusion criteria. Most (92%) were males, and 64% were between 16 and 34 years of age. Most injuries occurred between 1300 hrs and 1900 hrs, 52% occurred on the weekend, and 40% occurred in the spring. The average ISS was 22.1, and injuries to the central nervous system comprised 39% of all major injuries. Alcohol was involved in up to 56% of all incidents, and only 4 patients (16%) were known to be wearing a helmet at the time of injury. Average hospital LOS was 21.6 days.

Interpretation:
ATV-related incidents are a continuing source of major injury. This paper describes the epidemiology of ATV-related major trauma presenting to the sole tertiary care referral centre in one province. Information gained from this study should be used to influence ATV public education programs.
Hydrofluoric acid burn: a case report
Authors: Qureshi Roohi , House Ronald , Uhlig Eric , Genesove Leon , Holness D. Linn 
Published: July 2016

ABSTRACT:
A case of occupational hydrofluoric acid exposure is presented, accentuating the importance of eliciting an occupational history during the initial emergency department evaluation. Patients who present with major hydrofluoric acid burns are at risk for systemic complications, including potentially fatal hypocalcemia. Information regarding the accident and workplace circumstances may well allow the physician to anticipate the exposed patient’s course. These patients should be considered occupational index cases that will require follow up by government occupational health services. Identification of potential hazards, risk assessment and enforcement of recommendations for change (such as engineering controls, personal protective equipment, education) may be key to preventing similar injuries in the future.
Diagnostic parameters of CK–MB and myoglobin related to chest pain duration
Authors: Innes Grant , Christenson James , Weaver W. Douglas , Liu Tiepu , Hoekstra James , Every Nathan , Jackson Raymond E. , Frederick Paul , Gibler W. Brian 
Published: July 2016

ABSTRACT:Objective:Cardiac marker sensitivity depends on chest pain duration at the time of sampling. Our objective was to estimate the sensitivity, specificity, and likelihood ratios of early CK–MB and myoglobin assays in patients presenting to the emergency department (ED) with nondiagnostic ECGs, stratified by the duration of ongoing chest pain at the time of ED assessment.Methods:This was a prospective observational study carried out in 10 US and 2 Canadian EDs. Patients &gt;25 years of age with ongoing chest pain and nondiagnostic ECGs were stratified by pain duration (0–4 h, 4–8 h, 8–12 h, &gt;12 h). CK–MB and myoglobin assays were drawn at T = 0 (ED assessment) and T = 1 hr. Patients were followed for 7–14 days to identify all cases of acute myocardial infarction (AMI). ED test results were correlated with patient outcomes.Results:Of 5005 eligible patients, 565 had AMI. Pain duration was 0–4 h in 3014 patients, 4–8 h in 961, 8–12 h in 487, and &gt;12 h in 543. Marker sensitivity increased with pain duration, ranging from 28%–77% for CK–MB and 39%–73% for myoglobin. The maximal sensitivity achieved by a T = 0 assay was 73%, and this was in patients with 8–12 or &gt;12 h of ongoing pain. No combination of tests achieved 90% sensitivity in any pain duration strata.Conclusions:Regardless of chest pain duration, single assays and early serial markers (0+1 hr) do not rule out AMI; therefore, serial assays over longer observation periods are required. Likelihood ratios derived in this study will help physicians who use Bayesian analysis to determine post-test AMI likelihood in patients with chest pain.
Diagnostic test utilization in the emergency department for alert headache patients with possible subarachnoid hemorrhage
Authors: Perry Jeffrey J. , Stiell Ian , Wells George , Spacek Alena 
Published: July 2016

ABSTRACT:

Objectives:
This study evaluated the incidence of subarachnoid hemorrhage (SAH) and the use of computed tomography (CT) and lumbar puncture (LP) in a cohort of emergency department (ED) patients with acute headache.

Methods:
Health records from a tertiary care ED were used to identify all patients over 15 years of age who presented with headache over a 10-month period. Patients were excluded if they had been referred with confirmed SAH or if they had recurrent headache, head trauma, decreased level of consciousness or new neurologic deficits. Outcome measures included ED diagnosis, use of CT or LP, and ED length of stay. Analysis included descriptive statistics, 95% confidence intervals (CIs) and analysis of variance for length of stay.

Results:
The mean age of the 891 patients was 41.9 years. Ten (1.1%) of the patients had SAH, 313 (35.1%) underwent CT, and 85 (9.5%) underwent LP. Only 9 (2.9%) of the CT scans and 2 (2.4%) of the LPs were positive for SAH. Of the 296 patients with normal CT results, 232 (78.4%) did not undergo subsequent LP. The mean length of stay was 4.0 hours (95% CI, 3.8–4.1) if no diagnostic testing was performed, 5.0 hours (95% CI, 4.7–5.4) if CT was performed and 7.1 hours (95% CI, 6.3–7.9) if LP was performed (p = 0.001).

Conclusions:
Diagnostic testing was associated with substantially prolonged lengths of stay. CT and LP had low diagnostic yields, which suggests the need for a clinical decision rule to rule out SAH in ED patients with acute headache.
Pulse oximetry in discharge decision-making: a survey of emergency physicians
Authors: Brown Lance , Dannenberg Bernard 
Published: July 2016

ABSTRACT

Objectives:
Our primary objective was to describe the pulse oximetry discharge thresholds used by general and pediatric emergency physicians for well-appearing children with bronchiolitis and pneumonia, and to assess the related practice variability.

Methods:
This mail-in survey was conducted in August and September 2001 and included the 281 active members of the Pediatric Emergency Medicine Section of the American College of Emergency Physicians. The survey consisted of 2 case scenarios of previously healthy, well-appearing children: a 2-year-old with pneumonia and a 10-month-old with bronchiolitis. Respondents were asked about their years of experience, teaching load, percentage of children in their practice, whether they currently have a written departmental guideline at their institution, and the lowest pulse oximetry reading that they would accept and still discharge the patient directly home.

Results:
One hundred and eighty-two (65%) physicians answered the survey and met the inclusion criteria. The respondents’ median oximetry value and interquartile range (IQR) for the pneumonia and bronchiolitis cases were 93% (92%–94%) and 94% (92%–94%) respectively. With the exception of the 3 physicians practising &gt;1000 metres above sea level, the responses by subgroups were similar.

Conclusions:
There does not yet exist a safe, clinically validated pulse oximetry discharge threshold. Emergency physicians from this study sample have a modest degree of practice variability in a self-reported pulse oximetry discharge threshold. Emergency physicians may use this data to compare their own practice with that reported by this group.
Understanding the causes of overcrowding in emergency departments in the Capital Health Region in Alberta: a focus group study
Authors: Estey Angela , Ness Kathleen , Saunders L. Duncan , Alibhai Arif , Bear Robert A. 
Published: July 2016

ABSTRACTObjectives:To determine the perceptions of health care professionals and service providers with regard to emergency department (ED) overcrowding, including definitions of overcrowding, characteristics of an overcrowded ED, and causes of overcrowding, and secondarily to solicit potential solutions to the problem.Methods:Focus groups were conducted with front-line staff, physicians and managers from 7 EDs within an integrated health region. Participants received questions before the sessions, and an experienced moderator conducted the sessions and prepared transcripts from audio tapes. Analyses included identification of key themes and the interrelationships between those themes.Results:Focus group participants defined service pressures that result in overcrowding as “anything that impedes the flow of patients through the ED, affects the quality of care delivered or results in patient frustration and stress to staff.” Overcrowding, which can occur at any time of the day, was perceived to have many causes, including some seasonal factors. Two key problems were identified as causing many spin-off pressures: inefficient access to ED beds (stretchers) because of slow throughput of patients and staff shortages. Other perceived causes included the changing role and use of EDs and limited access to services such as home care, diagnostic imaging, laboratory services, social services and specialist care. Participants generally believed that the characteristics and causes of overcrowding could not be viewed independently; rather, in the search for remedies, they should be considered as interrelated variables.Conclusion:Qualitative studies of this complex issue can identify and describe complex interactions in real-world settings. The findings of such studies can lead to quantitative studies involving objective measurement.
Canadian Emergency Department Triage and Acuity Scale (CTAS): Rural Implementation Statement
Authors:   Society of Rural Physicians of Canada Emergency committee (SRPC-ER) Working Group
Published: July 2016

BACKGROUND
The Canadian Emergency Department Triage and Acuity Scale (CTAS) has been recognized as a significant improvement in standardizing triage in Canadian emergency departments (EDs), both urban and rural. Since its publication an increasing number of Canadian EDs have implemented the CTAS. It was intended to improve patient care through more appropriate triaging of patients, but a number of adverse effects from its implementation have been encountered in rural EDs.
Ethical challenges of informed consent in prehospital research
Authors: Thompson James 
Published: July 2016

ABSTRACTInformed consent to participation in research is an important protector of potential subjects’ rights and autonomy. Ethical research involving critically ill people is challenging because their medical condition often makes obtaining informed consent impossible. This is especially true in the prehospital setting, where additional barriers to obtaining informed consent exist. A recently published Canadian policy (Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans) specifies circumstances under which an exception to the requirement for informed consent may be granted so that vulnerable individuals are not denied the potential benefits of participating in research. This article reviews the rationale for theTri-Council Policy Statementand illustrates some problems with its application in the context of a Canadian prehospital study on continuous positive airway pressure. A new risk analysis model and a national research ethics board are discussed as possible ways to facilitate interpretation and application of the current exception of informed consent policy.
Mental nerve neuropathy: case report and review
Authors: Turner-Iannacci Amy , Mozaffari Eisa , Stoopler Eric T. 
Published: July 2016

ABSTRACT
Mental nerve neuropathy (MNN) or “numb chin syndrome” is a rare neurologic symptom most often associated with malignancy. Patients typically develop paresthesia or numbness localized to the chin and lower lip and will often seek care at their local emergency department. Pain and expansion of the lower jaw may also be present. We report a case of MNN associated with a metastatic lesion in the mandible. The purpose of this article is to highlight the importance of recognizing MNN, a potentially life-threatening symptom of metastatic carcinoma, and enable clinicians to properly diagnose MNN, which may mimic other conditions that affect the mandible.
What is the risk of bacterial meningitis in infants who present to the emergency department with fever and pyuria?
Authors: Goldman Ran D. , Matlow Anne , Linett Lauren , Scolnik Dennis 
Published: July 2016

ABSTRACTObjectives:To determine the rate of bacterial meningitis among febrile infants in the emergency department (ED) who have pyuria detected in an initial catheterized urine specimen.Methods:This retrospective chart review, conducted at the Hospital for Sick Children, Toronto, Ont., involved all children aged 0 to 3 months who presented to the ED with fever and pyuria (≥10 white blood cells/mm3) over a 3-year period. Cerebrospinal fluid (CSF) was evaluated using standard methods, and the rate of meningitis in children with pyuria was determined.Results:The study sample included 211 infants with fever and pyuria — 79 of these under 1 month of age. Eighty-one percent (171/211) had positive urine cultures, and 143 underwent lumbar puncture to rule out meningitis. Of these, 140 CSF samples were culture negative and 3 grew coagulase negativeStaphylococcus— 2 because of contamination and 1 because of a ventriculo-peritoneal shunt infection. Both children with CSF contamination grewEscherichia coliin the urine. The rate of bacterial meningitis in the study sample was 0% (95% confidence interval, 0%–2.6%).Conclusions:In this study of febrile children under 90 days of age with fever and pyuria, the incidence of concurrent meningitis was 0%. This suggests that recommendations for mandatory lumbar puncture in such children should be reconsidered. However, until larger prospective studies define a patient subset that does not require CSF analysis, it is prudent to rule out meningitis, administer parenteral antibiotics for urinary tract infection, and admit for close observation.
Systematic reviews in emergency medicine: Part II. Critical appraisal of review quality, data synthesis and result interpretation
Authors: Zed Peter J. , Rowe Brian H. , Loewen Peter S. , Abu-Laban Riyad B. 
Published: July 2016

ABSTRACTReviews of the medical literature have always been an important resource for physicians. Increasingly, qualitative and quantitative systematic reviews (SRs) have replaced the traditional “narrative review” as a means of capturing and summarizing current evidence on a topic or, when possible, answering a specific clinical question. This paper is Part II of a 2-part series designed to provide emergency physicians with the background necessary to locate, critically evaluate and interpret SRs. The paper expands on the critical appraisal principles discussed in Part I by focusing on quality assessment, data synthesis and interpretation of results. To illustrate key points and facilitate readability, examples from the emergency medicine literature have been included and technical details have been kept to a minimum. The references, however, are comprehensive and provide a resource for readers seeking further information.