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Children treated for brain tumors often experience social and emotional difficulties, including challenges with emotion regulation; our goal was to investigate the attention-related component processes of emotion regulation, using a novel eye-tracking measure, and to evaluate its relations with emotional functioning and white matter (WM) organization.
Fifty-four children participated in this study; 36 children treated for posterior fossa tumors, and 18 typically developing children. Participants completed two versions of an emotion regulation eye-tracking task, designed to differentiate between implicit (i.e., automatic) and explicit (i.e., voluntary) subprocesses. The Emotional Control scale from the Behavior Rating Inventory of Executive Function was used to evaluate emotional control in daily life, and WM organization was assessed with diffusion tensor imaging.
We found that emotional faces captured attention across all groups (F(1,51) = 32.18, p < .001, η2p = .39). However, unlike typically developing children, patients were unable to override the attentional capture of emotional faces when instructed to (emotional face-by-group interaction: F(2,51) = 5.58, p = .006, η2p = .18). Across all children, our eye-tracking measure of emotion regulation was modestly associated with the parent-report emotional control score (r = .29, p = .045), and in patients it was associated with WM microstructure in the body and splenium of the corpus callosum (all t > 3.03, all p < .05).
Our findings suggest that an attention-related component process of emotion regulation is disrupted in children treated for brain tumors, and that it may relate to their emotional difficulties and WM organization. This work provides a foundation for future theoretical and mechanistic investigations of emotional difficulties in brain tumor survivors.
Microencapsulation of functioning cells for transplantation therapies is particularly promising, but the cells must retain their proper physiology and viability after being encapsulated. K-562 cells are multipotential and exhibit erythroid, megakaryocytic, or granulocytic properties that can be exploited by using an array of physiologically differentiating factors. The potential for cell differentiation makes it attractive the use of K-562 cells as functional model to the assessment of the effects of encapsulation on cell viability and physiology. Thus, alginate and hybrid alginate matrices were produced by extrusion technique for K-562 cell encapsulation. The produced systems were composed of bare alginate (1–3 wt%) and alginate in combination with chitosan or silica. The resulting materials were characterized by dynamic laser scattering, zeta potential measurements, small-angle X-ray scattering, and Fourier transform infrared spectroscopy. To assess viability, the encapsulated cells were subjected to the Trypan blue exclusion technique and NAD(P)H-dependent oxidoreductase (MTT) assays; hemin-induced erythroid differentiation capacity was also evaluated. The encapsulated alginate-based systems were shown to be monomodal and bimodal, depending on the nature of the capsule, with mean sizes in the range between 414 and 4.129 nm. Encapsulated cells exhibited viability ratios compatible with their use for prolonged cell cultures. Erythroid differentiation occurred in the range between 39 and 44%. The present results allow the consideration of the viability of therapeutic cells encapsulated in both bare alginate and in hybrid matrices.
This study aimed to assess the effects of the inhibition of nitric oxide synthase (NOS) on events that modulate bovine in vitro oocyte maturation. Cumulus–oocyte complexes (COCs) were cultured with hemisections (HSs) of the follicular walls in a maturation medium supplemented with different concentrations (0.1–10.0 mM) of Nω-nitro-l-arginine methyl ester hydrochloride (l-NAME). Controls consisted of COCs cultured in the presence (+HSs) or absence of HSs (–HSs) with no additional l-NAME supplementation. The following parameters were assessed: oocyte nuclear maturation stage; cumulus cell (CC) membrane integrity; nitrate/nitrite, progesterone, and estradiol concentrations in the culture medium at 22 h of cultivation; and the concentrations of cGMP and cAMP in COCs during the first hour of maturation. The addition of 1.0 mM l-NAME increased the percentage of oocytes that reached metaphase II (MII) and the percentage of intact CCs (P < 0.05). All l-NAME concentrations reduced the nitrate/nitrite concentrations (P < 0.05), but none affected steroid concentrations compared with control +HSs (P > 0.05). The addition of 1.0 mM l-NAME reduced cGMP concentrations at 3 h and increased cAMP concentrations in the first hour of culture (P < 0.05). Our findings suggest that the NOS/NO/cGMP pathway participates in meiosis progression (MI to MII) of the bovine oocytes matured in vitro in the presence of hemisections of the follicular walls. Lastly, the mechanisms that lead to the progression of meiosis after NOS inhibition do not involve changes in steroid production.
Constitutive heterochromatin typically exhibits low gene density and is commonly found adjacent or close to the nuclear periphery, in contrast to transcriptionally active genes concentrated in the innermost nuclear region. In Triatoma infestans cells, conspicuous constitutive heterochromatin forms deeply stained structures named chromocenters. However, to the best of our knowledge, no information exists regarding whether these chromocenters acquire a precise topology in the cell nuclei or whether their 18S rDNA, which is important for ribosome function, faces the nuclear center preferentially. In this work, the spatial distribution of fluorescent Feulgen-stained chromocenters and the distribution of their 18S rDNA was analyzed in Malpighian tubule cells of T. infestans using confocal microscopy. The chromocenters were shown to be spatially positioned relatively close to the nuclear periphery, though not adjacent to it. The variable distance between the chromocenters and the nuclear periphery suggests mobility of these bodies within the cell nuclei. The distribution of 18S rDNA at the edge of the chromocenters was not found to face the nuclear interior exclusively. Because the genome regions containing 18S rDNA in the chromocenters also face the nuclear periphery, the proximity of the chromocenters to this nuclear region is not assumed to be associated with overall gene silencing.
Many biological processes are partitioned among organs and tissues, necessitating tissue-specific or organ-specific analysis (particularly for comparative -omics studies). Standardised techniques for tissue identification and dissection are therefore imperative for comparing among studies. Here we describe dissection protocols for isolating six key tissues/organs from larvae of the Asian longhorned beetle, Anoplophora glabripennis (Motschulsky) (Coleoptera: Cerambycidae): the supraoesophageal ganglion, posterior midgut, hindgut, Malpighian tubules, fat body, and thoracic muscle. We also describe how to extract haemolymph and preserve whole larvae for measurements such as protein, lipid, and carbohydrate content. We include dissection protocols for both fresh-killed and previously frozen specimens. Although this protocol is developed for A. glabripennis, it should allow standardised tissue collection from larvae of other cerambycids and be readily transferrable to other beetle taxa with similar larval morphology.
Introduction: It is unclear whether anticoagulant or antiplatelet medications increase the risk for intracranial bleeding in older adults after a fall. Our aim was to report the incidence of intracranial bleeding among older adults presenting to the emergency department (ED) with a fall, among patients taking anticoagulants, antiplatelet medications, both medications and neither medication. Methods: This was a systematic review and meta-analysis, PROSPERO reference CRD42019122626. Medline, EMBASE (via OVID 1946 - July 2019), Cochrane, Database of Abstracts of Reviews of Effects databases and the grey literature were searched for studies reporting on older adults who were evaluated after a fall. We included prospective studies conducted in the ED where more than 80% of the cohort were 65 years or older and had fallen. We contacted study authors for aggregate data on intracranial bleeding in patients prescribed anticoagulant medication, antiplatelet medication and neither medication. Incidences of intracranial bleeding were pooled using random effect models, and I2 index was used to assess heterogeneity. Results: From 7,240 publication titles, 10 studies met inclusion criteria. The authors of 8 of these 10 studies provided data (on 9,489 patients). All studies scored low or moderate risk of bias. The pooled incidence of intracranial bleeding among patients taking an anticoagulant medication was 5.1% (n = 5,016, 95% Confidence Interval (CI): 4.1 to 6.3%) I2 = 42%, a single antiplatelet 6.4% (n = 2,148, 95% CI: 5.4 to 7.6%) I2 = 75%, both anticoagulant and antiplatelet medications 5.9% (n = 212, 95% CI: 1.3 to 13.5%) I2 = 72%, and neither of these medications 4.8% (n = 1,927, 95% CI: 3.5 to 6.2%) I2 = 50%. A sensitivity analysis restricted to patients who had a head CT in the ED reported incidences of 6.1% (n = 3,561, 95% CI: 3 to 8.3%), 8.4% (n = 1,781, 95% CI: 5.5 to 11.8%), 6.7% (n = 206, 95% CI 1.5 to 15.2%) and 6.6% (n = 1,310, 95% CI: 5.0 to 8.4%) respectively. Conclusion: The incidence of fall-related intracranial bleeding in older ED patients was similar among patients who take anticoagulant medication, antiplatelet medication, both and neither medication, although there was heterogeneity between study findings.
Introduction: Out-of-hospital cardiac arrest (OHCA) constitutes a significant global health burden, with a survival rate of only 10-12%. Early intervention is vital but limited by ambulance response times, low rates of bystander assistance, and access to AEDs. Smartphone technologies have been developed that crowdsource willing volunteers to nearby OHCAs in order to initiate resuscitation prior to ambulance arrival. We performed a scoping review to map the available literature on these crowdsourcing technologies and compared their key operational features. Methods: A search strategy was developed for five online databases: Medline, Cochrane, Embase, and Web of Science, as well as Google Scholar. We searched for primary studies and grey literature describing mobile phone technologies that alerted users of nearby cardiac arrests in the community. Two reviewers independently screened all articles and extracted relevant study information. Subsequently, we performed a search of the Google and Apple app stores, a general internet search, and consulted experts to identify all available technologies that might not be described in literature. We contacted developers for information on technology use and specifications to create a detailed features table. Results: We included 72 articles examining bystander alerting technologies from 15 countries worldwide, owing to the increasing importance of this topic. We identified 25 unique technologies, of which 18 were described in the included literature. Technologies were either text message-based systems (n = 4) or mobile phone applications (n = 21). Most (23/25) used global positioning systems to direct bystanders to victims and nearby AEDs. Response radii for alerts varied widely from 200m to 10km. Some technologies had advanced features such as video-conferencing with ambulance dispatch and detailed alert settings. Not all systems required volunteers to have first aid training. There were 18 studies examining effects on bystander intervention, all of which showed significant improvements using the technologies. However, only six studies assessed impact on survival outcomes. Key barriers discussed included false positive alerts, legal liability, and potential psychological impact on volunteers. Conclusion: Our review provides a comprehensive overview of crowdsourcing technologies for bystander intervention in out-of-hospital cardiac arrest. Future work in this growing field should focus on survival outcomes and methods of addressing barriers to implementation.
Introduction: The emergency department (ED) is often the first point of health care contact for patients with mild traumatic brain injury (MTBI). Spontaneous resolution occurs in most patients within 7 days, yet 15-30% will develop post-concussion syndrome (PCS). Given the paucity of effective management strategies to prevent PCS and emerging evidence supporting exercise, the objective of this study was to evaluate the impact of prescribed early light exercise compared to standard discharge instructions for acute MTBI patients in the ED. Methods: This was a randomized controlled trial conducted in three Canadian EDs. Consecutive, adult (18-64 years) ED patients with a MTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise (e.g., walking), and the control group was given standard MTBI instructions advising gradual return to exercise following symptom resolution. Participants documented their daily physical activities and completed follow-up questionnaires at 7, 14, and 30 days. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days. Results: 367 patients were enrolled (control n = 184; intervention n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control 13.4 vs intervention 14.6; Δ1.2, 95% CI: -6.2 to 8.5). There were no differences in median change of RPQ scores (control 14 vs intervention 13; Δ1, 95% CI: -1 to 4), median number of return health care provider visits (control 1 vs intervention 1; Δ0, 95% CI: 0 to 0), or median number of missed school or work days (control 2 vs intervention 2; Δ0, 95% CI: 0 to 1) at 30 days. There was a nonsignificant difference in unplanned return ED visits within 30 days (control 9.9% vs intervention 5.6%; Δ1, 95% CI: -1.4 to 10.3). Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; Δ5, 95% CI: 2 to 15). Conclusion: To our knowledge, this is the first randomized trial of prescribed early light exercise for adults with acute MTBI. There were no differences in recovery or healthcare utilization outcomes. Results suggest prescribed early light exercise should be encouraged as tolerated at ED discharge following MTBI, but exercise prescription alone is not sufficient to prevent PCS.
Introduction: Cases of anaphylaxis in children are often not appropriately managed by caregivers. We aimed to develop and to test the effectiveness of an education tool to help pediatric patients and their families better understand anaphylaxis and its management and to improve current knowledge and treatment guidelines adherence. Methods: The GEAR (Guidelines and Educational programs based on an Anaphylaxis Registry) is an initiative that recruits children with food-induced anaphylaxis who have visited the ED at the Montreal Children's Hospital and at The Children's Clinic located in Montreal, Quebec. The patients and parents, together, were asked to complete six questions related to the triggers, recognition and management of anaphylaxis at the time of presentation to the allergy clinic. Participants were automatically shown a 5-minute animated video addressing the main knowledge gaps related to the causes and management of anaphylaxis. At the end of the video, participants were redirected to same 6 questions to respond again. To test long-term knowledge retention, the questionnaire will be presented again in one year's time. A paired t-test was used to compare the difference between the baseline score and the follow-up score based on percentage of correct answers of the questionnaire. Results: From June to November 2019, 95 pediatric patients with diagnosed food-induced anaphylaxis were recruited. The median patient age was 4.5 years (Interquartile Range (IQR): 1.6–7.4) and half were male (51.6%). The mean questionnaire baseline score was 0.77 (77.0%, standard deviation (sd): 0.16) and the mean questionnaire follow-up score was 0.83 (83.0%, sd: 0.17). There was a significant difference between the follow-up score and baseline score (difference: 0.06, 95% CI: 0.04, 0.09). There were no associations of baseline questionnaire scores and change in scores with age and sex. Conclusion: Our video teaching method was successful in educating patients and their families to better understand anaphylaxis. The next step is to acquire long-term follow up scored to determine retention of knowledge.
Introduction: Atrial Fibrillation (AF) is the most common arrhythmia seen in patients presenting to the emergency department (ED). AF increases the risk of ischemic stroke which can be mitigated by anticoagulant prescription. National guidelines advise that emergency physicians initiate anticoagulation when AF is first diagnosed. We aimed to evaluate the 90-day incidence of stroke and major bleeding among emergency patients discharged home with a new diagnosis of AF. Methods: This was a health records review of patients diagnosed with AF in two EDs. We included patients ≥ age 18, with a new diagnosis of AF who were discharged from the ED, between 1st May 2014 and 1st May 2017. Using a structure review we collected data on CHADS65 and CHADS2 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), ischemic gut, ischemic limb or other systemic embolism within 90 days of the index ED presentation. We extracted data on major bleeding events within 90 days, defined by the International Society of Thrombosis and Haemostasis criteria. All data were extracted in duplicate for validation. Results: We identified 399 patients fulfilling the inclusion criteria, median age 68 (IQR 57-79), 213 (53%) male. 11 patients were already prescribed an anticoagulant for another indication and 19 had a contraindication to prescription of a DOAC. 48/299 (16%) CHADS65 positive patients were initiated on an anticoagulant, 3 of whom had a contra-indication to initiation of anticoagulation in the ED (1 dual antiplatelet therapy, 2 liver cirrhosis). 1/100 CHADS65 negative patients was initiated on anticoagulation. The median CHADS2 score was 1 (IQR 0-2). Among the 49 patients initiated on anticoagulation, 3 patients had a stroke/TIA within 90 days, 6.1% (95% CI; 2.1-16.5%). There were no bleeding events 0.0% (95% CI; 0.0-7.3%). Among the 350 patients who were not initiated on anticoagulation in the ED, 4 patients had a stroke/TIA 1.1% (95% CI; 1.1-2.9%) within 90 days and 2 patients had a major bleeding event. Conclusion: Prescription of anticoagulation for new diagnoses of AF was under-utilized in these EDs. The 90-day stroke/TIA rate was high, even among those given an anticoagulant prescription in the ED. No patient had an anticoagulant-associated bleeding event.
Introduction: Participant interviews are often considered the ‘gold standard’ for measuring outcomes in diagnostic and prognostic studies. Participant exposure data are frequently collected during study interviews, but the reliability of this information often remains unknown. The objective of this study was to compare patient-reported medication exposures and outcomes to data extracted from electronic medical records (EMRs) to determine reliability. Methods: This was a secondary data analysis from a prospective observational cohort study enrolling older (≥ 65 years) patients who presented to one of three emergency departments after a fall. After patients had consented to participate in the study, they were asked about their use of antiplatelet and anticoagulation medications (exposures of interest). During follow up, participants were asked if a physician had told them they had bleeding in their head (diagnosis of intracranial hemorrhage). Patient-reported responses were compared to data extracted from a structured EMR review. Trained research assistants extracted medication exposure and outcome data from the hospital EMRs in duplicate for all visits to any hospital within 42 days. Inter-rater agreement was estimated using Cohen's kappa (K) statistics with 95% confidence intervals (CIs). Results: 1275 patients completed study interviews. 1163 (91%) responded to questioning about antiplatelet use and 1159 (91%) to anticoagulant use. Exact agreement between patient reported antiplatelet use compared to EMR review was 77%, with K = 0.50 (95% CI: 0.44 to 0.55). For anticoagulation use, exact agreement was 87%, with K = 0.68 (95% CI: 0.63 to 0.72). 986 (78%) patients had a follow up interview after 42 days. Exact agreement between patient reported intracranial bleeding and EMR review was 95%, with K = 0.30 (95% CI: 0.15 to 0.45). Using the EMR review as the reference standard, the sensitivity and specificity of patient reported intracranial bleeding was 34% (95% CI: 20 to 52%) and 97% (95% CI: 96 to 98%), respectively. Conclusion: In this population of older adults who presented to the ED after a fall, patient reported use of antiplatelet and anticoagulant medications was not a reliable method to identify medication use. Patients who were diagnosed with intracranial bleeding were particularly poor at reporting this diagnosis.
Introduction: In a busy emergency department (ED), effective communication is integral to the provision of safe medical care. Physicians working in the ED interact with multiple team members including patients, allied healthcare professionals and other physicians, who all need to understand their verbal and written instructions. Our study's objective was to identify and describe communication problems occurring in the ED setting, and how these problems contributed to patient safety events and increased medico-legal risk for physicians. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, medico-legal organization which represented over 97,000 physicians at the time of this study. We conducted a retrospective descriptive analysis where we extracted five years (2013-2017) of CMPA data describing closed medico-legal cases occurring in the ED involving physicians (any specialty) who experienced complaints due to communication issues. We then applied an internal contributing factor framework to identify data themes. Data were summarized using descriptive statistics. Results: We identified 517 eligible cases involving 521 patients (some cases involved >1 patient). We found that 99.8% (520/521) of patients experienced some form of healthcare-related harm in the ED. Specifically, there was poor communication between: the physician and patient or patient's family (202/517, 39.1%); two or more physicians (79/517, 15.3%), and physicians and other healthcare providers (55/517, 10.6%). Inadequate documentation was observed in more than half of the cases (324/517, 62.7%) and poor team communication affected physicians’ decision making process (326/517, 63%) in areas such as deficient assessments, inadequate investigations, failure or delay to attend to the patient, and disposition decisions. Conclusion: Team communication issues are prevalent among physician medico-legal cases occurring in the ED. Efforts to strengthen communication skills may enhance patient safety and reduce medico-legal risk.
Introduction: Each year, 3/1000 Canadians sustain a mild traumatic brain injury (mTBI). Many of those mTBI are accompanied by various co-injuries such as dislocations, sprains, fractures or internal injuries. A number of those patients, with or without co-injuries will suffer from persistent post-concussive symptoms (PPCS) more than 90 days post injury. However, little is known about the impact of co-injuries on mTBI outcome. This study aims to describe the impact of co-injuries on PPCS and on patient return to normal activities. Methods: This multicenter prospective cohort study took place in seven large Canadian Emergency Departments (ED). Inclusion criteria: patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of ED visit, with a Glasgow Coma Scale score of 13-15. Patients who were admitted following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. A research nurse then conducted three follow-up phone interviews at 7, 30 and 90 days post-injury, in which they assessed symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to estimate the influence of co-injuries. Results: A total of 1674 patients were included, of which 1023 (61.1%) had at least one co-injury. At 90 days, patients with co-injuries seemed to be at higher risk of having 3 symptoms ≥2 points according to the RPQ (RR: 1.28 95% CI 1.02-1.61) and of experiencing the following symptoms: dizziness (RR: 1.50 95% CI 1.03-2.20), fatigue (RR: 1.35 95% CI 1.05-1.74), headaches (RR: 1.53 95% CI 1.10-2.13), taking longer to think (RR: 1.50 95% CI 1.07-2.11) and feeling frustrated (RR: 1.45 95% CI 1.01-2.07). We also observed that patients with co-injuries were at higher risk of non-return to their normal activities (RR: 2.31 95% CI 1.37-3.90). Conclusion: Patients with co-injuries could be at higher risk of suffering from specific symptoms at 90 days post-injury and to be unable to return to normal activities 90 days post-injury. A better understanding of the impact of co-injuries on mTBI could improve patient management. However, further research is needed to determine if the differences shown in this study are due to the impact of co-injuries on mTBI recovery or to the co-injuries themselves.
Introduction: Mild traumatic brain injury (mTBI) is a serious public health issue and as much as one third of mTBI patients could be affected by persistent post-concussion symptoms (PPCS) three months after their injury. Even though a significant proportion of all mTBIs are sports-related (SR), little is known on the recovery process of SR mTBI patients and the potential differences between SR mTBI and patients who suffered non-sports-related mTBI. The objective of this study was to describe the evolution of PPCS among patients who sustained a SR mTBI compared to those who sustained non sport-related mTBI. Methods: This Canadian multicenter prospective cohort study included patients aged ≥ 14 who had a documented mTBI that occurred within 24 hours of Emergency Department (ED) visit, with a Glasgow Coma Scale score of 13-15. Patients who were hospitalized following their ED visit or unable to consent were excluded. Clinical and sociodemographic information was collected during the initial ED visit. Three follow-up phone interviews were conducted by a research nurse at 7, 30 and 90 days post-injury to assess symptom evolution using the validated Rivermead Post-concussion Symptoms Questionnaire (RPQ). Adjusted risk ratios (RR) were calculated to demonstrate the impact of the mechanism of injury (sports vs non-sports) on the presence and severity of PPCS. Results: A total of 1676 mTBI patients were included, 358 (21.4%) of which sustained a SR mTBI. At 90 days post-injury, patients who suffered a SR mTBI seemed to be significantly less affected by fatigue (RR: 0.70 (95% CI: 0.50-0.97)) and irritability (RR: 0.60 (95% CI: 0.38-0.94)). However, no difference was observed between the two groups regarding each other symptom evaluated in the RPQ. Moreover, the proportion of patients with three symptoms or more, a score ≥21 on the RPQ and those who did return to their normal activities were also comparable. Conclusion: Although persistent post-concussion symptoms are slightly different depending on the mechanism of trauma, our results show that patients who sustained SR-mTBI could be at lower risk of experiencing some types of symptoms 90 days post-injury, in particular, fatigue and irritability.
Introduction: The emergency department (ED) is the first point of health care contact for most head injured patients. Although early and spontaneous resolution occurs in most patients with mild traumatic brain injury (MTBI), between 15-30% develop post-concussion syndrome (PCS). To date, clinical prediction tools do not yet exist to accurately identify adult MTBI patients at risk of PCS. The objective of this study was to identify predictors of PCS within 30 days in adults with acute MTBI presenting to the ED. Methods: This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs evaluating prescribed light exercise compared to standard care. Adult (18-64 years) patients with a MTBI sustained within the preceding 48 hours were eligible for enrollment. Participants completed follow-up questionnaires at 7, 14, and 30 days. The primary outcome was the presence of PCS at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ) at 30 days. Backward, stepwise, multivariable logistic regression with a removal criterion probability of 0.05 was conducted to determine predictor variables independently associated with PCS at 30 days. Likelihood ratio tests were used to determine appropriate inclusion of variables in the multivariable model. Results are reported as odds ratios (OR) with 95% confidence intervals (CIs). Results: A total of 367 patients were enrolled, 18 (4.9%) withdrew, and 108 (29.4%) were lost to follow-up. Median (IQR) age was 32 (25 to 48) years, and 201 (57.6%) were female. Of the 241 patients who completed follow-up, 49 (20.3%) had PCS at 30 days. Headache at ED presentation (OR = 6.59; 95% CI: 1.31 to 33.11), being under the influence of drugs or alcohol at the time of injury (OR = 4.42; 95% CI: 1.31 to 14.88), the injury occurring via bike or motor vehicle collision (OR = 2.98; 95% CI: 1.39 to 6.40), history of anxiety or depression (OR = 2.49; 95% CI: 1.23 to 5.03), and the sensation of numbness or tingling at ED presentation (OR = 2.25; 95% CI: 1.04 to 4.88), were independently associated with PCS at 30 days. Conclusion: Five variables were found to be significant predictors of PCS. Although MTBI is a self-limited condition in the majority of patients, patients with these risk factors should be considered high risk and flagged for early follow-up. There continues to be an urgent need for a clinical prognostic tool that accurately identifies adult patients at risk for PCS early in their injury.
Background: Emergency physicians (EPs) can choose from several evidence-based pathways to diagnose pulmonary embolism (PE), however literature suggests that EPs frequently use computer tomography (CT) scanning as a stand-alone test for PE. This is a program of research to improve adherence to evidence-based PE diagnosis in the emergency department (ED). Aim Statement: To create a novel approach to PE diagnosis in the ED based on a framework explaining EP diagnostic PE behaviour and barriers to using evidence-based PE testing. Measures & Design: We conducted two types of qualitative interviews: 1). EPs in 5 Canadian cities watched videos of 2 simulated cases and then explained how they would test the patient. 2). Semi-structured EP interviews using the theoretical domains framework (TDF). The results of our analyses informed the construction of an explanatory framework for common EP diagnostic PE behaviours. Barriers to evidence-based behaviour were classified into domains. A Canadian EP expert group reviewed these results along with the existing evidence on ED PE diagnostic implementation. We developed a new approach to diagnosis of PE in the ED which addresses each of our domains. Evaluation/Results: We conducted 71 interviews. We identified 4 domains, each addressed in our pathway. ‘PE in a mythical and deadly beast’ PE kills and can masquerade so EPs look for PE in places where it does not exist and are rewarded for ‘over-testing’. Response: Creating a departmental conversation about missing PE, talking about the facts, busting the myths. EP feedback on PE testing including positive rate. ‘The end goal is CTPE’ PE creates anxiety for EPs and ordering a CTPE hands over responsibility to the radiologist. Response: A departmental protocol for PE testing which starts with D-dimer for every patient. Shifting focus to ruling out PE with D-dimer. Protocol is automated once initiated by EP. ‘PERC eases anxiety’ PERC is documented when it is negative and allows EP to stop. Response: EPs can choose to use and document PERC. ‘No-one has been fighting for the Wells score’ Poor understanding of purpose and function. Often at odds to Gestalt. Response: Protocol does not use Wells score. Discussion/Impact: We have developed a new diagnostic PE pathway which addresses current barriers to evidence-based practice which we will evaluate further.
Background: Atrial fibrillation (AF) is a risk for stroke. The Canadian Cardiovascular Society advises patients who are CHADS65 positive should be started on oral anticoagulation (OAC). Our local emergency department (ED) review showed that only 16% of CHADS65 positive patients were started on OAC and that 2% of our patients were diagnosed with stroke within 90 days. We implemented a new pathway for initiation of OAC in the ED (the SAFE pathway). Aim Statement: We report the effectiveness and safety of the SAFE pathway for initiation of OAC in patients treated for AF in the ED. Measures & Design: A multidisciplinary group of physicians and pharmacist developed the SAFE pathway for patients who are discharged home from the ED with a diagnosis of AF. Step 1: contraindications to OAC, Step 2: CHADS65 score, Step 3: OAC dosing if indicated. The pathway triggers referral to AF clinic, family physician letter and follow up call from the ED pharmacist. Patients are followed for 90 days by a structured medical record review and a structured telephone interview. We record persistence with OAC, stroke, TIA, systemic arterial embolism and major bleeding (ISTH criteria). Patient outcomes are fed back to the treating ED physician. Evaluation/ Results: The SAFE pathway was introduced in two EDs in June 2018. In total, 177 patients have had the pathway applied. The median age was 70 (interquartile range (IQR) 61-78), 48% male, median CHADS2 score 2 (IQR 0-2). 19/177 patients (11%) had a contraindication to initiating OAC. 122 patients (69%) had no contraindication to OAC and were CHADS65 positive. Of these 122 patients, 109 were given a prescription for OAC (96 the correct dose, 9 too high a dose and 4 too low a dose). 6 patients declined OAC and the physician did not want to start OAC for 7 patients. 73/122 were contacted by phone at 90 days, 15 could not be reached and 34 have not completed 90 days of follow up since their ED visit. Of the 73 who were reached by phone after 90 days, 65 were still taking an anticoagulant. To date, 1 patient who declined OAC (CHADS2 score of 2) had a stroke within 90 days and one patient prescribed OAC had a gastrointestinal bleed. Discussion/Impact: The SAFE pathway appears safe and effective although we continue to evaluate and improve the process.
Episodic memory is impaired in Alzheimer’s disease (AD) dementia but thought to be relatively spared in behavioral variant frontotemporal dementia (bvFTD). This view is challenged by evidence of memory impairment in bvFTD. This study investigated differences in recognition memory performance between bvFTD and AD.
We performed a retrospective analysis on the recognition trial of the Rey Auditory Verbal Learning Test in patients with bvFTD (n = 85), AD (n = 55), and control participants (n = 59). Age- and education-adjusted between-group analysis was performed on the total score and indices of discriminative ability and response bias. Correlations between recognition and measures of memory, language, executive functioning, and construction were examined.
Patients with AD had a significantly lower total recognition score than patients with bvFTD (control 28.8 ± 1.5; bvFTD 24.8 ± 4.5; AD 23.4 ± 3.6, p < .01). Both bvFTD and AD had worse discriminative ability than controls (A’ control 0.96 ± 0.03; bvFTD 0.87 ± 0.03; AD 0.84 ± 0.10, p < .01), but there was no difference in response bias (B” control 0.9 ± 0.2; bvFTD 1.6 ± 1.47; AD 1.4± 1.4, p < .01). AD had worse discriminability than bvFTD (p < .05). Discriminability was associated with memory for both patient groups (median correlation coefficient r = .34) and additionally associated with language (r = .31), but not executive functioning (r = −.03) in bvFTD. Response bias was unrelated to other cognitive functions (r = −.02).
Discriminability, but not response bias, differentiated patients with bvFTD from AD. The presence of an impaired discrimination index suggests a “pure” (recognition) memory deficit in bvFTD.