bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prospective time study derivation of emergency physician workload predictors
Authors: Innes Grant D. , Stenstrom Robert , Grafstein Eric , Christenson James M. 
Published: July 2016

ABSTRACT

Background:
A reliable emergency department (ED) workload measurement tool would provide a method of quantifying clinical productivity for performance evaluation and physician incentive programs; it would enable health administrators to measure ED outputs; and it could provide the basis for an equitable formula to estimate ED physician staffing requirements. Our objectives were to identify predictors that correlate with physician time needed to treat patients and to develop a multivariable model to predict physician workload.

Methods:
During 31 day, evening, night and weekend shifts, a research assistant (RA) shadowed 20 emergency physicians, documenting time spent performing clinical and non-clinical functions for 585 patient visits. The RA recorded key predictors including patient gender, age, vital signs and Glasgow Coma Scale (GCS) score, and the mode of arrival, triage level assigned, comorbidity and procedures performed. Multiple linear regression was used to describe the associations between predictor variables and total physician time per patient visit (TPPV), and to derive an equation for physician workload. Model derivation was based on 16 shifts and 314 patient visits; model validation was based on 15 shifts and 271 additional patient visits.

Results:
The strongest predictor variables were: procedure required, triage level, arrival by ambulance, GCS, age, any comorbidity, and number of prior visits. The derived regression equation is: TPPV = 29.7 + 8.6 (procedure required [Yes]) – 3.8 (triage level [1–5]) + 7.1 (ambulance arrival) – 1.1 (GCS [3–15]) + 0.1 (age in years) – 0.05 (n of previous visits) + 3.1 (any comorbidity). This model predicted 31.3% of the variance in physician TPPV (F [12, 29] = 13.2; p &lt; 0.0001).

Conclusions:
This study clarifies important determinants of emergency physician workload. If validated in other settings, the predictive formula derived and internally validated here is a potential alternative to current simplistic models based solely on patient volume and perceived acuity. An evidence-based workload estimation tool like that described here could facilitate ED productivity measurement, benchmarking, physician performance evaluation, and provide the substrate for an equitable formula to estimate ED physician staffing requirements.
Dog bites in Canadian children: a five-year review of severity and emergency department management
Authors: Lang Mia E. , Klassen Terry 
Published: July 2016

ABSTRACTObjectives:Dog bites are a common problem. The purpose of this study was to determine the characteristics of dog bites and their emergency department management in a Canadian pediatric population, and to provide treatment and prevention recommendations.Methods:The charts of all children ≤ 16 years of age presenting with a dog bite to either of the 2 tertiary emergency departments in Edmonton, Alberta, between 1998 and 2002 were retrospectively reviewed.Results:Overall, 287 cases were reviewed; 145 boys (50.5%) and 142 girls (49.5%). The mean age was 7.4 years. The patient's face was the most frequently bitten site (58.5%,n= 168), followed by an extremity (35.5%,n= 102). Most bites required sutures (54.5%,n= 155), and 72 (25.1%) were classified as severe, based on suture number (&gt;10 sutures,n= 69), associated fractures (n= 4), operating room repair (n= 21) or fatality (n= 1). The mean age of children with severe bites was significantly lower than children with mild bites (6.3 v. 7.8 yr,p&lt; 0.01). Most patients were treated solely in the emergency department (84.7%,n= 243); however 44 (15.3%) were admitted to hospital and required a total of 144 days of inpatient care. Signs of infection were described in 16 cases (5.6%); of these 8 had received 2 or more prior doses of antibiotics. Public health or police notification was documented in 56 cases (19.5%), and safety or preventive discussion was documented in 3 cases (1.0%).Conclusions:Dog bites in Canadian children are common, often serious or even lethal, and not always managed ideally. Preventive discussion and public health contact is infrequently documented and likely seldom occurs. In addition to medical care, emergency department staff should provide and document preventive guidance and ensure involvement of public health or police when indicated.
Spinal epidural abscess
Authors: Louis Amy , Fernandes Christopher M.B. 
Published: July 2016

ABSTRACT
Spinal epidural abscess is an uncommon condition. Predisposing factors include spinal surgery, recent trauma, immunosuppression, a distal site of infection and intravenous drug use; however, these are not always present, as illustrated by this case report describing a patient who had repeated emergency department visits and delayed diagnosis that was ultimately confirmed via magnetic resonance imaging.
Minimally angulated pediatric wrist fractures: Is immobilization without manipulation enough?
Authors: Al-Ansari Khalid , Howard Andrew , Seeto Brian , Yoo Solina , Zaki Salma , Boutis Kathy 
Published: July 2016

ABSTRACT

Background:
Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures.

Objectives:
The primary objective of this study was to determine the proportion of minimally angulated distal radius fractures managed in the ED with plaster immobilization that subsequently required manipulation. Our secondary objective was to document, at follow-up, changes in angulation for each wrist fracture.

Methods:
This retrospective cohort study reviewed consecutive records of all children with bi-cortical minimally angulated (≤15° of angulation in the sagittal plane and ≤0.5 cm of displacement) distal metaphyseal radius fractures, alone or in combination with distal ulnar fracture. Details of treatment, radiographic findings, and clinical outcomes during the subsequent orthopedic follow up were recorded.

Results:
Of 124 patients included in the analysis, none required manipulation after their ED visit. All but 14 (11.3%) fractures were angulated ≤20° within the follow-up period. Two (1.6%) fractures that were initially angulated ≤15° progressed to 30°–35°, but remodeled within 2 years to nearly perfect anatomic alignment. By 6 weeks post-injury, no patients had clinically apparent deformity and all had normal function.

Conclusions:
Minimally angulated fractures of the distal metaphyseal radius managed in plaster immobilization without reduction in the ED are unlikely to require future surgical intervention.
Impact of a multifaceted pediatric sedation course: self-directed learning versus a formal continuing medical education course to improve knowledge of sedation guidelines
Authors: Schneeweiss Suzan , Ratnapalan Savithiri 
Published: July 2016

ABSTRACTBackground:Procedural sedation guidelines were established for a tertiary care pediatric emergency department (ED). We developed a pediatric procedural sedation course to disseminate these guidelines.Objective:Our objective was to evaluate the effectiveness of a sedation course in improving physicians' knowledge of pediatric procedural sedation practices and guidelines, relative to individual self-directed learning.Methods:We recruited emergency staff physicians and fellows as well as fourth-year pediatric residents in a tertiary care pediatric ED to participate in a randomized, controlled, educational intervention. All consenting physicians received pediatric sedation educational material for individual study 2 weeks before a learning assessment. Participants were randomly assigned to one of 2 groups. The self-directed learning group (n= 24) completed a multiple-choice examination without receiving any formal teaching. The study group (n= 24) participated in a 4-hour formal multi-faceted sedation course before writing the multiple-choice examination.Results:The groups did not differ significantly in demographic characteristics or self-perceived knowledge of pediatric sedation. The formal teaching group's median examination score (83.3%; range 75.8%–96.5%) was significantly higher (p&lt; 0.0001) than the median examination score of participants in the self-directed study group (73.3%, range 43.5%–86.6%).Conclusion:The multifaceted sedation course was more effective in improving physician knowledge and understanding of sedation guidelines and practices than unstructured, self-directed learning.
Identification and correction of guide wire malposition during internal jugular cannulation with ultrasound
Authors: Stone Michael B. 
Published: July 2016

ABSTRACT
Real-time ultrasound guidance for central venous catheterization increases success and reduces procedural complications. I describe a case in which guide wire resistance was encountered and real-time ultrasound visualization of the guide wire facilitated correction of guide wire malposition. No additional passes of the introducer needle were necessary and the chances of inadvertent carotid artery puncture or pneumothorax were therefore reduced. The technique described here may prove valuable when guide wire resistance is encountered while placing a central venous catheter.
A case of Clostridium septicum spontaneous gas gangrene
Authors: Dylewski Joe , Drummond Robert , Rowen John 
Published: July 2016

ABSTRACT
Severe skin and soft tissue infections (SSTIs) are often life-threatening emergencies that require a rapid diagnosis. Gas gangrene is one of the most fulminant types of SSTI and is usually caused by Clostridium perfringens' contamination of an open wound.
Although gas gangrene is usually associated with fecally contaminated wounds, “spontaneous” cases occur and are most commonly caused by Clostridium (C.) septicum. We report a case of spontaneous gas gangrene caused by C. septicum that only became manifest while the patient was being monitored in the emergency department. We also review the diagnosis and treatment aspects of this entity.
Emergency department dispositions among 4100 youth injured by violence: a population-based study
Authors: Snider Carolyn E. , Lee Jacques S. 
Published: July 2016

ABSTRACTObjective:Concern about youth violence in Canada is growing. Because victims of violence are more likely to become future violent perpetrators, preventative interventions are often based out of inpatient units; however, the question of how often youth who have been injured due to violence are discharged from emergency departments (EDs), or whether there are opportunities for emergency healthcare workers to deliver violence prevention programs, is not known. The primary objectives of this study were to describe the frequency and patterns of violent injuries among youth, to determine how many injured youth are discharged directly from EDs and to estimate the proportion of injured youth who may benefit from ED-based intervention programs.Methods:We conducted an observational study using a population-based database that records information on all ED visits in Ontario. We analyzed age, sex, cause of injury and disposition for all patients aged 12–19 years who presented to Toronto EDs with violent injuries during a 2-year period (April 2002 to March 2004).Results:A total of 4100 patients aged 12–19 years visited Toronto EDs with violent injuries during the study period. Assault due to bodily force (in contrast to sharp objects, guns or other) was the most common injury mechanism, accounting for 48.7% of cases (95% confidence interval [CI] 47.1%–50.2%). The majority of patients (89.3%; 95% CI 88.3%–90.2%) were discharged directly from EDs, including 44% of gun-related injuries.Conclusion:In Toronto, a large proportion (89.3%) of youth injured in violent incidents are discharged directly from EDs. There are opportunities to develop ED-based youth violence prevention initiatives.
The effect of training on nurse agreement using an electronic triage system
Authors: Dong Sandy L. , Bullard Michael J. , Meurer David P. , Blitz Sandra , Holroyd Brian R. , Rowe Brian H. 
Published: July 2016

ABSTRACTObjectives:Emergency department (ED) triage prioritizes patients based on urgency of care, and the Canadian Triage and Acuity Scale (CTAS) is the national standard. We describe the inter-rater agreement and manual overrides of nurses using a CTAS-compliant web-based triage tool (eTRIAGE) for 2 different intensities of staff training.Methods:This prospective study was conducted in an urban tertiary care ED. In phase 1, eTRIAGE was deployed after a 3-hour training course for 24 triage nurses who were asked to share this knowledge during regular triage shifts with colleagues who had not received training (n= 77). In phase 2, a targeted group of 8 triage nurses underwent further training with eTRIAGE. In each phase, patients were assessed first by the duty triage nurse and then by a blinded independent study nurse, both using eTRIAGE. Inter-rater agreement was calculated using kappa (weighted κ) statistics.Results:In phase 1, 569 patients were enrolled with 513 (90.2%) complete records; 577 patients were enrolled in phase 2 with 555 (96.2%) complete records. Inter-rater agreement during phase 1 was moderate (weighted κ = 0.55; 95% confidence interval [CI] 0.49–0.62); agreement improved in phase 2 (weighted κ = 0.65; 95% CI 0.60–0.70). Manual overrides of eTRIAGE scores were infrequent (approximately 10%) during both periods.Conclusions:Agreement between study nurses and duty triage nurses, both using eTRIAGE, was moderate to good, with a trend toward improvement with additional training. Triage overrides were infrequent. Continued attempts to refine the triage process and training appear warranted.
Prévalence de la pneumonie chez les enfants de moins de 12 ans qui ont une radiographie abdominale à l'urgence
Authors: Homier Valérie , Bellavance Colette , Xhignesse Marianne 
Published: July 2016

RÉSUMÉObjectif:La pneumonie est une cause bien connue de douleur abdominale aiguë chez les enfants. L'utilité de la radiographie pulmonaire dans ce contexte est toutefois controversée. Nous avons cherché à déterminer la prévalence de la pneumonie chez les enfants de moins de 12 ans qui souffraient de douleur abdominale et ont eu une radiographie abdominale à l'urgence. Nous voulions aussi décrire les signes et les symptômes des enfants chez lesquels on a diagnostiqué une pneumonie dans ce contexte.Méthodes:Nous avons procédé à une analyse rétrospective des données électroniques tirées des visites effectuées à l'urgence d'un centre de soins tertiaires par des enfants de 12 ans et moins examinés entre le 1er juin 2001 et le 30 juin 2003 et qui ont eu une radiographie abdominale et pulmonaire au cours de la même visite, ou une radiographie abdominale au cours d'une première visite et une radiographie pulmonaire dans les 10 jours suivant la visite initiale.Résultats:Sur les 1584 visites étudiées, on a repéré 30 cas de pneumonie, ce qui représente une prévalence de 1,89 % (intervalle de confiance à 95 %, 1,22 %–1,56 %). Si on avait limité la radiographie pulmonaire aux enfants qui avaient de la fière, toussaient et présentaient des symptômes d'infection des voies respiratoires supérieures (IVRS), on aurait raté le diagnostic de pneumonie dans seulement 2 cas sur 1584 (0,13 %).Conclusion:Les enfants de 12 ans et moins qui se présentent à l'urgence avec une douleur abdominale aiguë et pour lesquels on demande une radiographie abdominale n'ont besoin que d'une radiographie pulmonaire s'ils toussent, ont de la fière ou présentent d'autres symptômes d'IVRS.
Physical exam myths: listening for carotid artery bruits in stroke patients
Authors: Nemeth Joe 
Published: July 2016

ABSTRACTWhen a patient presents to the emergency department with a neurologic deficit and a cerebrovascular event is included in the differential diagnosis, the classic recommendation is to examine the carotid artery and assess for the presence of a bruit. The diagnostic yield and utility of this practice has seldom been called into question. This critical appraisal will review the practice of listening for a carotid artery bruit (CAB) in suspected stroke patients and analyze its clinical utility, including the sensitivity and specificity of a CAB for detecting a significant lesion and the potential impact a CAB may have on the investigation and disposition of such patients.
Type I Monteggia lesion and associated fracture of the distal radius and ulna metaphysis in a child
Authors: Peter Noel , Myint Sein 
Published: July 2016

ABSTRACTWe report a rare case of a type I Monteggia lesion with an associated fracture of the distal radius and ulna metaphysis in a child. We discuss the mechanism of injury and the importance of thorough clinical examination in childhood injuries.
Patients presenting to the emergency department: the use of other health care services and reasons for presentation
Authors: Han Alice , Ospina Maria B. , Blitz Sandra , Strome Trevor , Rowe Brian H. 
Published: July 2016

ABSTRACT

Objective:
Some low-acuity emergency department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study assessed the frequency and determinants of patients' efforts to access alternative care before ED presentation.

Methods:
Patients aged 17 years and older were randomly selected from 2 urban ED sites in Edmonton. Survey data were collected on use and characteristics of alternative care before the ED visit. Information was also collected on patient demographics and factors influencing their perception of whether the ED was the best care option.

Results:
Of the 1389 patients approached, 905 (65%) completed the survey and data from 894 participants were analyzed. Sixty-one percent reported that they sought alternative care before visiting the ED. Eighty-nine of the patients who attempted alternative access before the ED visit felt that the ED was their best care option. Results of the multivariate logistic regression analysis showed that injury presentation, living arrangements, smoking status and whether or not patients had a family practitioner were predictors for seeking alternative care before visiting the ED.

Conclusion:
Most ambulatory patients attempt to look for other sources of care before presenting to the ED. Despite this attempted access to alternative care, while patients wait for ED care, they perceive that the ED is their best care option at that point in time.
Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial
Authors: Richards Doug , Meshkat Nazanin , Chu Jaqueline , Eva Kevin , Worster Andrew 
Published: July 2016

ABSTRACTIntroduction:Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP).Methods:Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations.Results:Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (χ2= 6.69,p&lt; 0.001) with a relative risk of 1.29 (95% confidence interval 1.18–1.40), and the results remained significant after a “worst case” sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary.Conclusion:When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.
Myth: Nephrolithiasis and medical expulsive therapy
Authors: Liu May , Henderson Sean O. 
Published: July 2016

ABSTRACTThere is a medical myth that ureteral stones larger than 5 mm will not pass spontaneously and require urological intervention for removal. Recent findings indicate that medical expulsive therapy can facilitate spontaneous passage for stones up to 10 mm. For the management of ureteral stones, we recommend administering tamsulosin and a corticosteroid (deflazacort or prednisone) along with the standard therapy of analgesics, antibiotics and hydration.
The ‘other’ coral symbiont: Ostreobium diversity and distribution
Authors: del Campo Javier , Pombert Jean-François , Šlapeta Jan , Larkum Anthony , Keeling Patrick J 
Published: July 2016

Abstract
Ostreobium is an endolithic algal genus thought to be an early-diverging lineage of the Bryopsidales (Ulvophyceae, Chlorophyta). Ostreobium can live in low-light conditions on calcium carbonate substrata in tropical conditions. It is best known as a symbiont of corals, where it lives deep within the animal skeleton and exchanges nitrogen and carbon, as well as providing nutrients and photoassimilates. In contrast to the relatively well-studied role of the photosynthetic zooxanthellae symbionts in coral (Symbiodinium), Ostreobium phylogeny, diversity and distribution are all poorly understood. Here, we describe the phylogenetic position and diversity of Ostreobium based on plastid 16S ribosomal DNA (rDNA), 18S rDNA and rbcL genes from a nuclear genome survey and complete plastid genome, and determined its environmental diversity and distribution by screening the publicly available environmental data for those genes. The results shed light on the phylogeny and the ecology of the ‘other’ coral symbiont.