bluuebunny/crossref_metadata_2025_split huggingface dataset:
Bias in a prehospital esophageal detector device trial: lessons learned
Authors: Verbeek P. Richard , Bandiera Glen , Morris Brian , Pierre Dennis St. 
Published: July 2016

ABSTRACTObjectives:Our goals were to determine whether selection bias occurred in a prehospital study comparing an esophageal detector device (EDD) to a disposable capnometer for detecting esophageal intubation, and to determine whether such a bias would have changed the study’s conclusions about EDD effectiveness.Methods:In a study of patients requiring prehospital intubation, we determined the sensitivity, specificity and predictive values of the EDD for detecting esophageal intubation. We then compared intubation success rate in patients who were enrolled in the study (n= 129) to that in eligible patients who were excluded from it (n= 107). After finding that the incidence of failed intubation was higher in the “excluded” group, we used sensitivity and specificity parameters derived from the study population to assess whether EDD test characteristics would differ in studied vs. excluded patients.Results:The first intubation attempt was successful in 125 of 129 study patients and 76 of 107 excluded patients (97% vs. 71%,p= 0.03), confirming the presence of selection bias. The negative predictive value of the EDD for esophageal intubation was 98% in the study cohort and would have been 77% in patients like those excluded (i.e., difficult intubation cases).Conclusions:Conclusion: The high “first attempt” intubation success rate seen in this study was due to selective exclusion of failed intubations. This selection bias led to a clinically important overestimation of the EDD’s negative predictive value. Bias may substantially alter the estimations of test accuracy reported in scientific studies. To reduce the chance of unrecognized selection bias in studies of diagnostic tests, investigators must determine whether recruited subjects resemble patients in whom the test will ultimately be used.
Thrombolytic therapy for acute ischemic stroke
Authors:   Canadian Association of Emergency Physicians Committee on Thrombolytic Therapy for Acute Ischemic Stroke
Published: July 2016

ABSTRACTCurrent evidence suggests that, in a small subset of acute stroke patients who can be treated within 3 hours of symptom onset, the administration of tissue plasminogen activator (tPA) confers a modest outcome benefit, but that this benefit is associated with an increased risk of intracranial hemorrhage that can be severe or fatal. The data show that tPA therapy must be limited to carefully selected patients within established protocols. Further evidence is necessary to support the widespread application of stroke thrombolysis outside research settings. Until it is clear that the benefits of this therapy outweigh the risks, thrombolytic therapy for acute stroke should be restricted to use within formal research protocols or in monitored practice protocols that adhere to the NINDS (the rt-PA Stroke Study Group trial of the National Institute of Neurological Disorders and Stroke) eligibility criteria. All data on protocol compliance and patient outcomes should be collated in a central Canadian registry for the purposes of tracking safety and efficacy.Stroke thrombolysis should be limited to centers with appropriate neurological and neuro-imaging resources that are capable of administering treatment within 3 hours. In such centres, emergency physicians should identify eligible patients, initiate low risk interventions and facilitate prompt computed tomography. Only physicians with demonstrated expertise in neuroradiology should interpret head CT scans used to determine whether to administer thrombolytic agents to stroke patients. Neurologists should be directly involved prior to the thrombolytic administration.
Clinical diagnosis of clavicle fractures: a pilot study
Authors: Landine Jim , McGraw Robert , Pickett William 
Published: July 2016

ABSTRACTObjective:Clavicle fractures are commonly encountered in the emergency department (ED). Our objective was to determine whether emergency physicians can clinically predict the presence and location of a clavicle fracture prior to obtaining x-rays.Methods:Over a 16-month period we prospectively studied ED patients who had injuries compatible with a clavicle fracture. Following clinical examination and prior to obtaining radiographs, ED physicians or senior emergency medicine (EM) residents were asked to predict whether the clavicle was fractured and, if fractured, the location of the fracture. Clinical predictions were later compared to the radiologist’s report.Results:Between April 1999 and August 2000, 184 patients with possible clavicle fracture were seen and 106 (58%) were enrolled. Of these, 94 had an acute fracture, and all 94 fractures were predicted on clinical grounds prior to x-ray. In 6 cases, physicians predicted a fracture but the radiograph was negative. In 6 additional cases, physicians were clinically unsure and the radiograph was negative. Physicians correctly predicted fracture location in 83 of 94 cases (88%; 95% confidence interval [CI], 82%–95%). In the 64 cases where physicians predicted a middle third fracture, they were 100% accurate (95% CI, 95%–100%). Errors made by physicians were conservative; that is, they occasionally predicted fractures in patients with only soft tissue injury, but they did not “miss” existing fractures.Conclusions:The results of this pilot study suggest that ED physicians can clinically predict the presence and location of clavicle fractures with a high degree of accuracy. It may be that x-rays are not always necessary in patients suspected of having a clavicle fracture. Future studies should define the indications for diagnostic radiography in patients with suspected clavicle fractures.
A survey of emergency medicine in 36 countries
Authors: Arnold Jeffrey L. , Dickinson Garth , Tsai Ming-Che , Han David 
Published: July 2016

ABSTRACTObjective:To assess the current level of development of emergency medicine (EM) systems in the world.Design:Survey of EM professionals from 36 countries during a 90-day period from Aug. 25 to Nov. 24, 1998.Participants:Thirty-six EM professionals from 36 countries and 6 continents completed the survey. Thirty-five (97%) were physicians, of whom 25 (69%) gave presentations at 1 of 4 international EM conferences during the study period. Three potential participants from 3 countries were excluded because of language barriers. Five additional participants from 5 other countries did not respond within the study period and were excluded.Measurements:Respondents completed a 103-question questionnaire about the presence of EM specialty, academic, patient care, information and management systems and the factors influencing the future of EM in their countries.Results:The overall response rate was 88%. Nearly all respondents (97%) stated that their countries had hospital-based emergency departments (EDs). More than 80% of respondents reported that their countries have emergency medical services (EMS), national EMS activation phone numbers and ED systems for pediatric emergency care. More than 70% stated that their countries had national EM organizations, EM research, ED systems for patient transfer and peer review and emergency physician (EP) training in Advanced Cardiac Life Support (ACLS) and the ability to perform rapid sequence intubation. More than 60% reported ED systems for trauma care and triage and EP training in Advanced Trauma Life Support (ATLS) and the ability to perform thrombolysis for acute myocardial infarction. Fifty percent reported EM residency training programs, official recognition of EM as an independent specialty, and EM journals.Conclusions:Basic emergency medicine components now exist in the majority of countries surveyed. These include many specialty, academic, patient care and administrative systems. The foundation for further EM development is widely established throughout the world.
Factors affecting survival after prehospital asystolic cardiac arrest in a Basic Life Support-Defibrillation system
Authors: Petrie David A. , De Maio Valerie , Stiell Ian G. , Dreyer Jonathan , Martin Michael , O’Brien Jo-Anne ,   OPALS Study Group
Published: July 2016

ABSTRACT

Objectives:
Previous studies have shown a low but meaningful survival rate in cases of prehospital cardiac arrest with an initial rhythm of asystole. There may be, however, an identifiable subgroup in which resuscitation efforts are futile. This study identified potential field criteria for predicting 100% nonsurvival when the presenting rhythm is asystole in a Basic Life Support-Defibrillation (BLS-D) system.

Methods:
This prospective cohort study, a component of Phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study, was conducted in 21 Ontario communities with BLS-D level of care, and included all adult arrests of presumed cardiac etiology according to the Utstein Style Guidelines. Analyses included descriptive and appropriate univariate tests, as well as multivariate stepwise logistic regression to determine predictors of survival.

Results:
From 1991 to 1997, 9899 consecutive cardiac arrest cases with the following characteristics: male (67.2%), bystander-witnessed (44.7%), bystander CPR (14.2%), call–response interval (CRI) ≤ 8 minutes (82%) and overall survival (4.3%) were enrolled. Of 9529 cases with available rhythm strip recordings, initial arrest rhythms were asystole in 40.8%, pulseless electrical activity in 21.2% and ventricular fibrillation or ventricular tachycardia in 38%. Of 3888 asystolic patients, 9 (0.2%) survived to discharge; 3 of these cases were unwitnessed arrests with no bystander CPR. There were no survivors if the CRI exceeded 8 minutes. Logistic regression analysis demonstrated that independent predictors of survival to admission were “CRI in minutes” (odds ratio [OR] = 0.87; 95% confidence interval [CI], 0.77–0.98) and “bystander-witnessed” (OR = 2.6; 95% CI, 1.5–4.4).

Conclusions:
In a BLS-D system, there is a very low but measurable survival rate for prehospital asystolic cardiac arrest. CRIs of over 8 minutes were associated with 100% nonsurvival, whereas unwitnessed arrests with no bystander CPR were not. These data add to the growing literature that will help guide ethical decision-making for protocol development in emergency medical services systems.
Lack of efficacy of humidification in the treatment of croup: Why do physicians persist in using an unproven modality?
Authors: Lavine Elana , Scolnik Dennis 
Published: July 2016

ABSTRACTBackground:Humidification is a time-honoured therapy for childhood croup (acute laryngotracheobronchitis). Despite a paucity of evidence supporting its use, many physicians, nurses and parents still apply this treatment. Our objective was to summarize available evidence and assess the rationale for the ongoing use of humidity to treat childhood croup.Methods:Searches of both MEDLINE and the Cochrane Database were conducted for English-language original or review literature on the treatment of croup with humidity, for the years 1966-1999.Results:Only 2 published studies have attempted to evaluate humidification therapy for croup, and none has been published since 1984. There is no published evidence to support the commonly held empirical view that humidity helps alleviate the symptoms of childhood croup, and no understanding of which factors of moisture or temperature affect patient outcomes. Risks may include scalding and unnecessary discomfort.Interpretation:There is no strong evidence supporting the use of humidity in the treatment of croup. Although such treatment is still widely used, it is not without risk, and further trials are required to address its efficacy.
Measures of association: an overview with examples from Canadian emergency medicine research
Authors: Worster Andrew , Rowe Brian H. 
Published: July 2016

ABSTRACT
The authors of studies often report their results using abbreviated terms such as RR, OR, ARR, RRR and NNT. These terms are quantities that express the strength of association between the dependent and independent variables and are collectively referred to as measures of association. The similarity between these measures and the multiple terms by which each is referred can be confusing. The purpose of this article is to explain in a straightforward manner the purpose, derivation, and limitations of some of the more commonly used categorical measures of association, including relative risk, odds ratio, absolute and relative risk reduction and number needed to treat, using results from recent emergency medicine studies published by Canadian researchers.
Successful treatment of severe atenolol overdose with calcium chloride
Authors: O’Grady John , Anderson Scott , Pringle Derrick 
Published: July 2016

ABSTRACTAtenolol, a selective β1-adrenergic antagonist, is commonly used to treat hypertension, ischemic heart disease and cardiac dysrhythmias. Few cases of severe atenolol intoxication have been described, and only one of these reports discussed the use of calcium chloride as a treatment. We present a case of atenolol overdose associated with shock and first-degree heart block, in which administration of calcium chloride led to dramatic improvement after failure of conventional treatment. In addition, we discuss the pharmacokinetics, toxicology and management of β-blocker overdose, focusing on the possible role of calcium chloride.
Is propofol an optimal agent for procedural sedation and rapid sequence intubation in the emergency department?
Authors: Wilbur Kerry , Zed Peter J. 
Published: July 2016

ABSTRACTObjective:We conducted a qualitative systematic review to evaluate the efficacy and safety of propofol for direct current cardioversion (DCC), rapid sequence intubation (RSI) and procedural sedation in adult emergency department (ED) patients.Data source:MEDLINE (1966 to September 2000), PubMed (to September 2000), EMBASE (1988 to September 2000), Database of Systematic Reviews (to September 2000), Best Evidence (1991 to September 2000) and Current Contents (1996 to September 2000) databases.Study selection:English-language, randomized, comparative evaluations of propofol for procedures routinely conducted in adults (&gt;18 years) were included. Direct current cardioversion, RSI and procedural sedation were considered.Data extraction:Efficacy and safety endpoints were evaluated for all trials. For DCC and procedural sedation trials, efficacy measures included induction and recovery times, as well as the association for successful procedure. For the RSI trials, optimal intubating conditions were evaluated as the primary efficacy endpoint. Safety measures included hemodynamic changes, apnea rates and adverse effects.Data synthesis:In the setting of DCC, efficacy and safety outcomes were similar for propofol, thiopental, etomidate and methohexital. All of these agents provided markedly shorter induction and recovery times than midazolam. Patients who were pre-medicated with fentanyl exhibited prolonged recovery times and greater decreases in blood pressure. When used for RSI, propofol administration was associated with satisfactory intubating conditions that were comparable to those seen with thiopental and etomidate. Blood pressure reductions were seen in both DCC and RSI studies. Apneic episodes (&gt;30 seconds) occurred in 23% of propofol recipients, 28% of thiopental recipients and 7% of etomidate and midazolam recipients. Apart from the DCC studies described, no procedural sedation studies met our predefined review eligibility criteria.Conclusion:The body of literature evaluating propofol for DCC and RSI in the ED is limited. There is evidence to support the use of propofol for DCC and RSI, but this evidence comes from stable patients in non-ED settings. Further ED-based randomized comparative trials should be conducted before propofol is adopted for widespread use in the ED.
Serotonin syndrome due to an overdose of moclobemide?
Authors: Ip Andrew , Renouf Tia 
Published: July 2016

ABSTRACTSerotonin syndrome, a triad of autonomic instability, altered mental status and neuromuscular abnormalities, is usually attributed to serotonergic overdoses. Moclobemide is a new selective monoamine oxidase inhibitor (MAOI) that generally causes mild, self-limited gastrointestinal and central nervous system effects after ingestion. We present a case of serotonin syndrome that occurred after moclobemide overdose, and discuss the recognition and treatment of this important condition. Serotonin syndrome may become increasingly common because of the liberal use of selective serotonin reuptake inhibitors, new MAOIs and other agents such as codeine and meperidine, which have the potential for harmful interaction.
The role of lumbar puncture in the diagnosis of subarachnoid hemorrhage when computed tomography is unavailable
Authors: Mann David 
Published: July 2016

ABSTRACTSubarachnoid hemorrhage (SAH) is an important but uncommon condition in the differential diagnosis of acute headache. Most authorities recommend that patients with suspected SAH undergo noncontrast computed tomography (CT) as a first diagnostic intervention. If the results of the CT scan are negative, a lumbar puncture should be performed. Many nonurban Canadian hospitals do not have CT scanners and must either transfer patients or consider performing lumbar puncture prior to CT. In selected patients, performing lumbar puncture first may be an option, but timing of the procedure and the interpretation of results is important.
Diagnosing streptococcal pharyngitis in the emergency department: Is a sore throat score approach better than rapid streptococcal antigen testing?
Authors: Rosenberg Paul , McIsaac Warren , MacIntosh Donald , Kroll Michael 
Published: July 2016

ABSTRACTBackground:Reducing the number of unnecessary antibiotic prescriptions given for common respiratory infections has been recommended as a way to limit bacterial resistance. This study assessed the validity of a clinical sore throat score in 2 community emergency departments (EDs) and its impact on antibiotic prescribing. We also attempted to improve on this approach by using a rapid streptococcal antigen test.Methods:A total of 126 patients with new upper respiratory tract infections accompanied by sore throat were assessed by a physician. Pharyngeal swabs were obtained for a rapid test and throat culture, and information was gathered to determine the sore throat score. The sensitivity and specificity of the score approach were compared with usual physician care based on the rapid test results.Results:Of the 126 cases of new upper respiratory infections with sore throat, physicians who followed their usual care routine, guided by the rapid test results, prescribed antibiotics for 46 patients. Of the 46 prescriptions, 18 were given to patients with culture-negative results for group A streptococcal (GAS) pharyngitis. Use of the sore throat score would not have reduced the number of prescriptions but would have missed only 1 patient with a positive culture result (p&lt; 0.05). The rapid test was not as sensitive as throat culture.Conclusions:An explicit clinical score approach to the management of GAS pharyngitis is valid in a community ED setting and could improve the pattern of antibiotic prescribing. While the addition of a rapid streptococcal antigen test significantly decreased the sensitivity of detecting GAS infections, a combined approach consisting of the clinical score and throat culture for patients with negative results on the rapid test would decrease antibiotic prescribing and telephone follow-up without decreasing the sensitivity of detecting GAS infection.
Canadian C-Spine Rule study for alert and stable trauma patients: II. Study objectives and methodology
Authors: Stiell Ian G. , Wells George A. , McKnight R. Douglas , Brison Robert , Lesiuk Howard , Clement Catherine M. , Eisenhauer Mary A. , Greenberg Gary H. , MacPhail Iain , Reardon Mark , Worthington James , Verbeek Richard , Dreyer Jonathan , Cass Daniel , Schull Michael , Morrison Laurie , Rowe Brian , Holroyd Brian , Bandiera Glen , Laupacis Andreas ,   Canadian CT Head and C-Spine (CCC) Study Group
Published: July 2016

ABSTRACTClinical prediction rules are decision-making tools that incorporate three or more variables from the history, physical examination or simple tests. They help clinicians make diagnostic or therapeutic decisions by standardizing the collection and interpretation of clinical data. There is growing interest in the methodological standards for their development and validation. This article describes the methods used to derive the Canadian C-Spine Rule and provides a valuable reference for investigators planning to develop future clinical prediction rules.
Acute compartment syndrome: How long before muscle necrosis occurs?
Authors: Vaillancourt Christian , Shrier Ian , Vandal Alain , Falk Markus , Rossignol Michel , Vernec Alan , Somogyi Dan 
Published: July 2016

ABSTRACTObjectives:Acute compartment syndrome (ACS) is a limb-threatening condition often first diagnosed by emergency physicians. Little is known about the rapidity with which permanent damage may occur. Our objective was to estimate the time to muscle necrosis in patients with ACS.Methods:This historical cohort analysis of all patients who had a fasciotomy for ACS was conducted in 4 large teaching hospitals. Diagnosis was confirmed clinically or by needle measurement of compartment pressure. Muscle necrosis was determined using pathology reports and surgeons’ operative protocols. We used descriptive statistics and estimated tissue survival probability using the Vertex exchange method for interval-censored data.Results:Between 1989 and 1997 there were 76 cases of ACS. Most cases occurred in young men (median age 32) as a result of a traumatic incident (82%). Forty-nine percent (37/76) of all patients suffered some level of muscle necrosis, and 30% (11/37) of those with necrosis lost more than 25% of the muscle belly. Necrosis occurred in 2 of 4 cases in which the patient had been operated on within 3 hours of the injury, and our exploratory survival analysis estimates that 37% (95% confidence interval, 13%-51%) of all cases of ACS may develop muscle necrosis within 3 hours of the injury.Conclusions:This is the largest cohort of ACS and the first clinical estimation of time to muscle necrosis ever published. Ischemia from ACS can cause muscle necrosis before the 3-hour period post-trauma that is traditionally considered safe. Further research to identify risk factors associated with the development of early necrosis is necessary.
Delayed diagnosis of splenic rupture following minor trauma: Beware of comorbid conditions
Authors: Peera Mohamed Ali , Lang Eddy S. 
Published: July 2016

ABSTRACT
Although rare, spontaneous splenic rupture has been reported in cases of chronic lymphocytic leukemia (CLL). In contrast, there are no published reports of splenic injury resulting from minor trauma in CLL patients. We report the case of an 81-year-old woman with a history of CLL, who presented with minor trauma to her coccygeal region, and was found to have a splenic rupture. We briefly describe the incidence, pathogenesis, presentation, diagnosis, management and prognosis of splenic injury, especially in cases with a history of splenomegaly.