bluuebunny/crossref_metadata_2025_split huggingface dataset:
Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre–post intervention study
Authors: Abbass Allan , Campbell Samuel , Magee Kirk , Tarzwell Robert 
Published: July 2016

ABSTRACTObjective:Somatization of emotions accounts for excess emergency department (ED) visits in the form of medically unexplained symptoms (MUS). Intensive short-term dynamic psychotherapy (ISTDP) has been used to diagnose and manage somatization. We examined the effectiveness of this procedure for ED patients with MUS.Methods:We implemented a service that included staff education, timely access to consultation and gathering of outcome data.Results:Patients were assessed and treated shortly after referral. There was a mean reduction of 3.2 (69.0%) ED visits per patient (standard deviation [SD] 6.4) the year afterward (95% confidence interval [CI] 1.3–5.0,p&lt; 0.001). In comparison revisit rates during the same time interval for 3 available ED populations (i.e., those matched by visit rates, those with matching complaints and all patients referred to the service but never seen) showed either smaller reductions or higher ED use (ranging from a 15% reduction to a 43% increase). Treatments averaged 3.8 sessions per patient (SD 5.3). Self-reported symptoms improved significantly with the Brief Symptom Inventory global rating, which changed from a mean of 1.21 (SD 0.58) before assessment to 0.86 (SD 0.63) (p&lt; 0.01) at the end of contact with the service. The service appeared acceptable to both emergency physicians and patients.Conclusion:This emotion-focused assessment and treatment method appeared to be feasible and may be effective in reducing both symptoms and repeat ED use.
International partnerships to foster growth in emergency medicine in Romania
Authors: Krym Valerie F. , Retezar Rodica , Scott Steve 
Published: July 2016

ABSTRACT
Emergency medicine (EM) is a growing specialty internationally, but has yet to be cultivated in countries with otherwise advanced health care systems. To promote the growth of EM, emergency physicians from countries where EM is a mature specialty can assist with knowledge transfer and development of emergency medical systems to make a lasting impact on the community served. We present our experience in assisting the development of emergency medicine in a university-affiliated regional hospital in Romania.
The International Emergency Medicine Fellowship program at the University of Toronto established links in Cluj-Napoca, Romania, in order to provide expertise and assist local leadership to stimulate growth in EM. In October 2005, a 3-member team travelled to Cluj-Napoca to provide input on how to best use a new physical plant, to deliver continuing education to physicians and nurses, and to help establish long-term development goals. The team identified the following priorities through a comprehensive needs assessment: physical plant organization and patient flow, staffing, staff education, equipment, medication and supplies, and infection control practices. In conjunction with local counterparts, a plan was developed addressing each priority.
Staff, hospital administration and university officials report positive growth in EM as a result of the collaboration. Further work is underway to implement the plan, including international exchange trips to promote mutual growth between partners.
Effect of online medical control on prehospital Code Stroke triage
Authors: Verma Aikta , Gladstone David J. , Fang Jiming , Chenkin Jordan , Black Sandra E. , Verbeek P. Richard 
Published: July 2016

ABSTRACT

Objective:
Prehospital Code Stroke triage has the potential to overwhelm stroke centres by falsely identifying patients as eligible for fibrinolysis. We sought to determine whether online medical control (whereby paramedics contact the medical control physician before a Code Stroke triage is assigned) reduced the proportion of false-positive Code Stroke patients.

Methods:
Following the introduction of a protocol for prehospital Code Stroke triage in an urban centre, online medical control alternated with off-line medical control (whereby paramedics implement Code Stroke triage independently) over 4 discreet intervals. We reviewed data for patients triaged to 3 regional stroke centres to compare the proportion of false-positive Code Stroke patients during online versus off-line medical control. We predefined false positives as patients triaged as Code Stroke who had symptoms discovered on awakening, were last seen in their usual state of health greater than 2 hours before assessment or had a final diagnosis other than stroke.

Results:
The proportion of false positives was lower during online medical control (31% v. 42%, p = 0.003). This was explained by a lower proportion of patients whose symptoms were discovered on awakening (8% v. 14%, p &lt; 0.001) and who were last seen in their usual state of health greater than 2 hours before assessment (22% v. 32%, p = 0.005). A final diagnosis of stroke was similar in the 2 groups (77% v. 79%, p = 0.39), as was the proportion of patients receiving fibrinolysis (35% v. 33%, p = 0.72). Eighteen percent of patients were denied Code Stroke triage during online control, most commonly because of the time of symptom onset.

Conclusion:
Online medical control is associated with a reduced proportion of false-positive Code Stroke triage.
Evaluation of the Prehospital Index, presence of high-velocity impact and judgment of emergency medical technicians as criteria for trauma triage
Authors: Lavoie Andre , Émond Marcel , Moore Lynne , Camden Stéphanie , Liberman Moishe 
Published: July 2016

ABSTRACTObjective:We sought to evaluate the performance of the Prehospital Index (PHI), the high-velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients.Methods:The study population included all prehospital trauma patients transported by an emergency medical service to 2 level-I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage.Results:Of 16 805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score ≥ 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the lowest rate of overtriage.Conclusion:Although the combination of PHI score, HVI presence and EMT judgment offers the highest sensitivity for the identification of patients that could benefit from direct transport to a level-I trauma centre, overall sensitivity remains low and overtriage is high. More research is required to improve prehospital triage.
Mentoring in emergency medicine: the art and the evidence
Authors: Yeung Marianne , Nuth Janet , Stiell Ian G. 
Published: July 2016

ABSTRACTA mentor is a person who takes a special interest in the professional development of a junior colleague and provides guidance and support. Mentoring can be beneficial for students, residents, junior colleagues and researchers and can be very rewarding for the physician who provides this guidance. Although mentoring is a well-recognized topic in academic medicine, relatively little has been written about mentoring in emergency medicine (EM). Consequently, we conducted a literature review on mentoring in EM and present our findings in this paper. We discuss different models of mentoring, factors that foster the development of strong mentorship programs, the responsibilities of mentors and mentees, and issues specific to mentorship of female, minority and research physicians. We also present several case scenarios as a basis for recommendations for teachers and learners in EM.
Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter
Authors: Stiell Ian G. , Clement Catherine M. , Perry Jeffrey J. , Vaillancourt Christian , Symington Cheryl , Dickinson Garth , Birnie David , Green Martin S. 
Published: July 2016

ABSTRACTObjective:There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.Methods:This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.Results:A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procaïnamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procaïnamide and 6.5 hours for those requiring electrical conversion.Conclusion:This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.
The utility of renal ultrasonography in the diagnosis of renal colic in emergency department patients
Authors: Edmonds Marcia L. , Yan Justin W. , Sedran Robert J. , McLeod Shelley L. , Theakston Karl D. 
Published: July 2016

ABSTRACTObjective:Computed tomography (CT) is an imaging modality used to detect renal stones. However, there is concern about the lifetime cumulative radiation exposure attributed to CT. Ultrasonography (US) has been used to diagnose urolithiasis, thereby avoiding radiation exposure. The objective of this study was to determine the ability of US to identify renal colic patients with a low risk of requiring urologic intervention within 90 days of their initial emergency department (ED) visit.Methods:We completed a retrospective medical record review for all adult patients who underwent ED-ordered renal US for suspected urolithiasis over a 1-year period. Independent, double data extraction was performed for all imaging reports and US results were categorized as “normal,” “suggestive of ureterolithiasis,” “ureteric stone seen” or “disease unrelated to urolithiasis.” Charts were reviewed to determine how many patients underwent subsequent CT and urologic intervention.Results:Of the 817 renal US procedures ordered for suspected urolithiasis during the study period, the results of 352 (43.2%) were classified as normal, and only 2 (0.6%) of these patients required urologic intervention. The results of 177 (21.7%) renal US procedures were suggestive of ureterolithiasis. Of these, 12 (6.8%) patients required urologic intervention. Of the 241 (29.5%) patients who had a ureteric stone seen on US, 15 (6.2%) required urologic intervention. The rate of urologic intervention was significantly lower in those with normal results on US (p&lt; 0.001) than in those with abnormal results on US.Conclusion:A normal result on renal US predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected urolithiasis.
Effect of an emergency department sepsis protocol on time to antibiotics in severe sepsis
Authors: Francis Marc , Rich Tom , Williamson Tyler , Peterson Daniel 
Published: July 2016

ABSTRACTObjective:We sought to evaluate the time to antibiotics for emergency department (ED) patients meeting criteria for severe sepsis before and after the implementation of an ED sepsis protocol. Compliance with published guidelines for time to antibiotics and initial empiric therapy in sepsis was also assessed.Methods:A retrospective chart review was conducted. Emergency department patient encounters with International Classification of Diseases codes related to severe infections were screened during a 3-month period before and after the implementation of a sepsis protocol. Encounters meeting criteria for severe sepsis were further assessed. The time to initiation of antibiotics was determined as well as the initial choice of antimicrobial therapy based on the presumed source of infection.Results:We reviewed 213 unique ED patient encounters meeting criteria for severe sepsis. Analysis of the period before implementation showed a median time from the time criteria for severe sepsis were met to delivery of antibiotics of 163 minutes (95% confidence interval [CI] 124 to 210 min). Analysis of the period after implementation of the protocol revealed a median time of 79 minutes (95% CI 64 to 94 min), representing an overall reduction of 84 minutes (95% CI 42 to 126 min). Before the implementation of the protocol, 47% of patients received correct antibiotic coverage for the presumed source of infection in compliance with locally published guidelines. After the initiation of the protocol, 73% received appropriate initial antibiotics, for an overall improvement of 26%.Conclusion:A guideline-based ED sepsis protocol for the evaluation and treatment of the septic patient appears to improve the time to administration of antibiotics as well as the appropriateness of initial antibiotic therapy in patients with severe sepsis.
A stone down below: a urethral stone causing acute urinary retention and renal failure
Authors: Bielawska Hanna , Epstein Norman L. 
Published: July 2016

ABSTRACTImpaction of a kidney stone in the male urethra is a rare sequela of an otherwise common disease process. Case reports of urethral stones in the recent literature are scarce. We report a case of a 48-year-old man who presented with an impacted urethral stone as a complication of nephrolithiasis. The pathology was twice missed, even with computed tomography showing the stone in the prostatic urethra, which highlights the challenges of making this diagnosis. We review the existing literature outlining the pathogenesis, clinical features and therapeutic considerations as they relate to urethral stones. We underscore the role of the emergency physician in the diagnosis and initial management of this entity, and draw attention to the need to evaluate not just the upper but also the lower genitourinary tracts when interpreting computed tomographic images obtained for the diagnosis of renal colic.
Dilute proparacaine for the management of acute corneal injuries in the emergency department
Authors: Michael Ball Ian , Seabrook Jamie , Desai Nimesh , Allen Larry , Anderson Scott 
Published: July 2016

ABSTRACTObjective:Dogma discourages the provision of topical anesthetics to patients with corneal injuries discharged from the emergency department because of the toxicity of concentrated solutions. We compared the analgesic efficacy of dilute topical proparacaine with placebo in emergency department patients with acute corneal injuries.Methods:We conducted a prospective randomized controlled trial of adults with corneal injuries presenting to one of 2 tertiary care emergency departments in London, Ont. Patients were randomly assigned to groups receiving either 0.05% proparacaine or placebo drops as outpatients and were followed up to healing by a single ophthalmologist. Our primary outcome was pain reduction as measured on a 10-cm visual analog scale.Results:Fifteen participants from the proparacaine group and 18 participants from the placebo group completed the study. The mean age of the patients was 38.7 (standard deviation 12.3) years and the majority were male (85%). Pain reduction was significantly better in the proparacaine group than in the placebo group, with a median improvement of 3.9 (interquartile range [IQR] 1.5–5.1 ) cm on the visual analog scale versus a median improvement of 0.6 (IQR 0.2–2.0) cm (p= 0.007). The proparacaine group was more satisfied (median level of satisfaction 8.0 [IQR 6.0–9.0] cm on a 10-cm visual analog scale v. 2.6 [IQR 1.0–8.0] cm,p= 0.027). There were no ocular complications or signs of delayed wound healing in either group.Conclusion:Dilute topical proparacaine is an efficacious analgesic for acute corneal injuries. Although no adverse events were observed in our study population, larger studies are required to evaluate safety.
Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey
Authors: Friedman Steven Marc , Sowerby Robert J. , Guo Ray , Bandiera Glen 
Published: July 2016

ABSTRACTObjective:We sought to characterize the perceptions of emergency medicine (EM) residents and fellows of their clinical and procedural competence, as well as their attitudes, practices and perceived barriers to reporting these perceptions to their supervisors.Methods:A Web-based survey was distributed to residents and fellows, via their residency directors, in all Canadian EM residency programs outside of Quebec.Results:Of 220 residents and fellows contacted in 9 of 10 EM programs of the Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of The College of Family Physicians of Canada, 82 (37.3%) completed all or part of the survey. Response rates varied slightly by question; 25 of 82 respondents (30.5% [95% confidence interval (CI) 19.9%–41.1%]) agreed with the statement, “I sometimes feel unsafe or unqualified with undertaking unsupervised responsibilities or procedures, but I do not report this to my senior physician” and 32 of 81 (39.5% [95% CI 28.2%–50.8%]) had felt this within the past 6 months. Moreover, 34 of 82 (41.5% [95% CI 30.2%–52.7%]) reported their lack of competence to a supervisor half the time or less. Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%–59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%–51.4%]). Nights on-call (30/79, 38% [95% CI 26.6%–49.3%]), admission decisions (13/79, 16.5% [7.6%–25.3%]) and central line insertion (13/79, 16.5% [95% CI 7.6%–25.3%]) were reported to be frequently undertaken despite not feeling competent. Suggestions to improve reporting included encouragement to report without penalty (41/82, 50.0% [95% CI 38.6%–61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI 27.9%–50.2%]).Conclusion:Emergency medicine trainees report that they frequently do not feel competent when undertaking responsibilities without supervision. Barriers to reporting these feelings or reporting adverse events appear to relate to social pressures and authority gradients. Modifications to the training culture are encouraged to improve patient safety.
Hypothermic modulation of anoxic brain injury in adult survivors of cardiac arrest: a review of the literature and an algorithm for emergency physicians
Authors: Green Robert S. , Howes Daniel 
Published: July 2016

ABSTRACT
Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously identified. Recent studies show that induced hypothermia reduces mortality and improves neurological outcomes in patients resuscitated from ventricular fibrillation. This article reviews the literature on induced hypothermia for anoxic brain injury and summarizes a treatment algorithm proposed by the Canadian Association of Emergency Physicians Critical Care Committee for hypothermia induction in cardiac arrest survivors.
Vasopressin versus epinephrine for out–of–hospital cardiopulmonary resuscitation
Authors: Worster Andrew , Upadhye Suneel , Fernandes Christopher M.B. 
Published: July 2016

Clinical questionDoes the use of vasopressin for adult patients suffering a non-traumatic, out-of-hospital cardiac arrest improve the rates of survival to hospital admission (and discharge) better than epinephrine?
A survey to describe sleep-facilitating substances used by Canadian emergency physicians
Authors: Bailey Benoit , Alexandrov Lubomir 
Published: July 2016

ABSTRACTBackground:Because night shifts disrupt the normal circadian rhythm, sleep management is crucial for emergency physicians. The purpose of the survey was to describe the use of sleep-facilitating substances (SFSs) by emergency physicians before or after a night shift and to evaluate factors associated with their use.Methods:All members of the Canadian Association of Emergency Physicians with a Canadian postal address were mailed a copy of the survey. Canadian physicians were eligible if they worked at least one night shift per month and spent 50% or more of their time in emergency medicine. Logistic regression was used to identify characteristics most predictive of using SFSs before or after a night shift.Results:Of the 1621 surveys mailed, 805 were returned completed, for a response rate of 49.6%. Of these, 628 respondents met inclusion criteria and 215 respondents (34%) reported consuming at least one SFS in their career to help them sleep around a night shift. The use of an SFS before a night shift was associated with the use of SFSs after a night shift (odds ratio [OR] 3.8; 95% confidence interval [CI] 2.4–5.9) and the use of SFSs at other times (OR 3.8; 95% CI 2.1–6.6). The use of SFSs after a night shift was associated with the use of a sleep-facilitating technique before a night shift (OR 2.1; 95% CI 1.3–3.3); use of an SFS before a night shift (OR 4.0; 95% CI 2.4–6.4); use of SFSs at other times (OR 4.7; 95% CI 2.6–8.4); and success of a nap before the night shift (OR 0.46; 95% CI 0.25–0.83).Conclusion:The rate of SFS use is similar in emergency physicians and other shift workers. Emergency physicians who use SFSs before or after a night shift are more likely to use them at other times as well, and less likely to use them if they nap successfully prior to a night shift.