bluuebunny/crossref_metadata_2025_split huggingface dataset:
Central serous retinopathy: an unusual cause of acute visual loss
Authors: Chu Jennifer L. , Tyberg Jeffrey 
Published: July 2016

ABSTRACT
Ophthalmologic complaints represent approximately 2% of emergency department (ED) visits. Acute vision loss is the most serious of such presentations and requires prompt assessment for a treatable cause. The differential diagnosis for acute vision loss includes retinal detachment, macular disorders, vaso-occlusive disorders, temporal arteritis, neuro-ophthalmologic disorders, and functional disorders. We report the case of a previously healthy 33-year-old man who presented to the ED with acute bilateral vision loss that was ultimately diagnosed as central serous retinopathy (CSR), an idiopathic, self-limited condition that typically affects males age 20 to 50 years. This condition is not mentioned in standard emergency medicine textbooks or the emergency medicine literature, and our hope is that our report will serve to illustrate a typical case of CSR and help prompt emergency physicians to consider this diagnosis in the appropriate circumstances.
Parents' willingness to have their child receive care by physician assistants in a pediatric emergency department
Authors: Doan Quynh , Sheps Sam , Wong Hubert , Singer Joel , Johnson David , Kissoon Niranjan 
Published: July 2016

ABSTRACTObjective:To determine the willingness of parents of children visiting a pediatric emergency department to have a physician assistant (PA) assess and treat their child and the waiting time reduction sufficient for them to choose to receive treatment by a PA rather than wait for a physician.Method:After describing the training and scope of practice of PAs, we asked caregivers of children triaged as urgent to nonurgent if they would be willing to have their child assessed and treated by a PA on that visit: definitely, maybe, or never. We also asked the minimum amount of waiting time reduction they would want to see before choosing to receive treatment by a PA rather than wait for a physician.Result:We approached 320 eligible subjects, and 273 (85.3%) consented to participate. Regarding whether they would be willing to have their child receive treatment by a PA, 140 (51.3%) respondents answered definitely, 107 (39.2%) said maybe, and 26 (9.2%) said never. Most respondents (64.1%) would choose to have their child seen by a PA instead of waiting for a physician if the waiting time reduction were at least 60 minutes (median 60 minutes [interquartile range 60 minutes]). Respondents' perception of the severity of their child's condition was associated with unwillingness to receive treatment by a PA, whereas child's age, presenting complaint, and actual waiting time were not.Conclusion:Only a small minority of parents of children visiting a pediatric emergency department for urgent to nonurgent issues are unwilling to have their child treated by PAs.
Cardiopulmonary resuscitation and automatic external defibrillator training in schools: “Is anyone learning how to save a life?”
Authors: Hart Devin , Flores-Medrano Oscar , Brooks Steve , Buick Jason E. , Morrison Laurie J. 
Published: July 2016

ABSTRACTObjectives:Bystander resuscitation efforts, such as cardiopulmonary resuscitation (CPR) and use of an automatic external defibrillator (AED), save lives in cardiac arrest cases. School training in CPR and AED use may increase the currently low community rates of bystander resuscitation. The study objective was to determine the rates of CPR and AED training in Toronto secondary schools and to identify barriers to training and training techniques.Methods:This prospective study consisted of telephone interviews conducted with key school staff knowledgeable about CPR and AED teaching. An encrypted Web-based tool with prespecified variables and built-in logic was employed to standardize data collection.Results:Of 268 schools contacted, 93% were available for interview and 83% consented to participate. Students and staff were trained in CPR in 51% and 80% of schools, respectively. Private schools had the lowest training rate (39%). Six percent of schools provided AED training to students and 47% provided AED training to staff. Forty-eight percent of schools had at least one AED installed, but 25% were unaware if their AED was registered with emergency services dispatch. Cost (17%), perceived need (11%), and school population size (10%) were common barriers to student training. Frequently employed training techniques were interactive (32%), didactic instruction (30%) and printed material (16%).Conclusions:CPR training rates for staff and students were moderate overall and lowest in private schools, whereas training rates in AED use were poor in all schools. Identified barriers to training include cost and student population size (perceived to be too small to be cost-effective or too large to be implemented). Future studies should assess the application of convenient and cost-effective teaching alternatives not presently in use.
Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users?
Authors: Scheuermeyer Frank Xavier , Andolfatto Gary , Qian Hong , Grafstein Eric 
Published: July 2016

ABSTRACTObjectives:Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) as part of emergency department (ED) treatment. We compared adverse events (AEs) using a variety of sedation regimens.Methods:This was a retrospective analysis of a PSA safety audit in two urban EDs. Consecutive self-reported IDUs were identified, and structured data describing comorbidities, vital signs, sedation regimens (propofol [P], propofol-fentanyl [PF], fentanyl-midazolam [FM], ketofol [1:1 ketamine:propofol, KF], and ketamine-propofol [KP]) and AEs were collected. The primary outcome was the proportion of patients in each sedation group having an AE; the secondary outcome was the proportion of patients having a cardiovascular or respiratory AE.Results:Data were collected on 276 IDUs (78 P, 82 PF, 65 FM, 25 KF, and 26 KP), and 18 patients had AEs (6.5%, 95% CI 4.0–10.3). The AE rates were 0.0%, 8.5%, 9.2%, 12.0%, and 7.6%, respectively, with propofol having a significantly lower rate (Pearson coefficient 14.9,p= 0.007). The cardiovascular/respiratory AE rates were significantly different as well, with P, KP, and KF having the lowest rates (Pearson coefficient 13.3,p= 0.01).Conclusions:For IDU PSA, the overall AE rate was 6.5%, and propofol appeared to have a significantly lower rate.
Unfavourable outcome for children leaving the emergency department without being seen by a physician
Authors: Gravel Jocelyn , Gouin Serge , Carrière Benoit , Gaucher Nathalie , Bailey Benoit 
Published: July 2016

ABSTRACTObjective:To assess the prevalence of an unfavourable outcome among children leaving without being seen by a physician in the emergency department (ED).Method:This was a prospective cohort study conducted over a complete year in a pediatric tertiary care ED. A random sample of all children younger than 19 years of age who left without being seen by a physician was contacted by phone 4 to 6 days following the ED visit. The primary outcome was the occurrence of an unfavourable outcome prospectively defined using a Delphi method among 15 pediatric emergency physicians. An unfavourable outcome was defined as hospitalization, the need for an invasive procedure (intravenous or intramuscular medication, fracture reduction, bone casting, or surgical intervention), suicide attempt, or death in the 72 hours following leaving without being seen by a physician. As a secondary outcome, multiple potential predictors were evaluated. The first analysis evaluated the proportion of unfavourable outcomes among children who left without being seen by a physician. Then logistic regression identified predictors of unfavourable outcomes.Results:During the study period, 61,909 children presented to the ED, 7,592 (12%) left without being seen by a physician, and 1,579 were recruited. Thirty-eight (2.4%; 95% CI 1.7–3.2) patients fulfilled the criteria for an unfavourable outcome. On multiple logistic regression, chief complaints related to trauma and absence of nurse counseling had higher risks of unfavourable outcome.Conclusions:Approximately 2% of children who left without being seen by a physician at a tertiary care pediatric ED had an unfavourable outcome.
Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency
Authors: Lee Patricia A. , Rowe Brian H. , Innes Grant , Grafstein Eric , Vilneff Renee , Wang Dongmei , van Rheenen Susan , Lang Eddy 
Published: July 2016

ABSTRACTObjectives:Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay.Methods:We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks.Results:The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82–239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485–1,274 minutes). The median CRT was 55 minutes (IQR 21–115 minutes), and the median DMI was 58 minutes (IQR 25–126 minutes). The CII measured 26% (95% CI 23–28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations.Conclusion:The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.
Streptococcus pneumoniae–induced purpura fulminans in a woman with functional asplenia
Authors: Wojtowicz Jeremy M. , Jones Graham Longden 
Published: July 2016

ABSTRACTPurpura fulminans is a rare complication of septic shock, often associated withStreptococcus pneumoniae. Patients with anatomic or functional asplenia are at increased risk for infection because of impairment of their ability to defend against encapsulated pathogens. We report the case of a previously healthy, unimmunized 33-year-old female with functional asplenia who presented in septic shock and purpura fulminans and died in spite of maximal resuscitative measures. The clinical presentation, diagnosis, and management of purpura fulminans are reviewed. Purpura fulminans is a rare condition that requires early diagnosis and aggressive management by emergency physicians.
Teaching the RAPID approach at the start of emergency medicine clerkship: an evaluation
Authors: Woods Robert A. , Trinder Krista , D’Eon Marcel , McAleer Sean 
Published: July 2016

ABSTRACTBackground:The RAPID approach (Resuscitation, Analgesia and assessment, Patient needs, Interventions, Disposition) was developed as an approach to managing emergency department patients. It is a mental checklist to help trainees provide comprehensive care, addressing issues in priority. Its impact on trainee performance has not been assessed.Methods:Forty-two clerkship students were enrolled, with 21 students in each group. They received or did not receive the teaching intervention on an alternate basis. Students were assessed through daily encounter cards, a case presentation, a self-assessment form, a prerotation case (case E), and a sixcase short-answer exit examination (cases A to F) with case E repeated. Case E was designed specifically to assess students’ ability to provide comprehensive care. Fourteen students participated in focus groups.Results:Students in the intervention group had significantly higher exit examination case E scores (11.67 of 14 v. 10.26 of 14, p 5 0.008) and improvement in their case E scores from pre- to postrotation (1.82 v. 0.26, p 5 0.006). There were no significant differences in the other outcome measures. Intervention group students made positive comments around analgesia, addressing nonmedical needs and counseling on health promotion during focus groups.Conclusions:Students exposed to the RAPID approach at the start of their emergency medicine rotation performed better on the one component of the written examination for which it was designed to improve performance. Students found it to be a useful mental checklist for comprehensive care, possibly addressing the hidden curriculum. Emergency medicine educators should consider further study and careful implementation of the RAPID approach.
Socioeconomic status of emergency department users in Ontario, 2003 to 2009
Authors: Tozer April P. , Belanger Paul , Moore Kieran , Caudle Jaelyn 
Published: July 2016

ABSTRACTObjective:Emergency department (ED) overcrowding in Canada is an ongoing problem resulting in prolonged wait times, service declines, increased patient suffering, and adverse patient outcomes. We explored the relationship between socioeconomic status (SES) and ED use in Canada's universal health care system to improve our understanding of the nature of ED users to both improve health care to the most deprived populations and reduce ED patient input.Methods:This retrospective study took information from the National Ambulatory Care Reporting System (NACRS) database for all ED visits in Ontario between April 1, 2003, and March 31, 2010. As there is no direct measure of SES available from ED visit records, a proxy measure of SES was used, namely a deprivation index (DI) developed from material and social factors from the 2006 Canadian census using the patient's residential neighbourhood. DI scores were assigned to ED visit records using Statistics Canada's Postal Code Conversion File, which links postal and census geography.Results:A total of 36,765,189 visits occurred during the study period. A cross-province trend was found wherein the most deprived population used EDs disproportionately more than the least deprived population (relative risk: 1.971 95% confidence interval 1.969–1.973,p&lt; 0.0001). This trend was stable across the entire study period, although the divergence is attenuating.Conclusion:Social determinants of health clearly impact ED use patterns. People of the lowest SES use ED services disproportionately more than other socioeconomic groups. Focused health system planning and policy development directed at optimizing health services for the lowest SES populations are essential to changing ED use patterns and may be one method of decreasing ED overcrowding.
Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice
Authors: Ahn Justin S. , Edmonds Marcia L. , McLeod Shelley L. , Dreyer Jonathan F. 
Published: July 2016

ABSTRACTObjective:To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE).Methods:An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs.Results:The survey response rate was 72.1% (31 of 43 physicians). For patients &lt; 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5–2.9]) and in patients &lt; 30 years old (87.9% v. CTPA 12.1% [OR 4.8; 95% CI 2.4–9.4]).Conclusions:Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution.
Holocord spinal epidural abscess in a pregnant patient presenting as premature labour: a rare presentation of an unusual diagnosis
Authors: Burton Kirsteen R. , Wang Xi , Dhanoa Deljit 
Published: July 2016

ABSTRACT
Spinal epidural abscess (SEA) is a rare clinical entity. It is less common when the entire epidural space is involved, known as a holocord or panspinal SEA, and it is even less common in a pregnant patient. We report a case of methicillin-resistant Staphylococcus aureus holocord SEA in a 30-year-old female at approximately 22 weeks' gestational age who presented with lumbar pain and pelvic pressure and the urge to bear down. Magnetic resonance imaging of the spine demonstrated extensive SEA and meningitis from the foramen magnum to the lumbar spine that was treated both medically and surgically. The incidence of, clinical presentation of, and risk factors for developing SEA are discussed. If untreated, expanding SEAs produce sensory symptoms and signs, motor dysfunction, and, eventually, paralysis and death. The medical and surgical management of SEA is also discussed. SEA can have an insidious and atypical presentation despite
extensive involvement of the epidural space. Therefore, the diagnosis of SEA should always be considered in patients who present to the emergency department with back pain.
Preparedness of urban, general emergency department staff for neonatal resuscitation in a Canadian setting
Authors: Kester-Greene Nicole , Lee Jacques S. 
Published: July 2016

ABSTRACTObjectives:The level of expertise and degree of training in neonatal resuscitation (NNR) of emergency physicians is not standardized and has not been measured. We sought to determine the self-reported comfort with, knowledge of, and experience with NNR of emergency department (ED) staff in a general ED prior to the opening of a new neonatal intensive care unit (NICU) and to explore factors associated with NNR comfort.Methods:Using Dillman methodology, we electronically surveyed full-time emergency physicians and nurses. Participants rated knowledge, comfort, and experience on 5-point Likert scales. We used logistic regression to explore factors associated with NNR comfort.Results:The response rate was 67.3% (n = 107). Only 4.2% of staff reported ever participating in a NNR, and only 38.7% reported any previous NNR training. Between 75 and 85% of participants rated their comfort level in caring for neonates, sense of preparedness, and knowledge of managing a sick neonate as poor or very poor. A recent neonatal clinical encounter was the strongest predictor of perceived comfort in NNR (OR = 22.2, 95% CI 5.0-98.7), as was completion of the Neonatal Resuscitation Provider (NRP) course (OR = 3.1, 95% CI 1.4-7.0).Conclusions:Perceived comfort with, knowledge of, and preparedness for NNR were poor in an urban, general ED prior to the opening of an NICU. Recent neonatal clinical encounter and participation in the NRP course were the strongest predictors of improved NNR comfort. In future work, we intend to assess the impact of simulation-based training on comfort with NNR among ED staff who primarily treat adults.
Point-of-care ultrasonography adoption in Canada: using diffusion theory and the Evaluation Tool for Ultrasound skills Development and Education (ETUDE)
Authors: Woo Michael Y. , Frank Jason R. , Lee A. Curtis 
Published: July 2016

ABSTRACTObjective:Point-of-care ultrasonography (PoCUS) first appeared in the 1980s in North America, but the extent of the diffusion of its adoption is unknown. We characterized early PoCUS adoption by emergency physicians in Canada and its barriers to use using Rogers' diffusion of innovations theory.Methods:We developed a questionnaire based on a pilot study and literature review to assess past, current, and potential use of PoCUS and potential barriers to adoption. A Dillman technique for electronic surveys was used for dissemination. Using Rogers' diffusion of innovations theory, we developed and validated the Evaluation Tool for Ultrasound skills Development and Education (ETUDE). ETUDE scores allowed categorization of respondents into innovators, early adopters, majority, and nonadopters. Descriptive statistics, correlations, and x2statistics were used to analyze the data.Results:The 296 respondents (36.4% of 814 surveyed) had a median age of 40 and were 72.5% male. Adoption scores using ETUDE revealed nonadopters (18.8%), majority (28.7%), early adopters (34.5%), and innovators (18.0%). Respondents endorsed “always” using PoCUS currently and in the future for focused assessment with sonography in trauma (FAST) (current 41.8%/future 88.4%), first trimester pregnancy (current 23.3%/future 73.7%), suspected abdominal aortic aneurysm (current 32.7%/future 92.6%), basic cardiac indications (current 30.7%/future 87.5%), and central venous catheterization (current 17.0%/future 80.3%). Several barriers to PoCUS were identified for part-time emergency physicians and those working in inner-city/urban/suburban settings.Conclusion:This is the first study to determine the state of adoption and barriers to the introduction of PoCUS in Canadian emergency medicine practice. The novel validated ETUDE instrument should be used to evaluate the uptake of PoCUS over time.
Trends in use in a Canadian pediatric emergency department
Authors: Doan Quynh , Genuis Emerson D. , Yu Alvis 
Published: July 2016

ABSTRACTIntroduction:Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED.Methods:A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS).Results:Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year.Conclusions:Over the course of the study period, there was a substantial increase in PED visits,which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.