Caregiving experiences are implicated in children’s depression risk; however, children’s neural reactivity to positive and negative feedback from mothers, a potential mediator of depression risk, is poorly understood. In a sample of 81 children (Mage = 11.12 years, SDage = 0.63), some of whom were recruited based on a maternal history of depression (n = 29), we used fMRI to characterize children’s neural responses to maternal praise and criticism. Maternal history of depression was unrelated to children’s brain activity during both the praise and criticism conditions; however, ROI analyses showed that children’s self-reported depressive symptoms were negatively associated with functional activity in the left anterior insula and right putamen while hearing maternal criticism. Whole-brain analyses showed that children’s depressive symptoms were positively associated with left inferior frontal gyrus activity while listening to maternal praise. These findings complement past work implicating these brain regions in the processing of emotionally salient stimuli, reward processing, and internal speech. Given associations between early depressive symptoms and later disorder, findings suggest that maladaptive neural processing of maternal feedback may contribute to children’s early emerging risk for depression.

Introduction: Patients hospitalized following a trauma will be frequently treated with opioids during their stay and after discharge. We examined the relationship between acute phase (< 3 months) opioid use after discharge and the risk of opioid poisoning (OP) or opioid use disorder (OUD) in older trauma patients Methods: In a retrospective multicenter cohort study conducted on registry data, we included all patients aged 65 years and older admitted (hospital stay >2 days) for injury in 57 trauma centers in the province of Quebec (Canada) between 2004 and 2014. We searched for OP and OUD from ICD-9 and ICD-10 code diagnosis that resulted in a hospitalization or a medical consultation after their initial injury. Patients that filled an opioid prescription within a 3-month period after sustaining the trauma were compared to those who did not fill an opioid prescription during that period using Cox proportional hazards regressions. Results: A total of 70,314 participants were retained for analysis; median age was 82 years (IQR: 75-87), 68% were women, and 34% of the patients filled an opioid prescription within 3-months of the initial trauma. During a median follow-up of 2.6 years (IQR: 1-5), 192 participants (0.30%; 95%CI: 0.25%-0.35%) were hospitalized for OP and 73 (0.10%; 95%CI: 0.07%-0.13%) were diagnosed with OUD. Having filled an opioid prescription within 3-months of injury was associated with an increased hazard ratio of OP (2.6; 95%CI: 1.9-3.5) and OUD (4.0; 95%CI: 2.3-7.0). However, history of OP (2.7; 95%CI: 1.2-6.1), of substance use disorder (4.3; 95%CI: 2.4-7.9), or of opioid prescription filled (2.7; 95%CI: 2.1-3.5) before trauma were also related to OP or OUD. Conclusion: Opioid poisoning and opioid use disorder are rare events after hospitalization for trauma in older patients. However, opioids should be used cautiously in patients with history of substance use disorder, opioid poisoning or opioid use during the past year.

Introduction: Malgré les progrès au niveau des soins de réanimation lors des dernières années, le pronostic des patients souffrant d'un arrêt cardiorespiratoire (ACR) demeure abyssal et aucun médicament ne semble influencer leur devenir au long cours. Cependant, les résultats de quelques études évaluant l'impact des bêtabloqueurs chez cette population s'avèrent cependant très encourageants. L'objectif de cette revue systématique, est d’évaluer l’évidence disponible quant à l'impact des bêtabloqueurs sur le devenir des patients traités pour un ACR dont le rythme initial est défibrillable. Methods: La présente revue systématique a été préalablement enregistrée sur Prospero (CRD42018105453). Les moteurs de recherche Medline, Embase et CENTRAL ont été fouillés de leur création jusqu'au 17 octobre 2018. La recherche de littérature grise s'est faite via Web of Science et Google Scholar. Les références de tous les articles inclus ainsi que des méta-analyses existantes sur le sujet ont également été révisées. Tous les types de devis ont été considérés, sauf les études de cas et les séries de cas. Les études devaient inclure des adultes (16 ans et plus) en ACR dont le rythme initial était défibrillable, dont une partie avait reçu un médicament bêtabloquants par voie intraveineuse pendant leur ACR et l'autre un traitement standard, et présenter une mesure de résultat centrée sur le patient (retour de circulation spontanée [RCS], survie ou bon devenir neurologique). La qualité des articles a été évaluée à l'aide du ‘Newcastle Ottawa scale’. Results: Deux études observationnelles rétrospectives, menées auprès d'un total de 66 patients, ont été incluses. Il y avait une association positive entre l'administration de bêtabloquants et l'occurrence d'un RCS (rapport de cotes [RC] = 5.76 [intervalle de confiance {IC} à 95% = 1.79-18.52], p = 0.003), ainsi qu'avec la présence d'un bon devenir neurologique (RC = 4.42 [IC95% = 1.05 - 18.56], p = 0.04). Une telle association n'a cependant pas été observée par rapport à la survie au congé hospitalier. Conclusion: L'administration de bêtabloquants semble associé à un meilleur devenir chez les patients en ACR avec un rythme initial défibrillable. Étant donné la nature du devis de ces études et leur petite taille, une étude prospective de qualité serait nécessaire afin de déterminer l'efficacité de cette classe de médicament et de faire une recommandation forte à ce sujet.

Introduction: The elderly (65 yo and more) increase in Canada is well documented along with a disproportionate use of Emergency Departments after a minor injury. These patients requires specific care given a 16% risk of functional decline following a visit to ED. To prevent functional decline, a multidimensional assessment of the elderly is recommended in the emergency department. Objective: To determine if ED grip strength can predict functional decline at 3 or 6 months post-injury. Methods: A multicentre prospective study in 5 ED across Canada was realized between 2013 and 16. Patients 65 years old and over, autonomous in daily living activities and consulting the emergency department for minor trauma were recruited 7 days a week. Clinical-demographic data, functional status, fear of falling, number of falls in the last month, grip strength measurement were collected in the ED. Functional decline (loss of at least points to functional status) was calculated at 3 and 6 months. Descriptive statistics and linear regression model with repeated measurements were used to determine if the grip strength was predictive of functional decline at 3 or 6 months. Results: 387 patient were recruited. Mean age was 74 ± 7 years old, 52% were male. XXX experienced a fall in the last month. The initial maximum grip strength was (24 ± 10 intervention vs. 28 ± 13 control; p ≤ 0.05). grip strength is associated with pre-injury functional status (p < 0.0001) and fear of falling (p = 0.0001) but does not predict 3 or 6 month functional decline. Conclusion: Given the strong association with fear of falling and functional status at initial ED evaluation, we recommend that grip strength measurement could be included in a multidisciplinary geriatric emergency department assessment as needed.

Introduction: Les patients ayant un retour de circulation spontanée (RCS) durant la phase préhospitalière de leur réanimation suite à un arrêt cardiaque extrahospitalier (ACEH) ont un meilleur taux de survie que ceux n'en ayant pas. La durée des efforts de réanimation avant l'initiation d'un transport ne varie généralement pas en fonction du rythme initial observé. Cette étude vise à comparer la durée des manœuvres de réanimation nécessaire afin de générer la majorité des RCS préhospitaliers et des RCS préhospitaliers menant à une survie en fonction du rythme initial. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients avec un ACEH d'origine médicale ont été inclus. Les patients dont l'ACEH était témoigné par les paramédics ont été exclus, tout comme ceux dont le rythme initial était inconnu. Nous avons comparé entre les groupes (rythme défibrillable [RD], activité électrique sans pouls [AESP] et asystolie) les taux de RCS préhospitalier et le temps nécessaires pour obtenir une majorité des RCS préhospitaliers et des RCS préhospitaliers menant à une survie. Results: Un total de 6002 patients (3851 hommes et 2151 femmes) d'un âge moyen de 52 ans ( ±10) ont été inclus dans l’étude, parmi lesquels 563 (9%) ont survécu jusqu’à leur congé hospitalier et 1310 (22%) ont obtenu un RCS préhospitalier. Un total de 1545 (26%) patients avaient un RD, 1654 (28%) une AESP et 2803 (47%) une asystolie. Les patients avec un RD ont obtenu plus fréquemment un RCS préhospitalier et un RCS préhospitalier menant à une survie que les patients avec une AESP qui eux même avaient un meilleur pronostic que ceux avec une asystolie initial (777 patients [55%] vs 385 [23%] vs 148 [5%], p < 0,001; 431 [28%] vs 85 [5%] vs 7 [0,2%], p < 0,001, respectivement). Les RCS survenaient également plus rapidement lorsque le rythme initial était un RD (13 minutes [ ±12] vs 18 [ ±13] vs 25 [ ±12], p < 0,001). Cependant, une période de réanimation plus longue était nécessaire afin d'obtenir 95% des RCS préhospitaliers menant à une survie pour les patients avec un RD (26 minutes vs 21 minutes vs 21 minutes). Conclusion: Les patients avec un rythme initial défibrillable suite à leur ACEH sont à meilleur pronostic. Il serait envisageable de transporter plus rapidement vers l'hôpital les patients avec une AESP ou une asystolie que ceux avec un rythme défibrillable si l'arrêt des manœuvres n'est pas envisagé.

Introduction: Opioid side effects are common when treating chronic pain. However, the rate of opioid side effects for acute pain has rarely been examined, particularly in the post emergency department (ED) setting. The objective of this study was to evaluate the short-term incidence of opioid induced side effects (constipation, nausea/vomiting, dizziness, and drowsiness) in patients discharged from the ED with an opioid prescription. Methods: This was a prospective cohort study of patients aged ≥18 years that visited the ED for an acute pain condition (≤ 2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain medication use and side effects. Results: Mean age of the 386 patients included was 55 ± 16 years; 50% were women. During the 2-week follow-up, 80% of patients consumed at least one dose of opioids. Among the patients who used opioids, 38% (95%CI: 33-48) reported constipation, 27% (95%CI:22-32) nausea/vomiting, 30% (95%CI:25-35) dizziness, 51% (95%CI:45-57) drowsiness, and 77% (95%CI:72-82) reported any side effects. Adjusting for age, sex, and pain condition, patients who used opioids were more likely to report any side effect (OR 7.5, 95%CI:4.3-13.3) and constipation (OR 7.5, 95%CI:3.1-17.9). A significant dose response effect was observed for constipation but not for the other side effects. Nausea/vomiting (OR 2.0, 95%CI:1.1-3.6) and dizziness (OR 1.9, 95%CI:1.1-3.4) were associated with oxycodone compared to morphine. Conclusion: Similar to chronic pain, opioid side effects are highly prevalent during short-term treatment for acute pain. Physicians should be aware and inform patients about those side effects.

Introduction: Near-infrared spectroscopy (NIRS) can be used to monitor the oxygen saturation of hemoglobin in any given superficial tissue. However, the measurements provided by different oximeters can vary a lot. Little is known about the specific patient characteristics that could affect the inter-device agreement of tissular oximeters. This study aimed to evaluate the association between the quantity of subcutaneous fat (assessed by skinfold thickness) and the inter-device agreement of two tissue oximeters, the INVOS 5100c and the Equanox 7600. Methods: In this prospective cohort study, tissue saturations and skinfold thickness were measured at four different sites on both sides of the body in healthy adult (≥18 years old) volunteers. The association between the quantity of subcutaneous fat (assessed by skinfold thickness) and the inter-device agreement (absolute difference between the oximetry values provided by the two oximeters) was first assessed with a Pearson's correlation and a scatter plot. Subsequently, a linear mixed model was used to evaluate the impact of the subcutaneous fat and other covariables (age, sex) on the inter-device agreement while adjusting for the repeated measurements across different sites for the same volunteers. Results: From January to March 2015, 53 healthy volunteers were included in this study with ages ranging between 20 and 81 years old, on which a total of 848 measures were taken. Higher skinfold measures were associated with an increase in the difference between measures provided by both oximeters (Slope = -0.59, Pearson correlation coefficient = -0.51, p < 0.001). This observed association persisted in a linear mixed model (-0.48 [95% confidence interval {CI}-0.61 to -0.36], p < 0.001). The sex of the volunteers also influenced the inter-oximeter agreement (Women:-5.77 [95%CI -8.43 to -3.11], p < 0.001), as well as the forearm sites (Left forearm: −7.16 [95%CI -9.85 to –4.47], p < 0.001; right forearm: −7.01 [95%CI -9.61 to −4.40], p < 0.001). Conclusion: The quantity of subcutaneous fat, as well as the sex of the volunteers and the measurement sites, impacted the inter-device agreement of two commonly used oximeters. Given these findings, monitoring using tissue oximetry should be interpreted with great care when there is a significant quantity of subcutaneous fat.

Introduction: Studies suggest that acute pain evolution after an emergency department (ED) visit has been associated with the development of chronic pain. Using group-based trajectory modeling (GBTM), we aimed to evaluate if ED discharged patients with similar pain intensity profiles of change over 14 days are associated with chronic pain at 3 months. Methods: This is a prospective cohort study of patients aged 18 years or older who visited the ED for an acute pain condition (≤2 weeks) and were discharged with an opioid prescription. Patients completed a 14-day diary in which they listed their daily pain intensity level (0-10 numeric rating scale). Three months post-ED visit, participants were interviewed by phone to report their pain intensity related to the initial pain. Results: A total of 305 patients were retained at 3 months (mean age ± SD: 55 ± 15 years, 49% women). Using GBTM, six distinct pain intensity trajectories were identified during the first 14 days of the acute pain period; two linear one with moderate or severe pain during the follow-up (representing almost 40% of the patients) and four cubic polynomial order trajectories, with mild or no-pain at the end of the 14 days (low final pain). Twelve percent (11.9; ±95%CI: 8.2-15.4) of the patients had chronic pain at 3 months. Controlling for age, sex and types of pain condition, patients with trajectories of moderate or severe pain and those with only severe pain were 5.1 (95%CI: 2.2-11.8) and 8.2 (95%CI: 3.4-20.0) times more likely to develop chronic pain at 3 months, respectively, compared to the low final pain group. Conclusion: Trajectories could be useful to early identification of patients at risk of chronic pain.

Introduction: While negative consequences of incident delirium on functional and cognitive decline have been widely studied, very limited data is available regarding functional and cognitive outcomes in Emergency Department (ED) patients. The aim of this study was therefore to evaluate the impact of ED stay-associated delirium on older patient's functional and cognitive status at 60 days post-ED visit. Methods: This study is a planned sub-analysis of a large multicentre prospective cohort study (the INDEED study). This project took place between March and July of the years 2015 and 2016 within 5 participating EDs across the province of Quebec. Independent non-delirious patients aged □65, with an ED stay at least 8hrs were monitored until 24hrs post-ward admission. A 60-day follow-up phone assessment was also conducted. Participants were screened for delirium using the validated Confusion Assessment Method (CAM) and the severity of its symptoms was measured using the Delirium Index. Functional and cognitive status were assessed at baseline as well as at the 60-day follow-up using the validated OARS and TICS-m. Results: A total of 608 patients were recruited, 393 of which completed the 60-day follow-up. Sixty-nine patients obtained a positive CAM during ED-stay or within the first 24 hours following ward admission. At 60-days, those patients experienced a loss of 3.1 (S.D. 4.0) points on the OARS scale compared to non-delirious patients who lost 1.6 (S.D. 3.0) (p = 0.03). A significant difference in cognitive function was also noted at 60-days, as delirious patients’ TICS-m score decreased by 2.1 (S.D. 6.2) compared to non-delirious patients, who showed a minor improvement of 0.5 (S.D. 5.8) (p = 0.01). Conclusion: People who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients and they will experience a more significant decline at 60 days post-ED visit.

Introduction: Les patients dont l'arrêt cardiaque extrahospitalier (ACEH) n'a pas été témoigné sont généralement exclus des protocoles de réanimation par circulation extracorporelle puisque le délai avant l'initiation de leur réanimation est inconnu. Il a été proposé que la présence d'un rythme initial défibrillable (RD) est fortement suggestif une très courte période avant l'initiation des manœuvres de réanimation. La présente étude vise à décrire l'association entre la durée avant l'initiation de la réanimation et la présence d'un RD chez des patients souffrant d'un ACEH. Methods: Cette étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients dont l'arrêt était témoigné, mais dont les témoins n'ont pas entamé de manœuvres de réanimation, ont été inclus. Nous avons également inclus les patients dont l'arrêt était témoigné par les paramédics comme groupe contrôle (durée avant l'initiation de la réanimation = 0 minute). Les patients avec un retour de circulation spontanée avant l'arrivée des services préhospitaliers ont été exclus, tout comme ceux dont le rythme initial était inconnu. Nous avons décrit l’évolution de la proportion de chacun des rythmes et construit une régression logistique multivariée ajustant pour les variables sociodémographiques et cliniques pertinentes. Results: Un total de 1751 patients (1173 hommes et 578 femmes) d'un âge moyen de 69 ans (±16) ont été inclus dans l'analyse principale, parmi lesquels 603 (34%) avaient un RD. Un total de 663 autres patients ont vu leur ACEH témoigné directement par les paramédics. Un plus court délai avant l'initiation des manœuvres est associé à la présence d'un RD (rapport de cotes ajusté = 0,97 [intervalle de confiance à 95% 0,94-0,99], p = 0,016). Cependant, cette relation n'est pas linéaire et la proportion de RD ne diminue pas avant notablement jusqu’à ce que 15 minutes s’écoulent avant le début de la réanimation (0 min = 35%, 1-5 min = 37%, 5-10 min = 35%, 10-15 min = 34%, +de 15 min = 16%). Conclusion: Bien que la proportion de patients avec un RD diminue lorsque le délai augmente avant l'initiation des manœuvres, cette relation ne semble pas linéaire. La baisse principale de la proportion de patients avec RD semble se produire suite à la quinzième minute de délai avant le début de la réanimation.

Introduction: La réanimation par circulation extracorporelle (R-CEC) permet potentiellement d'améliorer la survie de patients souffrant d'un arrêt cardiaque extrahospitalier (ACEH) réfractaire aux traitements habituels. Cette technique, se pratiquant généralement en centre hospitalier (CH), doit être réalisée le plus précocement possible. Un transport vers le CH en temps opportun est donc nécessaire. Cette étude vise à décrire la durée nécessaire des manœuvres de réanimation préhospitalières afin d'optimiser le moment du départ vers le CH dans le but d'obtenir un maximum de retour de circulation spontanée (RCS) préhospitalier. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Les patients éligibles à une R-CEC selon les critères locaux ont été inclus (<65 ans, rythme initial défibrillable, arrêt témoigné avec réanimation par un témoin). Les patients ayant eu un arrêt devant les paramédics ont été exclus, tout comme ceux avec un RCS avant l'arrivée des services préhospitaliers. Nous avons calculé la sensibilité et la spécificité à différents seuils afin de prédire un RCS préhospitalier et une survie au congé hospitalier. Une courbe ROC a également été construite. Results: Un total de 236 patients (207 hommes et 29 femmes) d'un âge moyen de 52 ans (±10) ont été inclus dans l’étude, parmi lesquels 93 (39%) ont survécu jusqu’à leur congé hospitalier et 136 (58%) ont obtenu un RCS préhospitalier. Le délai moyen avant leur RCS était de 13 minutes (±10). Plus de 50% des survivants avaient eu un RCS moins de 8 minutes après l'initiation des manœuvres de réanimation par les intervenants préhospitaliers, et plus de 90% avant 24 minutes. Plus de 50% de tous les RCS survenaient dans les 10 premières minutes de réanimation et plus de 90% dans les 31 premières minutes. La courbe ROC montrait visuellement que le délai avant le RCS maximisant la sensibilité et la spécificité pour prédire la survie chez ces patients était à 22 minutes (Sensibilité = 90%, spécificité = 78%; aire sous la courbe = 0,89 [intervalle de confiance à 95% 0,84-0,93]). Conclusion: Le départ vers le CH pourrait être considéré pour ces patients entre 8 et 24 minutes après l'initiation des manœuvres. Une période de réanimation de 22 minutes semble être le meilleur compromis à cet égard.

Introduction: The objective of the study was to evaluate the acute pain intensity evolution in ED discharged patients using Group-based trajectory modeling (GBTM). This method identified patient groups with similar profiles of change over time without assuming the existence of a particular pattern or number of groups. Methods: This was a prospective cohort study of ED patients aged ≥18 years with an acute pain condition (≤ 2 weeks) and discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level (0-10 numeric rating scale) and pain medication use. Results: Among the 372 included patients, six distinct post-ED pain intensity trajectories were identified: two started with severe levels of pain, one remained with severe pain intensity (12.6% of the sample) and the other ended with moderate pain intensity level (26.3%). Two other trajectories had severe initial pain, one decreased to mild pain (21.7%) and the other to no-pain (13.8%). Another trajectory had moderate initial pain which decreased to a mild level (15.9%) and the last one started with mild pain intensity and had no pain at the end of the 14-day (9.7%). The pain trajectory patterns were significantly associated with age, type of painful conditions, pain intensity at ED discharge, and with opioid consumption. Conclusion: Acute pain resolution following an ED visit seems to progress through six different trajectory patterns that are more informative than simple linear models and could be useful to adapt acute pain management in future research.

Introduction: Biphasic anaphylactic reactions are a concern in emergency medicine. Risk factors associated with this type of reaction remain ill-defined. The aim of this study was to investigate elements associated with biphasic anaphylactic reactions and to determine the impact of anaphylaxis treatments on biphasic reactions. Methods: From the multicenter Cross-Canada Anaphylaxis Registry prospective cohort, we selected adults (≥18 years) with a visit to the emergency department (ED) of Sacré-Cœur Hospital, an urban tertiary-care hospital. Then, a structured chart review was done to collect additional information on types and timing of treatments for the initial anaphylactic reaction, presence and treatment of biphasic reactions during the initial ED visit or upon patients’ return. Biphasic reactions were defined by the recurrence of any anaphylaxis symptoms within 72 hours of a resolved anaphylaxis episode. Potential factors associated with biphasic reactions were studied using Chi-Square and Mann-Whitney tests. Results: Patients with anaphylaxis were enrolled between April 2014 and February 2018. From the cohort, 401 adult patients were identified. We found 37 patients who developed a biphasic reaction. Amongst them, 33 received treatments and 9 required more than one dose of intramuscular epinephrine. None of the biphasic reaction patients required intravenous epinephrine, other vasopressors, ICU admission, or endotracheal intubation. Biphasic reactions appeared in a median time of 13.3h after the initial reaction ranging from 1.1h to 69.6h (IQR 30.2). There was no difference in age or gender of patients who developed a biphasic reaction compared those who did not. Pertinent past medical history, daily medications, mean of arrival to the ED, allergen type, ingestion route, or initial symptoms during the anaphylaxis episode were not significantly different in the two groups. Treatment with corticosteroids was similar in the two groups (9.0% vs. 8.1% p = 0.82). Treatment, dose and route of administration of epinephrine was not different in the two groups but longer delays before treatment with the first dose of epinephrine was more frequent in biphasic reaction patients (median delay of 64 minutes, p = 0.015). Conclusion: No patient characteristic, allergen, route of ingestion, symptom, nor treatment with corticosteroids has shown to be significantly different in patients with and without biphasic reactions. Delayed treatment with epinephrine is significantly associated with biphasic reactions.

Introduction: According to WHO, one third of patients aged ≥65 fall every year. Those falls account for 25% of all geriatric emergency department (ED) visits. Fear of falling (FOF) is common in older patients who sustained a fall and is associated with a decline in mobility and health issues for patients. We hypothesized that there is an association between FOF and return to ED (RTED) and future falls. Objective: To assess the relation between FOF and RTED and subsequent falls in older ED patients Methods: This research was conducted as part of the Canadian Emergency Team Initiative in elderly (CETIe) multicenter prospective cohort study from 2011 to 2016. Participants: Patients 65 years or older were assessed and discharged from ED following a minor trauma. They had to be independent in all basic activities of daily living and being able to communicate in English or French. Measures: Primary outcome was RTED and secondary outcome was subsequent falls. Both were self-reported at 3 and 6 months. Patients were stratified according to Short Falls Efficacy Scale International (SFES-I) score, assessing FOF in different situations. A total score is calculated to determine the mild, moderate or severe level of FOF. Previous falls and TUG were used to evaluate patients’ mobility. OARS, ISAR and SOF were used to evaluated patient frailty. Descriptive statistical were performed and multiple regression were performed to show the association between SFES-1 score and outcomes. Results: FOF was measured in 2899 participants, of which 2214 participated at the 3 months follow-up and 2009 participated at the 6 months follow-up. Odds Ratio (OR) of return to ED at 3 months was 1.10 for moderate FOF and 1.52 for severe FOF (Type 3 test p = 0.11). At 6 months, OR was 1.03 for moderate FOF and 1.25 for severe FOF (Type 3 test p = 0.63). OR of subsequent fall at 3 months was 1.80 for moderate FOF and 2.18 for severe FOF (Type 3 test p < 0.001). At 6 months, OR of subsequent fall was 1.63 for moderate FOF and 2.37 for severe FOF (Type 3 test p < 0.001). Conclusion: The multicenter cohort study showed that severe fear of falling is strongly associated with subsequent falls over the next 6 months following ED discharge, but not significantly associated with return to ED episodes. Further research should be done to analyze the association between severe FOF and RTED.

Introduction: Parmi les patients souffrant d'un arrêt cardiaque extrahospitalier (ACEH), ceux ayant un retour de circulation spontanée (RCS) durant la phase préhospitalière de leur réanimation ont un meilleur taux de survie. Il est plausible que les patients ayant un RCS plus précocement durant leur réanimation préhospitalière aient de meilleur taux de survie que les patients ayant un RCS plus tardif. Cette étude visait à décrire l'association entre la survie et la durée de la réanimation par les paramédics avant le RCS préhospitalier. Methods: La présente étude de cohorte a été réalisée à partir des bases de données collectées de la Corporation d'Urgences-santé dans la région de Montréal entre 2010 et 2015. Tous les patients adultes avec un RCS préhospitalier suite à un ACEH d'origine médicale ont été inclus. Les patients ayant eu un arrêt devant les paramédics ont été exclus, tout comme ceux avec un RCS avant l'arrivée des services préhospitaliers. L'association entre la survie et le temps de réanimation avant le RCS a été évaluée à l'aide d'une régression logistique multivariée ajustant pour les variables sociodémographiques et cliniques pertinentes (âge, sexe, rythme initial, heure de l'appel initial, arrêt témoigné, manœuvre par témoin, présence de premiers répondants ou de paramédics de soins avancés, délai avant l'arrivée des intervenants préhospitaliers). Results: Un total de 1194 patients (818 hommes et 376 femmes) d'un âge moyen de 64 ans ( ±17) ont été inclus dans l’étude, parmi lesquels 433 (36%) ont survécu jusqu’à leur congé hospitalier. Le délai moyen avant leur RCS était de 17 minutes ( ±12). Nous avons observé une association indépendante entre la survie au congé hospitalier et le délai avant le RCS préhospitalier (rapport de cotes ajusté = 0,91 [intervalle de confiance à 95% 0,89-0,92], p < 0,001). Plus de 50% des survivants avaient obtenu un RCS moins de 9 minutes après l'initiation des manœuvres de réanimation par les intervenants préhospitaliers, et plus de 95% avant 26 minutes. Aucun (0%) des 17 patients ayant eu un RCS plus de 56 minutes après l'initiation de la réanimation préhospitalière n'a survécu. Conclusion: Un RCS précoce semble être un facteur de bon pronostic parmi les patients souffrant d'un ACEH. La majorité des patients avec un RCS préhospitalier allant survivre à leur hospitalisation ont obtenus leur RCS dans les 9 minutes suivant l'initiation des manœuvres de réanimation.

Introduction: Delirium is a frequent pathology in the elderly presenting to the emergency department (ED) and is seldom recognised. This condition is associated with many medical complications and has been shown to increase the hospital length-of-stay. The objective of this study was to identify the predictor factors of developing delirium in this high-risk population. Methods: Design: This study was part of the multicenter prospective cohort INDEED study. Participants: Patients aged 65 and older, initially free of delirium and with an ED stay of 8h or longer, were followed up to 24h after ward admission. Measures: Clinical and demographic variables were collected by interview and chart review. A research professional assessed their delirium status twice daily using the Confusion Assessment Method (CAM). Analyses: A classification tree was used to select predictors and cut-points that minimized classification error of patients with incident delirium. After literature review, nineteen predictors were considered for inclusion in the model (eight non-modifiable and eleven modifiable factors). Results: Among the 605 patients included in this study, incident delirium was detected by the CAM in 69 patients (11.4%). In total, fourteen variables were included in a preliminary model, of which six were intrinsic to the patient and eight were modifiable in the ED. Variables with the greatest impact in the prediction of delirium includes age, cognitive status, ED length of stay, autonomy in daily activities, fragility and mobility during their hospital stay. The diagnostic performance of the model applied to the study sample gave a sensitivity of 78.3% (95% CI: 66.7 to 87.3), a specificity of 100.0% (95% CI: 99.3 to 100.0), a PPV of 100.0% (95% CI: 93.4 to 100.0) and a NPV of 97.3% (95% CI: 95.6 to 98.5). Conclusion: The delirium risk model developed in this study shows promising results with elevated sensitivity and specificity values. Considering the limited ability to predict and detect delirium among physicians, the potential increase in sensitivity provided by this tool could be beneficial to patients. This model will ultimately serve to identify high-risk patients with the goal of developing strategies to alter modifiable risk factors and subsequently decrease the incidence of delirium in this population.

Introduction: Le syndrome aortique aigu (SAA) est une condition potentiellement létale et nécessitant une prise en charge immédiate et fréquemment chirurgicale. Lutilisation dun test de D-dimère a été proposé afin dexclure ce diagnostic suite à de nombreuses études récentes sur le sujet. Dans ce contexte, lobjectif de la présente revue systématique et méta-analyse était dévaluer et de synthétiser lévidence disponible quant à la valeur diagnostique dun dosage de D-dimères pour le SAA. Methods: Les bases de données Medline, Cochrane, ACP Journal Club, DARE, Health technology assessment, NHS Economic evaluation et Embase ont été fouillées en utilisant les mots clés «D-Dimers» et «Acute aortic». Les bibliographies des articles retenus ont également été consultées. Les résultats des études incluses ont été regroupés pour calculer la sensibilité, la spécificité, le rapport de vraisemblance positif (RV+) et négatif (LR-) du test de D-dimères aux seuils choisis par les auteurs. Les sensibilités et spécificités sont présentées avec leurs intervalles de confiance (IC) à 95% et les RV+ et RV- sont donnés à titre indicatif. Results: À partir des 6942 articles initialement identifiés, 34 études portant sur lutilité diagnostique des D-dimères en SAA, incluant un total de 7938 patients, ont été retenues. La prévalence globale de SAA était de 27,1%, mais variait considérablement dune étude à lautre (médiane=38,5%; intervalle interquartile=29% ; prévalence minimale=0.7% ; prévalence maximale=100%). Les seuils de positivité des tests de D-dimères variaient également selon lentreprise les fabriquant. La sensibilité dun test de D-dimères selon le seuil proposé par leur fabriquant était de 91% (IC 95% 86-96) et la spécificité 46% (IC 95% 39-54). Le RV+ était de 1,69 et le VR- était de 0,2. Conclusion: La prévalence très variable du SAA dans la population regroupée par ces études laisse présager une différence entre ces populations et celles rencontrées en médecine durgence. Un test de D-dimères a sensibilité acceptable, mais imparfaite, qui ne semble pas permettre dexclure une pathologie aussi grave que le SAA.

Introduction: Overcrowding in emergency departments (EDs) is a constant problem. One of the major factors contributing to this situation is the inappropriate ED use by patients with low-acuity problems. In order to reduce overuse, EDs have developed agreements with clinics to reorient low-acuity ambulatory patients toward them. These agreements often leave the burden of decision on the triage personnel as to which patients can be safely redirected. The aim of this study was to evaluate the safety of redirecting patients to nearby medical clinics and to evaluate their satisfaction with this program. Methods: In the ED of a tertiary care facility, a computer-based algorithm allowing triage personnel to reorient patients presenting with one of 52 medical complaints, was implemented in 2016. Our prospective cohort study was composed of reorientation admissible ED patients between March 2017 and August 2017. Patient safety was evaluated with patient follow-up phone interviews one week after their visit to the ED to identify the number of patients who needed to return to a medical facility after their reorientation. Patient satisfaction with the reorientation program was evaluated during the same follow-ups. Results: Of the 980 reoriented patients interviewed, only 57 (5.9%; 95% confidence interval [CI] 4.57.5) had to unexpectedly go back to a health care facility. None of these returns were for severe complications. Over 84% of the reoriented patients were satisfied with their reorientation and 89% say they would use this program again. Having a transportation problem was most common reason mentioned by patients for refusing to be reoriented. Conclusion: Reorientation to medical clinics using a new computer-based algorithm was safe and no case of urgent return was seen during the 6-month study period. In addition, patients who were reoriented to medical clinics were satisfied by their treatment experience.

Introduction: Frailty is a geriatric syndrome conferring a high risk of declining functional capacities. Some serum biomarkers were associated with frailty, but no study has investigated this possible association among community-dwelling seniors with minor injuries in the emergency department (ED). The aim was to determine if ED serum biomarker assay combined with frailty status improve the prediction of 3-months functional or mobility impairments in this population, beyond frailty status alone. Methods: This prospective sub-study of the CETI cohort includes 190 participants (age 65 years, ED consultation within 2 weeks of a minor injury, independent in daily activities 4 weeks prior to injury, and discharged home from EDs). Biomarkers were obtained from blood samples at baseline (ED visit). Normal vs. at risk physiological states were defined according to clinical threshold values. Also, the patients were screened for frailty at baseline) while their functional (OARS scale) and mobility characteristics were assessed at the ED visit and 3 months later. Patients were classified as robust or pre-frail/frail according of the CHSA-CFS and SOF scales. Simple generalized linear models with a binomial distribution and a log link function were used to explore the differences in functional and mobility outcomes at three months across sub-groups (RR). Results: When compared to robust ones, ED pre-frail/frail patients were less functional in their instrumental activities of day living (p=0.004), slower walkers (p=0.02), more frequent users of walking aids (p=0.03), more fearful of falling (p=0.006), went outside their home less often weekly (p=0.004) and had higher abnormal creatinine levels (p=0.02). We observed an overall 3-month functional decline in around 10% of patients combined with worsened mobility characteristics. We found that vitamin D [RR: 0.51 (0.07-3.9)], glucose (RR: 0.27 [(0.03-2.16)]) and creatinine (RR: [1.10 [(0.40-2.97]) modulate the prediction of 3-months mobility impairments. However, ED frailty status with CHSA-CFS and SOF scales clearly remained the stronger predictor of mobility impairments [vitamin DRR: 2.93 (1.12-7.65); glucoseRR: 2.36 (0.85-6.55); creatinine: RR2.06 (1.21-3.53)]. Conclusion: Since they do not improve the prediction of 3-months functional or mobility impairments associated with frailty status, ED biomarker assays are not useful in adequately screening for frailty among independent seniors with minor injuries.

Introduction: Patients suffering from out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm (ventricular tachycardia or ventricular fibrillation) have higher odds of survival than those suffering from non-shockable rhythm (asystole or pulseless electrical activity). Because of that prognostic significance, patients with an initial non-shockable rhythm are often not considered for advanced resuscitation therapies such as extracorporeal resuscitation. However, the prognostic significance of the conversion to a shockable rhythm from an initially non-shockable rhythm remains uncertain. This study aimed to determine the degree of association between the conversion (or not) of a non-shockable rhythm to a shockable rhythm and resuscitation outcomes in patients with OHCA. It was hypothesized that such a conversion would be associated with a higher survival to discharge. Methods: The present study used a registry of adult OHCA between 2010 and 2015 in Montreal, Canada. Adult patients with non-traumatic OHCA and an initial non-shockable rhythm were included. The primary outcome measure was survival to hospital discharge, and the secondary outcome measure was prehospital return of spontaneous circulation (ROSC). The associations of interest were evaluated with univariate logistic regressions and multivariate models controlling for demographic and clinical variables (e.g. age, gender, type of initial non-shockable rhythm, witnessed arrest, bystander cardiopulmonary resuscitation). Assuming a survival rate of 3% and 25% of the variability explained by the control variables, including more than 4580 patients would allow to detect an absolute difference of 4% in survival between both groups with a power of more than 90%. Results: A total of 4893 patients (2869 men and 2024 women) with a mean age of 70 years (standard deviation 17) were included, of whom 450 (9.2%) experienced a conversion to a shockable rhythm during the course of their prehospital resuscitation. Among all patients, 146 patients (3.0%) survived to discharge and 633 (12.9%) experienced prehospital ROSC. In the univariate models, there was no association between the conversion to a shockable rhythm and survival (odds ratio [OR] 1.14 [95% confidence interval {CI} 0.66-1.95]), but a significant assocation was observed with ROSC (OR 2.00 [95% CI 1.57-2.55], p<0.001). However, there was no independent association between the conversion to a shockable rhythm and survival (adjusted OR [AOR] 0.92 [95% CI 0.51-1.66], p=0.78) and prehospital ROSC (AOR 1.30 [95% CI 0.98-1.72], p=0.073). Conclusion: There is no clinically significant association between the conversion to a shockable rhythm and resuscitation outcomes in patients suffering from OHCA. The initial rhythm remains a much better outcome predictor than subsequent rhythms and should be preferred when evaluating the eligibility for advanced resuscitation procedures.